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Long-Term Care MDS CMS has been involved with the development of several MDSs that are tied directly to reimbursement and used to evaluate the quality of care generic 160 mg super p-force otc what causes erectile dysfunction treatment. One of the better known of these data sets is the Long Term Care Resident Assessment Instrument (RAI) MDS (version 2 discount super p-force 160 mg on line erectile dysfunction treatment home. The four-page assessment form used to capture the core set of data elements contains more than 72 fields that have to be completed on every patient four times each year. While this data set is referred to as an MDS, ironically, the completion of these forms has placed additional data collection burdens on most facili- ties. Yet, Chapter 1 of the RAI manual states that The RAI should not be, nor was it ever meant to be, an additional burden for nurs- ing facility staff. Utilization Guidelines basically provide direction on when and how to use the RAI. This MDS, along with site inspection data, serves as the primary source for the public release of long-term care data, which was initiated in 2002. It also serves as the basic data tool for measuring what is known as outcome-based quality improvement (OBQI). OASIS was initially conceived in 1990 and sponsored jointly at that time by HCFA and the University of Colorado. Further refine- ments were achieved during a three-year demonstration project (1996–1999). Today, any home care agency wishing to participate in the Medicare program is required to participate in the OASIS initiative. The basic idea behind OASIS and OBQI is that if home care agencies under- The Search for A Few Good Indicators 93 stand the outcomes they produce, they will engage in remediation to improve the negative outcomes and reinforcement to maintain the pos- itive outcomes. The organization started its measurement journey in 1987 with the Agenda for Change. ORYX began as a fairly flexible and open approach to meeting the Joint Commission accreditation requirements. Hospitals were allowed to select from a broad range of indicators, but the problem was maintaining consistency across myriad indicators that did not have stan- dardized definitions. Currently, the ORYX initiative is in the process of transitioning to what are known as Core Measures. This approach offers a more specific and limited set of indicators that have standardized defini- tions and more clear specifications for data collection. After a pilot study on the proposed core measures, the following four clinical topics now form the basis of the Joint Commission Core Measures project: • Hospital acute myocardial infarction (AMI): nine specific indicators • Heart failure (HF): four specific indicators • Community-acquired pneumonia (CAP): six specific indicators • Pregnancy and related conditions (PR): three specific indicators Currently, hospitals are expected to select two of these four areas and submit data to the Joint Commission. Eventually, it is anticipated that all hospitals will be expected to submit data on all four clinical topics. The Joint Commission has also suggested that additional clinical areas (e. The ultimate goal of the Joint Commission initiatives is to be able to offer uni- form aggregated results that can be compared across all hospitals. To fur- ther establish the credibility of these measures, the Joint Commission has 94 The Healthcare Quality Book joined into a collaborative arrangement with CMS, the American Hospital Association (AHA), and a number of state hospital associations to collect and share the Core Measures results. This is seen as a positive step, since it is an attempt to minimize the burden of data collection being placed on hospitals and work toward a common MDS that can serve numerous pur- poses. Since this collaboration is still new, however, the exact details of how the data sharing will work need to be finalized; the value-added contribu- tion of the collaborative remains to be seen. Its primary purpose is to accredit health plans, primarily health mainte- nance organizations (HMOs) and preferred provider organizations (PPOs). But NCQA has also been involved with developing measures of quality and certification standards for individual physician offices, large medical groups, disease management entities, and credentialing organizations. Far fewer PPOs have gone through the accreditation process, basically because the PPO accreditation process was initiated in 2000 and it takes several years to gear up for a suc- cessful accreditation review. The NCQA Health Plan Report Card is the primary reference for large companies and other organizations interested in evaluating which health plans to offer to their employees. The Health Plan Employer Data and Information Set (HEDIS) is the MDS that NCQA has created to evaluate the quality of care and customer service provided by each health plan. The HEDIS data elements include quality of care, access to care, and member satisfaction with the health plan and the doc- tors they see.

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Follow instructions for omeprazole (Nexium) discount super p-force 160 mg visa natural erectile dysfunction treatment remedies, lansoprazole (Prevacid) purchase super p-force 160 mg fast delivery impotence blood circulation, panto- mixing the granules exactly. The granules should not be prazole (Protonix), and rabeprazole (Aciphex). Do cimetidine (Tagamet), famotidine (Pepcid), and others not take an antacid for 1 hour before or after taking one are available as both prescription and over-the-counter of these drugs. OTC products are indicated for heart- ✔ Take sucralfate on an empty stomach at least 1 hour be- burn, and smaller doses are taken than for peptic ulcer fore meals and at bedtime. These drugs usually should not be taken longer for 1 hour before or after taking sucralfate. The concern is that OTC drugs may delay diagnosis and ✔ For treatment of peptic ulcer disease, take antacids treatment of potentially serious illness. In addition, cime- 1 and 3 hours after meals and at bedtime (4 to 7 doses tidine can increase toxic effects of numerous drugs and daily), 1 to 2 hours before or after other medications. Antacids decrease absorption of many medications if Misoprostol (Cytotec) is given to prevent ulcers from taken at the same time. Also, chew chewable tablets NSAIDs, which are commonly used to relieve pain and in- thoroughly before swallowing, then drink a glass of water; flammation with arthritis and other conditions. This drug allow effervescent tablets to dissolve completely and al- should be taken only while taking a traditional NSAID most stop bubbling before drinking; and shake liquids such as ibuprofen. CHAPTER 60 DRUGS USED FOR PEPTIC ULCER AND ACID REFLUX DISORDERS 877 Guidelines for Therapy With Histamine-2 Guidelines for Therapy With Sucralfate Receptor Antagonists 1. For an acute ulcer, full dosage may be given up to administered for 4 to 8 weeks unless healing is con- 8 weeks. When the ulcer heals, dosage may be re- firmed by radiologic or endoscopic examination. For duodenal ulcers, a single evening or bedtime dose produces the same healing effects as multiple Guidelines for Therapy With Antacids doses. Commonly used nocturnal doses are cimeti- dine 800 mg, ranitidine 300 mg, nizatidine 300 mg, 1. To prevent stress ulcers in critically ill clients and to or famotidine 40 mg. For gastric ulcers, the optimal H2RA dosage sched- tion of gastric acid is desirable. Gastric ulcers heal administration must be sufficient to neutralize approx- more slowly than duodenal ulcers and most author- imately 50 to 80 mEq of gastric acid each hour. To maintain ulcer healing and prevent recurrence, through a nasogastric tube or by hourly administration. When a client has a nasogastric tube in place, antacid usually given as a single bedtime dose, but the dosage may be titrated by aspirating stomach contents, amount is reduced by 50% (ie, cimetidine 400 mg, determining pH, and then basing the dose on the pH. When prescribing antacids to treat active ulcers, it as every 4 hours may be required. For severe reflux esophagitis, multiple daily doses 3 hours after meals and at bedtime for greater acid may be required for adequate symptom control. Dosage of all these drugs should be reduced in the venient for many clients. Antacids are often given concurrently with H2RAs duodenal or gastric ulcers even though less acid neu- to relieve pain. It was formerly thought that liquid antacid preparations the antacid reduces absorption of the other drug. Now, tablets are considered as ef- H2RAs usually relieve pain after 1 week of admin- fective as liquids. These drugs are available in a wide array of products may be taken as needed. However, they should not be and precautions must be taken to ensure the correct taken in high doses or for prolonged periods because of formulation, dosage strength, and method of admin- potential adverse effects. For example, cimetidine is available in tablets of 100, 200, 300, 400, 800 mg, an oral liquid with 300 mg/5 mL, and injectable solu- Effects of Acid Suppressant tions. Ranitidine is available in tablets of 75, 150, and Drugs on Other Drugs 300 mg, effervescent tablets of 150 mg, capsules (Zantac GELdose) of 150 and 300 mg, a liquid syrup Antacids may prevent absorption of most drugs taken at the with 15 mg/mL, effervescent granules of 150 mg, and same time, including benzodiazepine antianxiety drugs, corti- injectable solutions of 1 mg/mL and 25 mg/mL. Ni- costeroids, digoxin, H2RAs (eg, cimetidine), iron supplements, zatidine is available in tablets of 75 mg and capsules phenothiazine antipsychotic drugs, phenytoin, fluoroquinolone of 150 and 300 mg and famotidine in tablets of 10, 20, antibacterials, and tetracyclines. Antacids increase absorption and 40 mg, chewable tablets of 10 mg, orally disinte- of a few drugs, including levodopa, quinidine, and valproic grating tablets (Pepcid RPD) of 20 and 40 mg, a pow- acid.

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They are usually associated with chronic immuno- who regularly use inhaled corticosteroids also need high suppression from immunosuppressant drugs or from ac- doses of systemic drugs during acute attacks because quired immunodeficiency syndrome (AIDS) 160mg super p-force visa impotence viriesiem. As soon as acute symptoms sub- these lymphomas are very sensitive to corticosteroids side buy super p-force 160mg amex impotence 16 year old, dosage should be tapered to the lowest effective main- and therapy is indicated once the diagnosis is established. Corticosteroid therapy may be useful in In chronic asthma, inhaled corticosteroids are drugs of first both supportive and definitive treatment of brain and choice. This recommendation evolved from increased knowl- spinal cord tumors; neurologic signs and symptoms often edge about the importance of inflammation in the patho- improve dramatically within 24 to 48 hours. Cortico- physiology of asthma and the development of aerosol steroids help to relieve symptoms by controlling edema corticosteroids that are effective with minimal adverse effects. Some clients can be tapered off general, inhaled corticosteroids can replace oral drugs when corticosteroids after surgical or radiation therapy; others daily dosage of the oral agent has been tapered to 10 to 15 mg require continued therapy to manage neurologic symp- of prednisone or the equivalent dosage of other agents. Adverse effects of long-term corticosteroid therapy a client is being switched from an oral to an inhaled cortico- may include mental changes ranging from mild agitation steroid, the inhaled drug should be started during tapering of the to psychosis and steroid myopathy (muscle weakness oral drug, approximately 1 or 2 weeks before discontinuing or and atrophy), which may be confused with tumor pro- reaching the lowest anticipated dose of the oral drug. Mental symptoms usually improve if drug client requires a systemic corticosteroid, coadministration of dosage is reduced and resolve if the drug is discontinued; an aerosol allows smaller doses of the systemic corticosteroid. Although the inhaled drugs can cause suppression of the HPA Chemotherapy-induced emesis. Corticosteroids have strong axis and adrenocortical function, especially at higher doses, antiemetic effects; the mechanism is unknown. They perform this of choice for chemotherapy with cisplatin, which is a important function by increasing the number and responsive- strongly emetic drug. Research studies indicate increased respon- siveness to beta-adrenergic bronchodilators within 2 hours Corticosteroids are more helpful in acute exacerbations than and increased numbers of beta receptors within 4 hours of cor- in stable disease. For a client with inadequate relief from a bronchodilator, a trial of Cancer a corticosteroid (eg, prednisone 20 to 40 mg each morning for 5 to 7 days) may be justified. Treatment should be continued Corticosteroids are commonly used in the treatment of lym- only if there is significant improvement. In tions, the lowest effective dose is needed to minimize adverse these disorders, corticosteroids inhibit cell reproduction and drug effects. In addition to their anticancer Inhaled corticosteroids can also be tried. They produce effects in hematologic malignancies, corticosteroids are ben- minimal adverse effects, but their effectiveness in COPD has eficial in treatment of several signs and symptoms that often not been clearly demonstrated. With severe disease, clients often require hospitaliza- and other disorders. Clients tend to feel better when taking tion, IV fluids for hydration, and parenteral corticosteroids corticosteroids, although the basic disease process may be until symptoms subside. The capsule dissolves steroid therapy of cancer and associated symptoms: in the small intestine and acts locally before being absorbed 348 SECTION 4 DRUGS AFFECTING THE ENDOCRINE SYSTEM into the bloodstream and transported to the liver for metabo- plication, including aerosols for oral or nasal inhalation, lism. It has fewer adverse effects than systemic corticosteroids, formulations for topical application to the skin, eyes, but is also less effective and more expensive. With ulcerative colitis, corticosteroids are usually used • Use ADT, which involves titrating the daily dose to the when aminosalicylates (eg, mesalamine) are not effective or lowest effective maintenance level, then giving a double when symptoms are more severe. If not effective, oral prednisone 20 to 60 mg daily may be given until symptoms subside. In clients with severe disease, oral prednisone may be required Use in Children initially. A major concern with children is growth retardation, enteral corticosteroids. One regimen uses IV hydrocorti- which can occur with small doses and administration by in- sone 300 mg/day or the equivalent dose of another drug. Many children have a growth spurt when the drug is discontinued, Prevention of Acute but drug effects on adult stature are unknown. Adrenocortical Insufficiency Parents and health care providers can monitor drug effects by recording height and weight weekly. ADT is less likely to Suppression of the HPA axis may occur with corticosteroid impair normal growth and development than daily adminis- therapy and may lead to life-threatening inability to increase tration. In addition, for both systemic and inhaled cortico- cortisol secretion when needed to cope with stress. The risk of HPA suppression is high with sys- temic drugs given for more than a few days, although clients vary in degree and duration of suppression with comparable Use in Older Adults doses, and the minimum dose and duration of therapy that cause suppression are unknown.

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Other signs and symptoms includ- ed a bright white facial complexion order super p-force 160 mg impotence means, devitalized essence spirit super p-force 160mg amex impotence depression, a cold body and chilled limbs, a pale tongue with white fur, and a deep, slow, forceless pulse. Urine tests were normal in all cases, and x-ray showed no abnormalities. Children had to be more than three years old to be enrolled in this study. Treatment method: The medicinal cakes that were used on all members of the moxi- bustion on medicinal cakes group were made from unspecified amounts of: 148 Treating Pediatric Bed-wetting with Acupuncture & Chinese Medicine Fu Zi (Radix Lateralis Praeparatus Aconiti Carmichaeli) Rou Gui (Cortex Cinnamomi) Ding Xiang (Flos Caryophylli) These three medicinals were ground into powder. This powder was then mixed with 70% alcohol to make the medicinal cakes which were 2. The circular medicinal cakes were placed on one of the fol- lowing points: Guan Yuan (CV 4) Ming Men (GV 4) Then a moxa cone 1. This process was then repeated each treatment, alternating between the two points, and one treatment was given every other day. Each time, five cones were used on each point, and six treat- ments equaled one course. The acupoints used on all members of the acupuncture group were also: Guan Yuan (CV 4) Ming Men (GV 4) One of these two points was needled each treatment and then the other point was needled the following treatment. The points were stimulated every five minutes, and one treatment was given every other day. Study outcomes: In the moxibustion on medicinal cakes group, 91 cases were cured, 24 cases improved, and five cases had no improvement. In the acupunc- ture group, 42 cases were cured, 30 cases improved, and 28 cases had no improvement. From A Comparitive Study on the Treatment of Pediatric Enuresis with Moxibustion & Acupuncture by Xu Tian-bin, Zhen Ci Yan Jiu (Acupuncture Research), 1999, #2, p. In the moxibustion group, there were 30 patients, 18 males and 12 females. The course of disease in this group ranged from three months to five years. In the acupuncture group, there were 15 patients, eight males and seven females. The youngest child in this group was five years old and the oldest was 13. Treatment method: Both groups were treated at the same group of acupoints: Guan Yuan (CV 4) Shen Shu (Bl 23) San Yin Jiao (Sp 6) In the acupuncture group, the needles were retained for 30 min- utes after the qi was obtained. Supplementation method was used, and stimulation was applied one time every five minutes. In other words, the acupuncture group received acupunc- ture plus moxibustion, while the moxibustion group only received moxibustion. These treatments were administered one time each day in both groups, and seven days equaled one course of treat- ment. Study outcomes: In the moxibustion group, 22 cases were cured, five cases improved, and five cases had no improvement. In the acupuncture group, 12 cases were cured, two cases improved, and one case had no improvement. From The Treatment of Pediatric Enuresis with Rubbing the Abdomen & Spinal Pinch Pull by Su Ping & Cheng Yun, An Mo Yu Dao Yin (Massage & Dao Yin), 2002, #6, p. The course of enuresis was as short as one half year and as long as eight years. Nineteen cases had enuresis two times per night, 37 cases had enuresis one time per night, and 33 cases had enuresis 2-3 times per week. All 89 patients had taken Chinese medicinals without results prior to their initial assess- ment. Treatment method: Abdominal massage consisted of the patient lying on their back with their abdomen exposed and then massaging the following points: Liang Men (St 21) Jian Li (CV 11) Zhong Wan (CV 12) Tian Shu (St 25) Qi Hai (CV 6) Guan Yuan (CV 4) Zhong Ji (CV 3) For patients with kidney qi insufficiency pattern, more time was spent massaging the main points Qi Hai, Guan Yuan, and Zhong Ji. For patients with spleen-lung qi vacuity pattern, more time was spent massaging the main points Jian Li, Zhong Wan, and Qi Hai. Each point was massaged for 2-3 minutes mainly using supple- mentation method. With the child lying on their stomach and back exposed, the back was first rubbed to relax the muscles.

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