Infection Control Precautions

The incidence of hepatitis C is falling (Baker, 2000). This is partly because of testing for the presence of the virus in donor blood and in biological agents that are made from blood and injected for various treatments, such as concentrated factor VII for bleeding disorders.

Unfortunately, vaccines are not available. Efforts to develop them continue, but the results are not encouraging. Although the use of gamma globulin has not been specifically tested as prophylaxis against HCV, studies with this preparation several years ago in efforts to prevent posttransfusion hepatitis, which was primarily caused by HCV, were unsuccessful. Since there is no reason to believe that gamma globulin would be helpful, it is not recommended. Tattoos and body piercing have been implicated and should be avoided. The sharing of needles during illicit drug use is now the most common mode of transmission (Achord, 2002).

Presently, there is no vaccine for hepatitis C, but there are vaccines for hepatitis A and B. The CDC recommends these vaccines, particularly the hepatitis A vaccine, for HCV-positive individuals. Becoming infected with hepatitis A virus can be life threatening for someone with HCV infection. In May, the FDA approved a combined hepatitis A and B vaccine called Twinrix, (Bren, 2001).

As discussed briefly in the first parts of this paper, HCV exists in many different forms, called genotypes, confounding researchers in their quest to develop a vaccine effective for all variations. Also, HCV mutates frequently within infected patients, so even if an effective vaccine is developed, it could be rendered useless by a new strain of mutant virus (Henkel, 1999).

A major focus of hepatitis research is development of a cell culture through which scientists can study HCV outside the human body. By understanding how the virus replicates and how it injures cells, researchers may be able to develop ways to control the virus as well as drugs to block it. It is very likely that a vaccine specific to hepatitis C will be developed in the near future. The cost of the research to acquire a vaccine will definitely be justified when you consider all of the demands made upon the healthcare system.

Prognosis

Prognosis is highly variable. With drug etiology, disease may regress completely when offending agent is withdrawn. Cases associated with HBV or HCV tend to progress slowly and are usually relatively resistant to therapy. Autoimmune cases generally improve substantially with treatment. With adequate therapy, patients usually live several years or decades, but hepatocellular failure, cirrhosis, or both eventually develop in many cases (The Merck Manual, 1999).

Treatment

Treatment includes cessation of causative drugs and management of complications (eg, ascites, encephalopathy). Autoimmune hepatitis is best treated by corticosteroids with or without azathioprine. These drugs suppress the inflammatory reaction, perhaps partly by beneficially altering the immune response, and have increased long-term survival.

In most patients, symptoms lessen, biochemical abnormalities largely resolve, and histologic inflammation regresses. However, fibrosis may progress despite apparent clinical and laboratory control, and attempts to discontinue therapy usually lead to relapse; most patients require long-term low-dose maintenance treatment. Drug dosage should be supervised by a specialist.

Therapy for both chronic hepatitis B and C is evolving. Corticosteroids are contraindicated, because viral replication is enhanced. Interferon- is now widely used to suppress viral replication, but overall results are relatively disappointing.

Chronic hepatitis C is treated with a combination of interferon- 3 million IU sc three times weekly plus oral ribavirin 1200 mg daily in two divided doses, which gives better results than interferon alone. This initially suppresses inflammation in about 2/3 of patients. Responders are treated for either 6 or 12 months depending on the specific viral genotype, but most relapse when treatment is stopped; successful long-term disease suppression is only about 30-40% overall. Response depends in part on the viral genotype, viral load, and histologic stage of the disease. Pegylated interferon, a recently developed modification of the drug molecule, will likely replace standard interferon in the near future because it requires injection only once a week and gives marginally better results (The Merck Manual, 1999).

In addition to having limited efficacy, interferon- is expensive, must be given by injection, produces bothersome flu-like side effects in most patients, and induces more serious side effects in a minority of cases. Treatment should be supervised by a specialist. Other antiviral and immunomodulatory drugs against HBV and HCV have been evaluated or are being studied, but no major breakthrough appears imminent.

Liver transplantation has not generally been suitable for end-stage liver disease caused by HBV, because of aggressive disease reference in the graft, but treatment with lamivudine can now help ameliorate this problem. Transplantation for advanced hepatitis C is much more successful; although HCV infection universally recurs, the clinical course is generally indolent, and long-term survival rates are relatively high. In many transplant centers, hepatitis C is now the most common indication for adult liver transplantation.

The demand for liver transplantation is therefore increasing largely due to the increased incidence of HCV. It is without no doubt that this will continue to grow rapidly in the years to come. Of course, liver donations are not too many compared to those who need liver transplants. And so a question of who should have liver transplants arises. There will be a problem of who should get liver transplants first.

The United States has policies for this. Revised policy in the United States for the allocation of donated cadaver livers now distributes available organs depending on medical urgency rather than regional location. The new policy is aimed at making donated livers available to people at greatest risk of imminent death. Those with the most urgent need, often with a life expectancy of less than one week, are considered status one. The next most urgent group is status two A, followed by status two B and status three (Howard, 2003).

Previously, donated livers were offered to a person with a status one rating who resided in the locale where the organ was donated. If no match was found, it was offered to someone with a status two or three rating in the same local area. With revised allocation guidelines, a donated liver still will be offered to a person with a status one rating in the location it was donated, but if no match is found, it will be offered to someone with a status one rating in the larger UNOS region before being offered locally to someone with a status two or three rating. The revised policy is expected to increase the number of transplantations performed for people who have a status one rating by up to 80% and cut waiting time in half (Howard, 2003)

The goal of treatment is sustained response--meaning that the virus is not measurable in the blood after drug therapy is completed. Those who continue to have measurable levels of the virus after treatment are considered non-responders. Relapsers "clear" the virus during therapy or shortly thereafter, but the virus returns after therapy ends (Bren, 2001).

Evaluation of the safety of clinical practice in my workplace

Health care professionals are among those that are at high risk for hepatitis C. Treating and having to take care of people who are infected with the hepatitis C virus poses a great risk for health care professionals. Safety measures have therefore to be examined within health care institutions. So far, within my workplace, standard operating procedure regarding care of patients infected with HCV have been strictly followed, as well as the handling of specimen from HCV carriers. Personal hygiene can also help prevent the spread of hepatitis. Unnecessary transfusions should be also avoided in order to minimize incidence of hepatitis.

Preventing transmission from healthcare workers to patients has been controversial. Although transmission has been documented, it is rare and limited to case reports. Up to half of the reports were confounded by other factors like contamination of patients' narcotics used for healthcare workers' surreptitious habit of IV drug use. The calculated risk for HCV transmission from an RNA-positive surgeon to a patient during an invasive procedure is 0.00018%, which was roughly comparable to the chance of acquiring HCV by transfusion in the United States in the year 2000. It is recommended in some countries (Berklan, 2000) that no HCV-infected healthcare professional be restricted from his or her work. Despite this recommendation, some health departments have required HCV-infected physicians to obtain informed consent before performing surgery on their patients (Pearlman, 2004).

Healthcare organizations should treat hepatitis C in the same manner that they treat HIV or AIDS. Recommendations should include strict adherence to worldwide admitted precautions and education on hepatitis C for all healthcare workers. This education should include emphasizing the importance of reporting all percutaneous sticks. Presently, healthcare workers are screened only if there is a known exposure to hepatitis C (Dillman, 1999). Because hepatitis C is insidious in nature, testing should be done for both the source patient and the healthcare worker, regardless of known status. If a healthcare worker is identified as being positive, counseling and treatment for hepatitis C should be offered.

The value of prevention is skyrocketing. It should be noted that many individuals with the disease are unaware they are infected with HCV because symptoms often do not appear until serious liver damage has already occurred. Therefore, many individuals go through their lives not knowing they have the virus, such wasted time could have been used to start treating the individual infected. Also, given the fact that there is no vaccine yet against hepatitis C, an awareness campaign is indeed a necessity. The chances for individuals getting the infection are increased with the lack of a vaccine against the virus.

Hepatitis C awareness campaigns should be made not only for work environments but for the general public as well. Programs on awareness would put individuals at a concern over prevention of hepatitis C. An awareness campaign is needed which should be focused on raising hepatitis C awareness in the minds of the general public, elected officials, and policy-makers.

Elected officials and policy makers are specifically mentioned as target populations for hepatitis C awareness since they are the ones who are more in the position to create programs that will further strengthen the awareness campaign. They are in a very good position to implement measures that will help individuals lessen their chances of contacting the deadly virus.

The impact of hepatitis C on societies is staggering. Billions are estimated as being spent on the disease worldwide (Henkel, 1999). This includes billions spent on treatment which would have been preventable if only there was a vaccine or individuals are more aware of the infection. If such a trend would continue, allocations for other medical concerns would therefore lessen in favor of the infectious disease, which does not sound very good. Continued research and awareness campaigns therefore have to be done in order to lessen the staggering costs of the disease management and prevention. This of course is only secondary to the aim of helping millions of individuals that are infected with the disease.

In summary, with no vaccine and no effective post-exposure prophylaxis against the hepatitis C virus, best efforts at fighting the silent dragon should be directed toward counseling HCV-infected patients and those at risk of developing infection. Adequate sterilization of medical and surgical instruments and equipment, consistent use of personal protective equipment during patient care, and use of safety devices for venous access should be routine practice for all health care providers. In addition, promotion of community programs for safe injection practices and testing for people in high-risk categories could be a focus with measurable outcomes for all of society.

Conclusion

Hepatitis C is dangerous not only because of the damage it inflicts, but because people may be asymptomatic for years before they realize they are suffering from incurable liver disease. It almost exclusively is spread by dirty needles. Currently there is little hope for treatment of hepatitis C. A drug called Interferon Alpha-2B (inferferon is an immunity substance naturally present in small amounts in the body) has proven somewhat successful in combating the virus, but only in about 15 to 20 percent of the cases. While scientists are conducting research to find more-powerful antidotes, the best hope of curbing the spread of the virus continues to lie mainly in prevention. Health care institutions also have to be aware of the specific measures needed to be able to avoid and prevent infection with the hepatitis C virus. Further programs are needed for populations to educate them of the severity of the disease and its complications.

Hepatitis C infection is therefore a major public health problem throughout the world as can be seen by its effects on the body and the society in general. Yet for all its severity, it is largely preventable. Prevention can happen through awareness campaigns, rigorous efforts to protect blood supplies usually in health care environments, and major education and intervention programs for such at-risk populations as recreational intravenous drug users.

Infection Control Precautions

The incidence of hepatitis C is falling (Baker, 2000). This is partly because of testing for the presence of the virus in donor blood and in biological agents that are made from blood and injected for various treatments, such as concentrated factor VII for bleeding disorders.

Unfortunately, vaccines are not available. Efforts to develop them continue, but the results are not encouraging. Although the use of gamma globulin has not been specifically tested as prophylaxis against HCV, studies with this preparation several years ago in efforts to prevent posttransfusion hepatitis, which was primarily caused by HCV, were unsuccessful. Since there is no reason to believe that gamma globulin would be helpful, it is not recommended. Tattoos and body piercing have been implicated and should be avoided. The sharing of needles during illicit drug use is now the most common mode of transmission (Achord, 2002).

Presently, there is no vaccine for hepatitis C, but there are vaccines for hepatitis A and B. The CDC recommends these vaccines, particularly the hepatitis A vaccine, for HCV-positive individuals. Becoming infected with hepatitis A virus can be life threatening for someone with HCV infection. In May, the FDA approved a combined hepatitis A and B vaccine called Twinrix, (Bren, 2001).

As discussed briefly in the first parts of this paper, HCV exists in many different forms, called genotypes, confounding researchers in their quest to develop a vaccine effective for all variations. Also, HCV mutates frequently within infected patients, so even if an effective vaccine is developed, it could be rendered useless by a new strain of mutant virus (Henkel, 1999).

A major focus of hepatitis research is development of a cell culture through which scientists can study HCV outside the human body. By understanding how the virus replicates and how it injures cells, researchers may be able to develop ways to control the virus as well as drugs to block it. It is very likely that a vaccine specific to hepatitis C will be developed in the near future. The cost of the research to acquire a vaccine will definitely be justified when you consider all of the demands made upon the healthcare system.

Prognosis

Prognosis is highly variable. With drug etiology, disease may regress completely when offending agent is withdrawn. Cases associated with HBV or HCV tend to progress slowly and are usually relatively resistant to therapy. Autoimmune cases generally improve substantially with treatment. With adequate therapy, patients usually live several years or decades, but hepatocellular failure, cirrhosis, or both eventually develop in many cases (The Merck Manual, 1999).

Treatment

Treatment includes cessation of causative drugs and management of complications (eg, ascites, encephalopathy). Autoimmune hepatitis is best treated by corticosteroids with or without azathioprine. These drugs suppress the inflammatory reaction, perhaps partly by beneficially altering the immune response, and have increased long-term survival.

In most patients, symptoms lessen, biochemical abnormalities largely resolve, and histologic inflammation regresses. However, fibrosis may progress despite apparent clinical and laboratory control, and attempts to discontinue therapy usually lead to relapse; most patients require long-term low-dose maintenance treatment. Drug dosage should be supervised by a specialist.

Therapy for both chronic hepatitis B and C is evolving. Corticosteroids are contraindicated, because viral replication is enhanced. Interferon- is now widely used to suppress viral replication, but overall results are relatively disappointing.

Chronic hepatitis C is treated with a combination of interferon- 3 million IU sc three times weekly plus oral ribavirin 1200 mg daily in two divided doses, which gives better results than interferon alone. This initially suppresses inflammation in about 2/3 of patients. Responders are treated for either 6 or 12 months depending on the specific viral genotype, but most relapse when treatment is stopped; successful long-term disease suppression is only about 30-40% overall. Response depends in part on the viral genotype, viral load, and histologic stage of the disease. Pegylated interferon, a recently developed modification of the drug molecule, will likely replace standard interferon in the near future because it requires injection only once a week and gives marginally better results (The Merck Manual, 1999).

In addition to having limited efficacy, interferon- is expensive, must be given by injection, produces bothersome flu-like side effects in most patients, and induces more serious side effects in a minority of cases. Treatment should be supervised by a specialist. Other antiviral and immunomodulatory drugs against HBV and HCV have been evaluated or are being studied, but no major breakthrough appears imminent.

Liver transplantation has not generally been suitable for end-stage liver disease caused by HBV, because of aggressive disease reference in the graft, but treatment with lamivudine can now help ameliorate this problem. Transplantation for advanced hepatitis C is much more successful; although HCV infection universally recurs, the clinical course is generally indolent, and long-term survival rates are relatively high. In many transplant centers, hepatitis C is now the most common indication for adult liver transplantation.

The demand for liver transplantation is therefore increasing largely due to the increased incidence of HCV. It is without no doubt that this will continue to grow rapidly in the years to come. Of course, liver donations are not too many compared to those who need liver transplants. And so a question of who should have liver transplants arises. There will be a problem of who should get liver transplants first.

The United States has policies for this. Revised policy in the United States for the allocation of donated cadaver livers now distributes available organs depending on medical urgency rather than regional location. The new policy is aimed at making donated livers available to people at greatest risk of imminent death. Those with the most urgent need, often with a life expectancy of less than one week, are considered status one. The next most urgent group is status two A, followed by status two B and status three (Howard, 2003).

Previously, donated livers were offered to a person with a status one rating who resided in the locale where the organ was donated. If no match was found, it was offered to someone with a status two or three rating in the same local area. With revised allocation guidelines, a donated liver still will be offered to a person with a status one rating in the location it was donated, but if no match is found, it will be offered to someone with a status one rating in the larger UNOS region before being offered locally to someone with a status two or three rating. The revised policy is expected to increase the number of transplantations performed for people who have a status one rating by up to 80% and cut waiting time in half (Howard, 2003)

The goal of treatment is sustained response--meaning that the virus is not measurable in the blood after drug therapy is completed. Those who continue to have measurable levels of the virus after treatment are considered non-responders. Relapsers "clear" the virus during therapy or shortly thereafter, but the virus returns after therapy ends (Bren, 2001).

Evaluation of the safety of clinical practice in my workplace

Health care professionals are among those that are at high risk for hepatitis C. Treating and having to take care of people who are infected with the hepatitis C virus poses a great risk for health care professionals. Safety measures have therefore to be examined within health care institutions. So far, within my workplace, standard operating procedure regarding care of patients infected with HCV have been strictly followed, as well as the handling of specimen from HCV carriers. Personal hygiene can also help prevent the spread of hepatitis. Unnecessary transfusions should be also avoided in order to minimize incidence of hepatitis.

Preventing transmission from healthcare workers to patients has been controversial. Although transmission has been documented, it is rare and limited to case reports. Up to half of the reports were confounded by other factors like contamination of patients' narcotics used for healthcare workers' surreptitious habit of IV drug use. The calculated risk for HCV transmission from an RNA-positive surgeon to a patient during an invasive procedure is 0.00018%, which was roughly comparable to the chance of acquiring HCV by transfusion in the United States in the year 2000. It is recommended in some countries (Berklan, 2000) that no HCV-infected healthcare professional be restricted from his or her work. Despite this recommendation, some health departments have required HCV-infected physicians to obtain informed consent before performing surgery on their patients (Pearlman, 2004).

Healthcare organizations should treat hepatitis C in the same manner that they treat HIV or AIDS. Recommendations should include strict adherence to worldwide admitted precautions and education on hepatitis C for all healthcare workers. This education should include emphasizing the importance of reporting all percutaneous sticks. Presently, healthcare workers are screened only if there is a known exposure to hepatitis C (Dillman, 1999). Because hepatitis C is insidious in nature, testing should be done for both the source patient and the healthcare worker, regardless of known status. If a healthcare worker is identified as being positive, counseling and treatment for hepatitis C should be offered.

The value of prevention is skyrocketing. It should be noted that many individuals with the disease are unaware they are infected with HCV because symptoms often do not appear until serious liver damage has already occurred. Therefore, many individuals go through their lives not knowing they have the virus, such wasted time could have been used to start treating the individual infected. Also, given the fact that there is no vaccine yet against hepatitis C, an awareness campaign is indeed a necessity. The chances for individuals getting the infection are increased with the lack of a vaccine against the virus.

Hepatitis C awareness campaigns should be made not only for work environments but for the general public as well. Programs on awareness would put individuals at a concern over prevention of hepatitis C. An awareness campaign is needed which should be focused on raising hepatitis C awareness in the minds of the general public, elected officials, and policy-makers.

Elected officials and policy makers are specifically mentioned as target populations for hepatitis C awareness since they are the ones who are more in the position to create programs that will further strengthen the awareness campaign. They are in a very good position to implement measures that will help individuals lessen their chances of contacting the deadly virus.

The impact of hepatitis C on societies is staggering. Billions are estimated as being spent on the disease worldwide (Henkel, 1999). This includes billions spent on treatment which would have been preventable if only there was a vaccine or individuals are more aware of the infection. If such a trend would continue, allocations for other medical concerns would therefore lessen in favor of the infectious disease, which does not sound very good. Continued research and awareness campaigns therefore have to be done in order to lessen the staggering costs of the disease management and prevention. This of course is only secondary to the aim of helping millions of individuals that are infected with the disease.

In summary, with no vaccine and no effective post-exposure prophylaxis against the hepatitis C virus, best efforts at fighting the silent dragon should be directed toward counseling HCV-infected patients and those at risk of developing infection. Adequate sterilization of medical and surgical instruments and equipment, consistent use of personal protective equipment during patient care, and use of safety devices for venous access should be routine practice for all health care providers. In addition, promotion of community programs for safe injection practices and testing for people in high-risk categories could be a focus with measurable outcomes for all of society.

Conclusion

Hepatitis C is dangerous not only because of the damage it inflicts, but because people may be asymptomatic for years before they realize they are suffering from incurable liver disease. It almost exclusively is spread by dirty needles. Currently there is little hope for treatment of hepatitis C. A drug called Interferon Alpha-2B (inferferon is an immunity substance naturally present in small amounts in the body) has proven somewhat successful in combating the virus, but only in about 15 to 20 percent of the cases. While scientists are conducting research to find more-powerful antidotes, the best hope of curbing the spread of the virus continues to lie mainly in prevention. Health care institutions also have to be aware of the specific measures needed to be able to avoid and prevent infection with the hepatitis C virus. Further programs are needed for populations to educate them of the severity of the disease and its complications.

Hepatitis C infection is therefore a major public health problem throughout the world as can be seen by its effects on the body and the society in general. Yet for all its severity, it is largely preventable. Prevention can happen through awareness campaigns, rigorous efforts to protect blood supplies usually in health care environments, and major education and intervention programs for such at-risk populations as recreational intravenous drug users.

QUALITY ASSURANCE IN BRACHYTHERAPY FOR PROSTATE CANCER

The Prostate

The prostate is a fibromuscular glandular organ that surrounds the prostatic urethra. It is about 1 ¼ inches (3 cm) long and lies between the neck of the bladder above and the urogenital diaphragm below. It is surrounded by a fibrous capsule. Outside the capsule is a fibrous sheath, which is part of the visceral layer of pelvic fascia. The numerous glands of the prostate are embedded in a mixture of smooth muscle and connective tissue, and their ducts open into the prostatic urethra. The prostate is incompletely divided into five lobes (Snell, 2000).

The function of the prostate is the production of a thin, milky, fluid containing citric acid and acid phospatase. It is added to the seminal fluid at the time of ejaculation. The prostatic secretion is alkaline and helps neutralize the acidity in the vagina.

The prostate gland has a reputation as a health destroyer. Prostate cancer is the most common malignancy (Ward-Smith, 2003), and is the third most prevalent cancer in men (Marieb, 2004). Prostate cancer is a vexing disease because the cure - removal of the prostate - often causes impotence or incontinence. In the past, the main alternative was a combination of hormone therapy to shrink the tumor and radiation treatments to kill cancer cells, which was often less effective and still caused considerable discomfort (Koplowitz, 1999). As a rule, prostatic cancer is a slow-growing, hidden condition, but it can also be a swift and deadly killer. The treatment of localized prostate cancer is highly controversial, with many treatment options.

Treatment of prostate cancer can include surveillance, "watchful waiting," radical prostatectomy, androgen hormone ablation, internal or external radiation, surgery, chemotherapy, or a combination of any of these modalities (Gray, 2002; Scrofine, 2004). Treatment decisions should consider the patient's age, medical history, tumor stage, and contributing family medical history. The risk/benefit ratio of each treatment option should be considered and discussed thoroughly with the patient and his significant other. The use of radioactive seeds in brachytherapy to provide radiation therapy is one of the three recommended treatment options for localized carcinoma of the prostate (Davis, 1998). Brachytherapy, or the insertion of radioisotopes directly into the cancer-bearing organ, is gaining acceptance as a treatment, with survival outcomes similar to other treatments. This outpatient procedure has the advantage of patient convenience and cost effectiveness (Ward-Smith, 2003).

Overview of Radiation Therapy

Radiation therapy, or radio therapy, is a branch of radiology used to treat cancer. Radiation is the emission of electromagnetic waves or atomic particles that result from the disintegration of nuclei of unstable or radioactive elements. The treatment of malignant disease of radiation may be referred to as radiation therapy, brachytherapy, or radiotherapy. Ionizing radiation is used for this type of therapy, which involves the use of high-voltage radiation and other radioactive elements to injure or destroy cells. Like surgical resection and photodynamic therapy, radiation therapy is localized therapy that is applicable for a limited number of specific tumors (Phillips, 2004).

A patient is exposed to ionizing radiation in doses to kill a malignancy. Malignant tissues are more sensitive than normal tissues to radiation exposure and can be treated if they have not spread throughout the body and are not surrounded by normal tissue that is especially sensitive to radiation, such as the spinal cord. Sophisticated physical and biological techniques are used for radiation therapy, often accompanied by computer analyses. A radiation therapist develops a treatment plan that permits the absorption of a fatal amount of radiation by all tumor cells but causes relatively minor damage to normal tissue. The usual mode of therapy is an external high-energy beam directed at the tumor site for a few minutes a day for 2 to 6 weeks, depending on the type of malignancy. X-rays, gamma rays, and such isotopes as cobalt-60 and iodine-31 are often used.

To further understand why quality assurance in radiotherapy is vital and why it is important in treatment delivery, a discussion on the effects of radiation on cells will first be provided.

Effects of Radiation on Cells

Cancer cells multiply out of normal body control; they are in a state of active, uncontrolled mitosis (the nuclear division of the cytoplasm and nucleus). Radiation affects the metabolic activity of the cells. Cells in an active state of mitosis are most susceptible. Over time, gamma rays and x-rays cause a cessation of cell growth and a regression of the tumor mass. Cells die and are replaced by fibrous tissue (Phillips, 2004).

The sensitivity of a tumor to radiation varies. Some tumors can be destroyed by a small amount of radiation, whereas others require a large amount. The sensitivity of the tumor cells is determined by the sensitivity of the normal cells from which the tumor cells are derived.

The effects of radiation therapy also depend to a large extent on tissue oxygenation. As a tumor grows, the periphery is well oxygenated but the central portion becomes necrotic and poorly oxygenated. The number of cells killed by radiation therapy is directly related to the amount of tissue and oxygen within the tumor. Therefore the hypoxic effect is a factor in determining therapeutic dosage of radiation.

Radiation therefore cannot be limited solely to the area being treated. The danger of injuring normal surrounding tissue is a limiting factor in the dosage and selection of the most appropriate type of radiation therapy. A factor of dosage is the ratio of tumor tissue to the surrounding normal tissue. The penetration of radiation energy is calculated from the rate of decay or disintegration, known as half-life. Half-life is the time required for half of the radioactive material to disintegrate and to lose one half of its activity through decay.

Treatment Modality/Implantation of Radiation Source - Brachytherapy

All radiation sources for implantation are prepared in the desired therapeutic dosages by personnel in the nuclear medicine department. Many types of sources are used to deliver maximum radiation to the primary tumor. It is important to remember that no single type is ideal for every tumor or anatomic site.

Brachytherapy is on type of radiation therapy. The term brachytherapy comes from a Greek term meaning “short-range treatment.” Brachytherapy, or "seeding" the cancer directly with radioactive isotopes embedded in capsules the size of rice grains (Koplowitz, 1999). Tiny titanium cylinders that contain a radioactive isotope are implanted to deliver a dose of radiation from the inside out that kills cancer cells while sparing healthy tissue. Brachytherapy is performed fro many types of cancers including breast and prostate. It is useful for delivering higher cell-killing doses in shorter periods than conventional radiation treatments. The capsules are placed under ultrasound guidance (Phillips, 2004).

Brachytherapy requires the implantation of radioactive iodine-125 or palladium-103 seeds directly into the prostate. They emit highly localized radiation energy to kill localized cancer cells without excessive harm to nearby healthy cells. Proper placement of these seeds is critical, and a preprocedural map of the prostate gland, using ultrasound or CT, is obtained. A grid is then placed over the perineum and ultrasonic or CT imaging used to deliver seeds to the prostate alone. These seeds remain in the body, but their radioactivity declines over a period of months (Black & Hawks, 2004). It has only been over the past couple of years that seeding has become the treatment of choice for a growing number of doctors and their patients (Koplowitz, 1999).

Quality Assurance Systems in Place that Govern the Safe Delivery of Brachytherapy

Preparation for brachytherapy typically includes bowel cleansing and administration of prophylactic antibiotics. An oral bowel stimulant such as magnesium citrate may be combined with a cleansing enema to prepare the bowel. The patient should be advised to maintain a clear liquid diet 12 to 24 hours preceding the study as directed. The patient should also be instructed that the procedure is likely to produce rectal pressure or mild discomfort when the ultrasound probe is placed, but pain is not associated with implantation of radioactive seeds (Black & Hawks, 2004).

The patient should be educated and informed that the implantation will cause inflammation of the prostate that is likely to provoke bothersome LUTS, including daytime voiding frequency, an increase in nocturia, and difficulty initiating a urinary stream. These manifestations are typically transient and subside as prostatic inflammation diminishes (Black & Hawks, 2004).

In general, the patient and the caregiver should be taught the principles of radiation safety before, during and following brachytherapy. This should be in consultation with the radiation oncologist and based on institutional policies. The cardinal factors of protection from radiation sources, regardless of implantation sites, are distance, time, and shielding. For both personnel and patients, the following principles of radiation safety also apply to handling all types of radioactive materials:

* The intensity of radiation varies inversely with the square of the distance from it. Personnel should stay as far from the source as feasible.
* Radiation sources such as needles, seeds, capsules, and suspensions are prepared by the personnel in the nuclear medicine department. Personnel prepare these sources behind a lead screen, and their hands are protected by lead-lined gloves, if possible, or special forceps during handling.
* Radiation sources are transported in a long-handled lead carrier so they are as close to the floor as and as far away from the body of the transporter as possible. The lead carrier should be stored away from personnel and patient traffic areas while it is in the operating room suite.
* When radiation sources are delivered to the operating room, each needle, seed, or capsule as are the ones placed in the prostate, is counted by the surgeon with the radiation therapist. This number is recorded.
* Glutaraldehyde solution is poured into the lead carrier to completely submerge the radiation sources. When ready to use, the radiation source is transported in the lead carrier into the operating room. The needles, seeds, or capsules are removed from the lead container with sterile, long-handled instruments and are rinsed thoroughly with sterile water.
* All radiation sources are handled with special long, ring-handled forceps from behind a lead protection shield. Radiation sources should never be touched with bare hands or gloves. Radiation sources are never handled with a crushing forceps because the seal of hollow containers can be broken. A groove-tipped forceps that is designed for this purpose is used.
* Radiation sources are handled as quickly as possible to limit the time that personnel are exposed to radiation.
* All radiation sources are accounted for before and after use, and any loss is immediately reported. Nothing should be removed from the room. To locate a lost radiation source, a radiation therapist or nuclear medicine department technician is called to bring a Geiger counter. A Geiger counter has a radiation-sensitive gauge with an indicator that moves and a sound that increases when near radioactive substances.
* A radiation documentation sheet is completed and put in the patient’s chart. The surgeon fills in the amount and exact time of insertion and the time the source is to be removed. Each health care professional who cares for the patient on the unit signs this sheet just before going off duty, thereby passing responsibility for checking the patient and radiation source to the health care professional who relieves.
* The patient’s bed and door to the room are conspicuously labeled with a radiation-in-use card or symbol.
* The radiation source is removed by the surgeon at the exact time indicated so the patient will not be overexposed.
* Radiation is neither seen nor felt. Therefore the rules are carefully observed. Exposure is monitored and minimized.

Effects of Radiation Therapy on the Patient

The patient may be undergoing several treatment modalities and may experience the specific tissue and systemic effects of each. Health care professionals caring for the patient should understand how radiation affects the patient and how it affects the attainment of desired outcomes. The plan of care therefore should include consideration for the potential side effects of radiation therapy.

In one study, it was demonstrated that when brachytherapy is evaluated 6 months after treatment, bowel, bladder, and sexual functioning are affected. The impact of brachytherapy on quality of life of the patient appears to be tolerable. Although each of the participants in the study made several statements related to their post treatment physical functioning, the negative statements were qualified by minimizing the problem, or stating the possibility that other factors may be influencing the difficulty (Ward-Smith, 2003).

Acute urinary retention is also one of the most common complications following prostate brachytherapy, occurring in 1% to 22% of patients in various studies (Newman, 2003). However, one study also demonstrated that reducing urethral dosage in patients undergoing brachytherapy for localized prostate cancer decreases the rate of post-implant urinary retention (O’Malley, 2003)

Summary and Conclusion

The process of radiation therapy involves the use of rays that could be harmful to the body. Quality assurance is therefore vitally important in all aspects of radiation therapy to ensure that the treatments delivered are safe and effective. Brachytherapy for treatment of prostate cancer has been widely used and although found to have some side effects in the long run, are able to treat cancer patients well. Although some studies have shown negative effects as a result of brachytherapy, it is tolerable and is not without a remedy. A safe and effective brachytherapy could do wonders for the patient and its side effects are just minima compared to what harm could have been done if brachytherapy was not performed. The principles of radiation safety also apply to handling brachytherapy to ensure a safe and effective treatment.

QUALITY ASSURANCE IN BRACHYTHERAPY FOR PROSTATE CANCER

The Prostate

The prostate is a fibromuscular glandular organ that surrounds the prostatic urethra. It is about 1 ¼ inches (3 cm) long and lies between the neck of the bladder above and the urogenital diaphragm below. It is surrounded by a fibrous capsule. Outside the capsule is a fibrous sheath, which is part of the visceral layer of pelvic fascia. The numerous glands of the prostate are embedded in a mixture of smooth muscle and connective tissue, and their ducts open into the prostatic urethra. The prostate is incompletely divided into five lobes (Snell, 2000).

The function of the prostate is the production of a thin, milky, fluid containing citric acid and acid phospatase. It is added to the seminal fluid at the time of ejaculation. The prostatic secretion is alkaline and helps neutralize the acidity in the vagina.

The prostate gland has a reputation as a health destroyer. Prostate cancer is the most common malignancy (Ward-Smith, 2003), and is the third most prevalent cancer in men (Marieb, 2004). Prostate cancer is a vexing disease because the cure - removal of the prostate - often causes impotence or incontinence. In the past, the main alternative was a combination of hormone therapy to shrink the tumor and radiation treatments to kill cancer cells, which was often less effective and still caused considerable discomfort (Koplowitz, 1999). As a rule, prostatic cancer is a slow-growing, hidden condition, but it can also be a swift and deadly killer. The treatment of localized prostate cancer is highly controversial, with many treatment options.

Treatment of prostate cancer can include surveillance, "watchful waiting," radical prostatectomy, androgen hormone ablation, internal or external radiation, surgery, chemotherapy, or a combination of any of these modalities (Gray, 2002; Scrofine, 2004). Treatment decisions should consider the patient's age, medical history, tumor stage, and contributing family medical history. The risk/benefit ratio of each treatment option should be considered and discussed thoroughly with the patient and his significant other. The use of radioactive seeds in brachytherapy to provide radiation therapy is one of the three recommended treatment options for localized carcinoma of the prostate (Davis, 1998). Brachytherapy, or the insertion of radioisotopes directly into the cancer-bearing organ, is gaining acceptance as a treatment, with survival outcomes similar to other treatments. This outpatient procedure has the advantage of patient convenience and cost effectiveness (Ward-Smith, 2003).

Overview of Radiation Therapy

Radiation therapy, or radio therapy, is a branch of radiology used to treat cancer. Radiation is the emission of electromagnetic waves or atomic particles that result from the disintegration of nuclei of unstable or radioactive elements. The treatment of malignant disease of radiation may be referred to as radiation therapy, brachytherapy, or radiotherapy. Ionizing radiation is used for this type of therapy, which involves the use of high-voltage radiation and other radioactive elements to injure or destroy cells. Like surgical resection and photodynamic therapy, radiation therapy is localized therapy that is applicable for a limited number of specific tumors (Phillips, 2004).

A patient is exposed to ionizing radiation in doses to kill a malignancy. Malignant tissues are more sensitive than normal tissues to radiation exposure and can be treated if they have not spread throughout the body and are not surrounded by normal tissue that is especially sensitive to radiation, such as the spinal cord. Sophisticated physical and biological techniques are used for radiation therapy, often accompanied by computer analyses. A radiation therapist develops a treatment plan that permits the absorption of a fatal amount of radiation by all tumor cells but causes relatively minor damage to normal tissue. The usual mode of therapy is an external high-energy beam directed at the tumor site for a few minutes a day for 2 to 6 weeks, depending on the type of malignancy. X-rays, gamma rays, and such isotopes as cobalt-60 and iodine-31 are often used.

To further understand why quality assurance in radiotherapy is vital and why it is important in treatment delivery, a discussion on the effects of radiation on cells will first be provided.

Effects of Radiation on Cells

Cancer cells multiply out of normal body control; they are in a state of active, uncontrolled mitosis (the nuclear division of the cytoplasm and nucleus). Radiation affects the metabolic activity of the cells. Cells in an active state of mitosis are most susceptible. Over time, gamma rays and x-rays cause a cessation of cell growth and a regression of the tumor mass. Cells die and are replaced by fibrous tissue (Phillips, 2004).

The sensitivity of a tumor to radiation varies. Some tumors can be destroyed by a small amount of radiation, whereas others require a large amount. The sensitivity of the tumor cells is determined by the sensitivity of the normal cells from which the tumor cells are derived.

The effects of radiation therapy also depend to a large extent on tissue oxygenation. As a tumor grows, the periphery is well oxygenated but the central portion becomes necrotic and poorly oxygenated. The number of cells killed by radiation therapy is directly related to the amount of tissue and oxygen within the tumor. Therefore the hypoxic effect is a factor in determining therapeutic dosage of radiation.

Radiation therefore cannot be limited solely to the area being treated. The danger of injuring normal surrounding tissue is a limiting factor in the dosage and selection of the most appropriate type of radiation therapy. A factor of dosage is the ratio of tumor tissue to the surrounding normal tissue. The penetration of radiation energy is calculated from the rate of decay or disintegration, known as half-life. Half-life is the time required for half of the radioactive material to disintegrate and to lose one half of its activity through decay.

Treatment Modality/Implantation of Radiation Source - Brachytherapy

All radiation sources for implantation are prepared in the desired therapeutic dosages by personnel in the nuclear medicine department. Many types of sources are used to deliver maximum radiation to the primary tumor. It is important to remember that no single type is ideal for every tumor or anatomic site.

Brachytherapy is on type of radiation therapy. The term brachytherapy comes from a Greek term meaning “short-range treatment.” Brachytherapy, or "seeding" the cancer directly with radioactive isotopes embedded in capsules the size of rice grains (Koplowitz, 1999). Tiny titanium cylinders that contain a radioactive isotope are implanted to deliver a dose of radiation from the inside out that kills cancer cells while sparing healthy tissue. Brachytherapy is performed fro many types of cancers including breast and prostate. It is useful for delivering higher cell-killing doses in shorter periods than conventional radiation treatments. The capsules are placed under ultrasound guidance (Phillips, 2004).

Brachytherapy requires the implantation of radioactive iodine-125 or palladium-103 seeds directly into the prostate. They emit highly localized radiation energy to kill localized cancer cells without excessive harm to nearby healthy cells. Proper placement of these seeds is critical, and a preprocedural map of the prostate gland, using ultrasound or CT, is obtained. A grid is then placed over the perineum and ultrasonic or CT imaging used to deliver seeds to the prostate alone. These seeds remain in the body, but their radioactivity declines over a period of months (Black & Hawks, 2004). It has only been over the past couple of years that seeding has become the treatment of choice for a growing number of doctors and their patients (Koplowitz, 1999).

Quality Assurance Systems in Place that Govern the Safe Delivery of Brachytherapy

Preparation for brachytherapy typically includes bowel cleansing and administration of prophylactic antibiotics. An oral bowel stimulant such as magnesium citrate may be combined with a cleansing enema to prepare the bowel. The patient should be advised to maintain a clear liquid diet 12 to 24 hours preceding the study as directed. The patient should also be instructed that the procedure is likely to produce rectal pressure or mild discomfort when the ultrasound probe is placed, but pain is not associated with implantation of radioactive seeds (Black & Hawks, 2004).

The patient should be educated and informed that the implantation will cause inflammation of the prostate that is likely to provoke bothersome LUTS, including daytime voiding frequency, an increase in nocturia, and difficulty initiating a urinary stream. These manifestations are typically transient and subside as prostatic inflammation diminishes (Black & Hawks, 2004).

In general, the patient and the caregiver should be taught the principles of radiation safety before, during and following brachytherapy. This should be in consultation with the radiation oncologist and based on institutional policies. The cardinal factors of protection from radiation sources, regardless of implantation sites, are distance, time, and shielding. For both personnel and patients, the following principles of radiation safety also apply to handling all types of radioactive materials:

* The intensity of radiation varies inversely with the square of the distance from it. Personnel should stay as far from the source as feasible.
* Radiation sources such as needles, seeds, capsules, and suspensions are prepared by the personnel in the nuclear medicine department. Personnel prepare these sources behind a lead screen, and their hands are protected by lead-lined gloves, if possible, or special forceps during handling.
* Radiation sources are transported in a long-handled lead carrier so they are as close to the floor as and as far away from the body of the transporter as possible. The lead carrier should be stored away from personnel and patient traffic areas while it is in the operating room suite.
* When radiation sources are delivered to the operating room, each needle, seed, or capsule as are the ones placed in the prostate, is counted by the surgeon with the radiation therapist. This number is recorded.
* Glutaraldehyde solution is poured into the lead carrier to completely submerge the radiation sources. When ready to use, the radiation source is transported in the lead carrier into the operating room. The needles, seeds, or capsules are removed from the lead container with sterile, long-handled instruments and are rinsed thoroughly with sterile water.
* All radiation sources are handled with special long, ring-handled forceps from behind a lead protection shield. Radiation sources should never be touched with bare hands or gloves. Radiation sources are never handled with a crushing forceps because the seal of hollow containers can be broken. A groove-tipped forceps that is designed for this purpose is used.
* Radiation sources are handled as quickly as possible to limit the time that personnel are exposed to radiation.
* All radiation sources are accounted for before and after use, and any loss is immediately reported. Nothing should be removed from the room. To locate a lost radiation source, a radiation therapist or nuclear medicine department technician is called to bring a Geiger counter. A Geiger counter has a radiation-sensitive gauge with an indicator that moves and a sound that increases when near radioactive substances.
* A radiation documentation sheet is completed and put in the patient’s chart. The surgeon fills in the amount and exact time of insertion and the time the source is to be removed. Each health care professional who cares for the patient on the unit signs this sheet just before going off duty, thereby passing responsibility for checking the patient and radiation source to the health care professional who relieves.
* The patient’s bed and door to the room are conspicuously labeled with a radiation-in-use card or symbol.
* The radiation source is removed by the surgeon at the exact time indicated so the patient will not be overexposed.
* Radiation is neither seen nor felt. Therefore the rules are carefully observed. Exposure is monitored and minimized.

Effects of Radiation Therapy on the Patient

The patient may be undergoing several treatment modalities and may experience the specific tissue and systemic effects of each. Health care professionals caring for the patient should understand how radiation affects the patient and how it affects the attainment of desired outcomes. The plan of care therefore should include consideration for the potential side effects of radiation therapy.

In one study, it was demonstrated that when brachytherapy is evaluated 6 months after treatment, bowel, bladder, and sexual functioning are affected. The impact of brachytherapy on quality of life of the patient appears to be tolerable. Although each of the participants in the study made several statements related to their post treatment physical functioning, the negative statements were qualified by minimizing the problem, or stating the possibility that other factors may be influencing the difficulty (Ward-Smith, 2003).

Acute urinary retention is also one of the most common complications following prostate brachytherapy, occurring in 1% to 22% of patients in various studies (Newman, 2003). However, one study also demonstrated that reducing urethral dosage in patients undergoing brachytherapy for localized prostate cancer decreases the rate of post-implant urinary retention (O’Malley, 2003)

Summary and Conclusion

The process of radiation therapy involves the use of rays that could be harmful to the body. Quality assurance is therefore vitally important in all aspects of radiation therapy to ensure that the treatments delivered are safe and effective. Brachytherapy for treatment of prostate cancer has been widely used and although found to have some side effects in the long run, are able to treat cancer patients well. Although some studies have shown negative effects as a result of brachytherapy, it is tolerable and is not without a remedy. A safe and effective brachytherapy could do wonders for the patient and its side effects are just minima compared to what harm could have been done if brachytherapy was not performed. The principles of radiation safety also apply to handling brachytherapy to ensure a safe and effective treatment.

Types of medication - Medications for different conditions and body systems - Generic vs. Brand Name

A medication may have as many as three different names (Potter & Perry, 2004). A medication’s chemical name provides an exact description of the medication’s composition and molecular structure. Chemical names are rarely used in clinical practice.



The manufacturer who first develops the medication gives the generic or nonproprietary name, with an approval from a high naming council. The generic name becomes the official name that is listed in official publications. The trade name, brand name, or proprietary name is the name under which a manufacturer markets a medication. The trade name has a symbol TM on the upper right of the name, indicating that the manufacturer has trademarked the medication’s name.



Manufacturers have chosen names that are easy to pronounce, spell, and remember so that laypersons will recognize their trade names. Many companies may produce the same medication, so similarities in trade names can be confusing, especially for the older adults. In fact, similarities in trade names are a common cause of medical errors. Hospitals and clinics pharmacies attempt to consistently dispense medications with the same trade names so that health care professionals can become familiar with them.



Although it is not necessary for the patients to categorize medications, they might still be given a background about this. Health care professionals learn to categorize medications with similar characteristics by their class. Medication classification indicates the effect of the medication on a body system, the symptoms the medication relieves, or the medication’s desired effects. One medication may also be part of more than one class (Potter & Perry, 2004).



Legal Considerations - over the counter and prescription use in the elderly



There has been past interest in the value of written materials, especially package inserts, in communicating with older patients. The items asking about written materials in the prescription or Rx drug survey found that patients reported receiving them often, reading them, and finding them useful. They did not believe, however, that most people read the instructions supplied with over-the-counter medicines. Given the strong preference for doctor communication throughout, one would expect written materials to be most effective when presented by physicians (Cunningham, et al, 1994).



On the whole, communication about Rx medicines appears better than for over-the-counter medicines. The burden of communicating about over-the-counter medicines falls squarely on the patients in these studies, although they see the pharmacist as playing a stronger role in communicating about Rx medicines. Still, if patients do not introduce the topic it is unlikely to be discussed. Given the potential of over-the-counter drugs to interact with Rx drugs, more attention to the topic of over-the-counter drugs seems warranted. Patients reported that their doctors did not talk to them enough about over-the-counter drugs, although patients did agree that most doctors mentioned over-the-counter drugs when prescribing Rx drugs (Cunningham, et al, 1994).



Use of OTC medications is widespread among the general population. According to a recent survey, a large percentage of adults ages 18 and older have used over the counter pain relievers at least once, often without consulting a pharmacist. Furthermore, that although adults frequently use over the counter medications, many consumers fail to read the product warning labels. Finally, consumers frequently are unaware of the type of medication they take (e.g., NSAID or analgesic). For example, only one in three adults are familiar with the product names acetaminophen, aspirin, or ibuprofen and are able to link these product names to specific brand names. As a result, many consumers are not fully aware of the potential risks of taking these products, particularly in combination with other prescription medications or alcohol (Crabb & Weathermon, 1999).



Another factor contributing to an increasing risk of medication-medication interactions is that many medications that previously were available only by prescription are gaining over the counter status. Over the counter marketing strategies, however, often lead the consumer to think that these medications are safe to use on an "as-needed" basis, even though they can be potentially dangerous when used with alcohol. For example, the message that "acid blocker" medications can be used before or during a spicy meal to prevent heartburn symptoms may lead consumers to believe that this practice is also acceptable when they drink alcohol with their meal (Crabb & Weathermon, 1999).



Because of the potential risks related to medication administration, the patient is also given rights. It is the patient’s right to be informed of the medication’s name, purpose, action, and potential undesired effects. The patient, even if it is an elderly patient and his or her health depends largely on the medication, can still also refuse medication regardless of consequences. The patient also has the right to be properly advised of the experimental nature of medication therapy and to give written consent for its use. The patient has the right to receive appropriate supportive therapy in relation to medication therapy. However, in the case of the mental health patient or an elderly patient who may have impaired reasoning due to degeneration, the family of the patient can decide instead and take over the right of the patient.



Medication usage - - side of effects of medication - storage of medication - frequency of medication usage in the elderly



Approximately two thirds of older adults use prescription and non prescription drugs with one third of all prescriptions being written for older adults (Beers & Berkow, 2000). Most older adults use at least one drug daily; many use several drugs daily. The most commonly used medications are cardiovascular drugs, antihypertensives, analgesics, antiarthritic agents, sedatives, tranquilizers, laxatives, and antacids (Eliopoulos, 1999).



Older adults are at risk for adverse reactions with the medicines that they are taking. These side effects of mediation could be largely attributed to the fact that the elderly have age-related changes in the absorption, distribution, metabolism, and excretion of drugs. As one is probably aware, most of the elderly usually take a lot of medications. Medications may interact with one another, adding or negating the effect of another drug. Medications of the elderly may also cause confusion; affect balance and mobility; cause dizziness, nausea, and vomiting; or lead to constipation, urinary frequency, or incontinence. Because of these side effects, there are some elderly patients who are not willing to take medications.



Self-management of prescriptive medications requires diverse knowledge, behaviors, judgments, and decisions ranging from those associated with obtaining medications to monitoring for medication side effects. Although most research on prescription medication use by older adults has focused on adherence, some findings indicate prescriptive medication use is often the result of deliberate decision making rather than automatically following the directives of health-care providers (Conn & Taylor, 1992).



Polypharmacy, or the concurrent use of many medications, increases the risk for adverse reactions. The use of several prescribing physicians or several pharmacies, and inadequate communication among the physicians and pharmacies is often implicated as the principal cause of inappropriate polypharmacy. Strategies for preventing the problem focus on improving-communication between physicians and patients with regard to the exact number and type of medications used, the use of a single pharmacy or pharmacy network and regular, comprehensive medication reviews (Sadovsky, 1998).



Complicating the assessment of medication affects and side effects, some of the elderly, perhaps as many as 50%, take their medications incorrectly because they do not understand the instructions about their medications (Hayes, 1998).



Older adults consuming prescriptive medications are a group at risk for negative health outcomes. Demographic trends of increasing numbers of older adults, increasing health-care costs for older adults, and fragmentation of care for older adults are factors stimulating efforts to identify effective alternative care systems. Although only one in five older adults will be admitted to a hospital during a given year, those who have been hospitalized are at increased risk for rehospitalization. Recently hospitalized older adults are especially vulnerable to problems with medications because they are likely to be on more prescriptive medications and are in poorer health than the general population (Conn & Taylor, 1992).



General advice regarding the elderly taking medications - take medications as prescribed by the doctor. - set up systems, such as a weekly pillbox, to remember medications - keep up to date record on all medications and dosages. - throw away discontinued out dated medications



Standards are those actions that ensure safe nursing practice. Registered mental health nurses should be aware of nursing standards called the six rights of medication administration in order to ensure safe medication administration to the elderly patients (Potter & Perry, 2004). All medication administration errors can be linked in some way to any inconsistency in adhering strictly to the six rights of medication administration. These six rights are as follows:

* The right medication
* The right dose
* The right patient
* The right route
* The right time
* The right documentation



The dramatic increase in the number of new medications, including biotechnology products, makes it difficult to keep current on their proper use, and can overwhelm the best intentions of all health care practitioners, including doctors and nurses. Administration of the wrong drug is the most common error that occurs. Factors that contribute to wrong drug error include similar labeling and packaging of products, medications with very similar names and storage of these similar products together. In addition, poor communication is a common cause of administering the wrong drug.



The management of medications in the elderly is a very important component of maintaining and promoting good health in old age. For some older adults on large numbers of medications, safely managing medications can be a complex activity that can easily become overwhelming.



The health care professional must work collaboratively with the older adult to ensure safe and appropriate use of all medications that the elderly needs. This includes both prescribed and over-the-counter medications. The older adult should be taught the names of all drugs being taken, when and how to take them, and the desirable and undesirable effects of the drugs. If for some reason the elderly cannot understand, then it is better that another family member or a caregiver must be taught. The health care professional must also teach the elderly patient how to avoid adverse effects or interactions of drugs and how to establish and follow an appropriate self-administration pattern.



Strategies for reducing the risk for an adverse medication reaction in the older adult include reviewing the medications with the older adult at each visit, examining for potential interactions with food or other drugs, simplifying and individualizing the drug regimen, taking every opportunity to inform the older adult and family about all aspects of medication use, and encouraging the older adult to question the physician, nurse, and/or pharmacist about all prescribed drugs and all over-the-counter drugs.

Types of medication - Medications for different conditions and body systems - Generic vs. Brand Name

A medication may have as many as three different names (Potter & Perry, 2004). A medication’s chemical name provides an exact description of the medication’s composition and molecular structure. Chemical names are rarely used in clinical practice.



The manufacturer who first develops the medication gives the generic or nonproprietary name, with an approval from a high naming council. The generic name becomes the official name that is listed in official publications. The trade name, brand name, or proprietary name is the name under which a manufacturer markets a medication. The trade name has a symbol TM on the upper right of the name, indicating that the manufacturer has trademarked the medication’s name.



Manufacturers have chosen names that are easy to pronounce, spell, and remember so that laypersons will recognize their trade names. Many companies may produce the same medication, so similarities in trade names can be confusing, especially for the older adults. In fact, similarities in trade names are a common cause of medical errors. Hospitals and clinics pharmacies attempt to consistently dispense medications with the same trade names so that health care professionals can become familiar with them.



Although it is not necessary for the patients to categorize medications, they might still be given a background about this. Health care professionals learn to categorize medications with similar characteristics by their class. Medication classification indicates the effect of the medication on a body system, the symptoms the medication relieves, or the medication’s desired effects. One medication may also be part of more than one class (Potter & Perry, 2004).



Legal Considerations - over the counter and prescription use in the elderly



There has been past interest in the value of written materials, especially package inserts, in communicating with older patients. The items asking about written materials in the prescription or Rx drug survey found that patients reported receiving them often, reading them, and finding them useful. They did not believe, however, that most people read the instructions supplied with over-the-counter medicines. Given the strong preference for doctor communication throughout, one would expect written materials to be most effective when presented by physicians (Cunningham, et al, 1994).



On the whole, communication about Rx medicines appears better than for over-the-counter medicines. The burden of communicating about over-the-counter medicines falls squarely on the patients in these studies, although they see the pharmacist as playing a stronger role in communicating about Rx medicines. Still, if patients do not introduce the topic it is unlikely to be discussed. Given the potential of over-the-counter drugs to interact with Rx drugs, more attention to the topic of over-the-counter drugs seems warranted. Patients reported that their doctors did not talk to them enough about over-the-counter drugs, although patients did agree that most doctors mentioned over-the-counter drugs when prescribing Rx drugs (Cunningham, et al, 1994).



Use of OTC medications is widespread among the general population. According to a recent survey, a large percentage of adults ages 18 and older have used over the counter pain relievers at least once, often without consulting a pharmacist. Furthermore, that although adults frequently use over the counter medications, many consumers fail to read the product warning labels. Finally, consumers frequently are unaware of the type of medication they take (e.g., NSAID or analgesic). For example, only one in three adults are familiar with the product names acetaminophen, aspirin, or ibuprofen and are able to link these product names to specific brand names. As a result, many consumers are not fully aware of the potential risks of taking these products, particularly in combination with other prescription medications or alcohol (Crabb & Weathermon, 1999).



Another factor contributing to an increasing risk of medication-medication interactions is that many medications that previously were available only by prescription are gaining over the counter status. Over the counter marketing strategies, however, often lead the consumer to think that these medications are safe to use on an "as-needed" basis, even though they can be potentially dangerous when used with alcohol. For example, the message that "acid blocker" medications can be used before or during a spicy meal to prevent heartburn symptoms may lead consumers to believe that this practice is also acceptable when they drink alcohol with their meal (Crabb & Weathermon, 1999).



Because of the potential risks related to medication administration, the patient is also given rights. It is the patient’s right to be informed of the medication’s name, purpose, action, and potential undesired effects. The patient, even if it is an elderly patient and his or her health depends largely on the medication, can still also refuse medication regardless of consequences. The patient also has the right to be properly advised of the experimental nature of medication therapy and to give written consent for its use. The patient has the right to receive appropriate supportive therapy in relation to medication therapy. However, in the case of the mental health patient or an elderly patient who may have impaired reasoning due to degeneration, the family of the patient can decide instead and take over the right of the patient.



Medication usage - - side of effects of medication - storage of medication - frequency of medication usage in the elderly



Approximately two thirds of older adults use prescription and non prescription drugs with one third of all prescriptions being written for older adults (Beers & Berkow, 2000). Most older adults use at least one drug daily; many use several drugs daily. The most commonly used medications are cardiovascular drugs, antihypertensives, analgesics, antiarthritic agents, sedatives, tranquilizers, laxatives, and antacids (Eliopoulos, 1999).



Older adults are at risk for adverse reactions with the medicines that they are taking. These side effects of mediation could be largely attributed to the fact that the elderly have age-related changes in the absorption, distribution, metabolism, and excretion of drugs. As one is probably aware, most of the elderly usually take a lot of medications. Medications may interact with one another, adding or negating the effect of another drug. Medications of the elderly may also cause confusion; affect balance and mobility; cause dizziness, nausea, and vomiting; or lead to constipation, urinary frequency, or incontinence. Because of these side effects, there are some elderly patients who are not willing to take medications.



Self-management of prescriptive medications requires diverse knowledge, behaviors, judgments, and decisions ranging from those associated with obtaining medications to monitoring for medication side effects. Although most research on prescription medication use by older adults has focused on adherence, some findings indicate prescriptive medication use is often the result of deliberate decision making rather than automatically following the directives of health-care providers (Conn & Taylor, 1992).



Polypharmacy, or the concurrent use of many medications, increases the risk for adverse reactions. The use of several prescribing physicians or several pharmacies, and inadequate communication among the physicians and pharmacies is often implicated as the principal cause of inappropriate polypharmacy. Strategies for preventing the problem focus on improving-communication between physicians and patients with regard to the exact number and type of medications used, the use of a single pharmacy or pharmacy network and regular, comprehensive medication reviews (Sadovsky, 1998).



Complicating the assessment of medication affects and side effects, some of the elderly, perhaps as many as 50%, take their medications incorrectly because they do not understand the instructions about their medications (Hayes, 1998).



Older adults consuming prescriptive medications are a group at risk for negative health outcomes. Demographic trends of increasing numbers of older adults, increasing health-care costs for older adults, and fragmentation of care for older adults are factors stimulating efforts to identify effective alternative care systems. Although only one in five older adults will be admitted to a hospital during a given year, those who have been hospitalized are at increased risk for rehospitalization. Recently hospitalized older adults are especially vulnerable to problems with medications because they are likely to be on more prescriptive medications and are in poorer health than the general population (Conn & Taylor, 1992).



General advice regarding the elderly taking medications - take medications as prescribed by the doctor. - set up systems, such as a weekly pillbox, to remember medications - keep up to date record on all medications and dosages. - throw away discontinued out dated medications



Standards are those actions that ensure safe nursing practice. Registered mental health nurses should be aware of nursing standards called the six rights of medication administration in order to ensure safe medication administration to the elderly patients (Potter & Perry, 2004). All medication administration errors can be linked in some way to any inconsistency in adhering strictly to the six rights of medication administration. These six rights are as follows:

* The right medication
* The right dose
* The right patient
* The right route
* The right time
* The right documentation



The dramatic increase in the number of new medications, including biotechnology products, makes it difficult to keep current on their proper use, and can overwhelm the best intentions of all health care practitioners, including doctors and nurses. Administration of the wrong drug is the most common error that occurs. Factors that contribute to wrong drug error include similar labeling and packaging of products, medications with very similar names and storage of these similar products together. In addition, poor communication is a common cause of administering the wrong drug.



The management of medications in the elderly is a very important component of maintaining and promoting good health in old age. For some older adults on large numbers of medications, safely managing medications can be a complex activity that can easily become overwhelming.



The health care professional must work collaboratively with the older adult to ensure safe and appropriate use of all medications that the elderly needs. This includes both prescribed and over-the-counter medications. The older adult should be taught the names of all drugs being taken, when and how to take them, and the desirable and undesirable effects of the drugs. If for some reason the elderly cannot understand, then it is better that another family member or a caregiver must be taught. The health care professional must also teach the elderly patient how to avoid adverse effects or interactions of drugs and how to establish and follow an appropriate self-administration pattern.



Strategies for reducing the risk for an adverse medication reaction in the older adult include reviewing the medications with the older adult at each visit, examining for potential interactions with food or other drugs, simplifying and individualizing the drug regimen, taking every opportunity to inform the older adult and family about all aspects of medication use, and encouraging the older adult to question the physician, nurse, and/or pharmacist about all prescribed drugs and all over-the-counter drugs.

Jill lives in Sydney. She decides to spend to spend three months of her holidays working in the Andes in Bolivia. What kind of respiratory and other

Mountain climbers have found that when they climb up a mountain slowly over a period of days, rather than a period of hours, they can withstand far lower atmospheric oxygen concentrations than when they ascend rapidly.

The event just described is acclimatization to the low oxygen. Jill's body would have to acclimatize to living in high altitude. The reason for this effect is that within 2 to 3 days the respiratory center in the brain stem loses about four fifths of its sensitivity to changes in arterial PCO2 (partial pressure of carbon dioxide) and hydrogen ions (Guyton & Hall, 2000).

The following sentences describe the events that would go through Jill's body as she adjusts to the height changes. The higher the altitude, the lower the oxygen in the air. Therefore, the excess ventilatory blow-off of carbon dioxide that would normally inhibit an increase in respiration now fails to do so, and the low oxygen can drive the respiratory system to a much higher level of alveolar ventilation than under short-term low-oxygen conditions (Ganong, 2001).

Instead of a 70% increase in ventilation that might occur on acute exposure to low oxygen, the alveolar ventilation often increases 400 to 500 % after two to three days of low oxygen (Guyton & Hall, 2000). This helps immensely in supplying additional oxygen to Jill.

Jill lives in Sydney. She decides to spend to spend three months of her holidays working in the Andes in Bolivia. What kind of respiratory and other

Mountain climbers have found that when they climb up a mountain slowly over a period of days, rather than a period of hours, they can withstand far lower atmospheric oxygen concentrations than when they ascend rapidly.

The event just described is acclimatization to the low oxygen. Jill's body would have to acclimatize to living in high altitude. The reason for this effect is that within 2 to 3 days the respiratory center in the brain stem loses about four fifths of its sensitivity to changes in arterial PCO2 (partial pressure of carbon dioxide) and hydrogen ions (Guyton & Hall, 2000).

The following sentences describe the events that would go through Jill's body as she adjusts to the height changes. The higher the altitude, the lower the oxygen in the air. Therefore, the excess ventilatory blow-off of carbon dioxide that would normally inhibit an increase in respiration now fails to do so, and the low oxygen can drive the respiratory system to a much higher level of alveolar ventilation than under short-term low-oxygen conditions (Ganong, 2001).

Instead of a 70% increase in ventilation that might occur on acute exposure to low oxygen, the alveolar ventilation often increases 400 to 500 % after two to three days of low oxygen (Guyton & Hall, 2000). This helps immensely in supplying additional oxygen to Jill.

PNEUMONIA

Introduction

Pneumonia is an acute infection of the alveolar spaces of the lungs. The term includes any inflammatory condition of the lung in which some or all of the alveoli are filled with fluid and blood cells.

The patient experienced bacterial pneumonia. This is a common type of pneumonia, caused most frequently by pneumococci. This disease begins with infection in the alveoli; the pulmonary membrane becomes inflamed and highly porous so that fluid and even red and white blood cells leak out of the blood into the alveoli. Thus, the infected alveoli become progressively filled with fluid and cells, and the infection spreads by extension of bacteria from alveolus to alveolus. Eventually, large areas of the lungs, sometimes whole lobes or even a whole lung, become "consolidated," which means that they are filled with fluid and cellular debris (Guyton & Hall, 2000).

The patient had a history of acute febrile illness associated with chill, chest pain and cough, especially with expectoration of viscid, rusty sputum which is practically diagnostic of pneumonia itself. The diagnosis is confirmed after physical examination of the patient discloses tachycardia, tachypnea, cyanosis, and signs of consolidation.


Cellular Pathophysiology

Pneumococci reach the lungs via the respiratory passages. They lodge in the alveoli, proliferate, and initiate an inflammatory process that begins with an outpouring of protein-rich fluid into the alveolar spaces. This fluid acts as a culture medium for the pneumococci and as a vehicle for their spread to other alveoli, segments (lobules), and lobes (Robbins, 1998).

Pathologically, the early stage of pneumonia (the first 12 to 48 hours) is called red hepatization because of the liver-like, reddish appearance of the consolidated lung that results from the characteristic widespread dilation of pulmonary blood vessels and the extravasation of erythrocytes into the alveoli (Robbins, 1998).

A few hours after the pulmonary capillaries dilate and the edema fluid pours into the alveoli, polymorphonuclear leukocytes enter the alveolar spaces, rapidly fill the alveoli, and consolidate the lung (grey hepatization). Surface phagocytosis occurs, without antibodies, by leukocytic trapping of the bacteria against an alveolar wall or another leukocyte; the process is more active when large numbers of leukocytes are present (Robbins, 1998). Tissue sections show few pneumococi in the consolidated lung, but many in the advancing margin of the lesion where edema fluid is abundant and leukocytes are sparse (Bloom & Fawcett, 1994).

The macrophage reaction occurs next, as large mononuclear cells enter the alveoli, engulf any remaining pneumococci, and phagocytized the cellular debris of the exudate. This process continues until resolution is complete, which is indicated by physical examination and x-ray evidence that the lungs are clear (Bloom & Fawcett, 1994).

The pathogenesis of other bacterial pneumonias resembles that of pneumococcal infections, but abscess formation may occur when infection is caused by organisms that destroy pulmonary tissue.



Systemic Pathophysiology

The patient who has pneumonia would experience a sudden, with a shaking chill, sharp pain in the involved hemothorax on the onset. Along with this are the appearance of cough with early sputum production, fever, and headache. All these symptoms are usually present as an effect of the cellular events that took place: red hepatization, grey hepatization, surface phagocytosis, and macrophage reaction.

All these cellular events lead to changes in the gas exchange functions of the lungs. In pneumonia, the gas exchange functions of the lungs change in different stages of the disease. In the early stages, the pneumonia process might well be localized to only one lung, with alveolar ventilation reduced while blood flow through the lung continues normally (Ganong, 2001). This results in two major pulmonary abnormalities: (1) reduction in the total available surface area of the respiratory membrane and (2) decreased ventilation-perfusion ratio. Both these effects cause hypoxemia (low blood oxygen) and hypercapnia (high blood carbon dioxide).



Human Pathophysiology

The effect of the resulting decreased ventilation-perfusion ratio in the patient with pneumonia is that the blood passing through the aerated lung becomes 97 per cent saturated with oxygen, whereas that passing through the unaerated lung is about 60 per cent saturated, causing the mean saturation of the blood in the left heart and in the aorta to be about 78 per cent, which is far below normal (Guyton & Hall, 2000).

Oxygen is one of the most necessary nutrients in the body. Whenever the availability of oxygen to the tissues decreases, such as in pneumonia, the blood flow through the tissues increases markedly.

Pneumococcal pneumonia is the most common bacterial pneumonia; many of its features are similar to those of pneumonia caused by other organisms. The disease is generally sporadic. Healthy carriers are usually responsible for the infection of others, but there is no practical way to identify carriers and eliminate the organisms (Robbins, 1998).