Curative drug monitoring refers to the individualisation of dose by keeping plasma or blood drug concentrations within a mark scope ( curative scope, curative window ) . There are two major beginnings of variableness between single patients in drug response.

dosage and plasma concentration ( pharmacokinetic variableness )

drug concentration at the receptor and the response ( pharmacodynamic variableness )

By seting doses to keep plasma drug concentrations within a mark scope, variableness in the pharmacokinetic stage of drug action is greatly reduced.Therapeutic Dose Monitoring Of Sodium Health Essay Paper

The major beginnings of pharmacokinetic variableness are:


Age – newborns, kids, elderly

Physiology – gender, gestation

Disease – liverwort, nephritic, cardiovascular, respiratory

Drug interactions

Environmental influences on drug metamorphosis

Familial polymorphisms of drug metamorphosisThe features of drugs which make them suited for, or do them necessitate, curative drug monitoring are:

marked pharmacokinetic variableness

concentration related curative and inauspicious effects

narrow curative index

defined curative ( mark ) concentration scope

desired curative consequence hard to supervise

One such drug which needs to be monitored is PHENYTOIN SODIUM.


Phenytoin Na is an antiepileptic drug which can be used in the intervention of epilepsy. The primary site of action appears to be the motor cerebral mantle where spread of ictus activity is inhibited. Possibly by advancing Na outflow from nerve cells, phenytoin tends to stabilise the threshold against hyperexcitability caused by inordinate stimulation or environmental alterations capable of cut downing membrane Na gradient. This includes the decrease of posttetanic potentiation at synapses. Loss of posttetanic potentiation prevents cortical ictus focal point from exploding next cortical countries. Phenytoin reduces the maximum activity of encephalon root centres responsible for the tonic stage of tonicclonic ( expansive mal ) seizures.Therapeutic Dose Monitoring Of Sodium Health Essay Paper


When ciphering a diphenylhydantoin dosage for a patient, three chief factors must be considered:

serum albumen position

nephritic map

non-linear metamorphosis of diphenylhydantoin.

Serum albumen position: Phenytoin is normally extremely bound to serum albumen. Hypoalbuminemia ( low serum albumen ) increases the proportion of unbound ( ‘free ‘ ) diphenylhydantoin that is able to exercise a pharmacological consequence. There is a expression which can be applied to cipher the adjusted diphenylhydantoin concentration that would be observed if the patient had a normal serum albumen concentration, utilizing the patient ‘s ascertained diphenylhydantoin degree, the unnatural serum albumen concentration and the normal albumin concentration ( 40g/L ) .

Nephritic map: Patients with nephritic failure have an increased proportion of unbound

diphenylhydantoin. This is partially attributable to the lessening in serum albumen associated with advanced nephritic failure and the alteration in adhering affinity of diphenylhydantoin to serum albumen.

Phenytoin metamorphosis: For most drugs, the rate of metamorphosis is relative to the plasma concentration. This follows the rules of first-order dynamicss ( i.e. duplicating the dosage of the drug consequences in an approximative doubling of the plasma concentration ) . However, the rate of diphenylhydantoin metamorphosis approaches its upper limit at curative concentrations. This is described as capacity-limited metamorphosis, follows the rules of zero-order dynamicss. Increasing the care dosage of

diphenylhydantoin consequences in disproportional rises in plasma concentration, which can do dose accommodation hard.

As a general regulation, when steady-state diphenylhydantoin concentrations exceed 12mg/L, a day-to-day dose addition should non transcend 25mg, but any addition should be tailored to the single patient ‘s parametric quantities and possible alterations in binding.

The half life of diphenylhydantoin is sometimes reported as 22 hours but, since it increases as the plasma concentration additions, it may be between seven and 42 hours. Many other drugs reach steady province concentrations in four to five half-lives, but with diphenylhydantoin this can take much longer, so the clip at which a diphenylhydantoin degree is taken is non important. In clinical pattern, a trough degree ( pre-dose ) is normally considered acceptable for everyday monitoring.Therapeutic Dose Monitoring Of Sodium Health Essay Paper




Bioavailability ( F ) :

0.90 – 1.0

Salt Factor ( S ) :

0.92 – Diphenylhydantoin Na+A ( caps, IV )

1.0 – Diphenylhydantoin Acid ( check, susp )

Protein Binding:

90 % ( 87-93 )

Volume of Distribution ( Vd ) :

0.7L/Kg – Adults

1.0L/Kg – Child

Half-Life ( tA? ) :

a map of plasma concentration

mean – 22 hours ( run 8 – 60 hours )


capacity limited metamorphosis ( Zero order )

1-5 % recovered unchanged in the piss

Cpss ( SI ) :

40-80 umol/L ( & gt ; 20umol/L )

Time to Steady State:

2-4 hebdomads ( longer with higher doses )

Conversion factor to metric:

Divide by 4 to change over from umol/L to mg/L

B. DOSINGA A Empiric dosing guidelines ( utilize TBW )


Load DOSE*



15-18 mg/kg – entire dose direct at maximal rate of 50 mg/minA


Dilute to 5-20 mg/mL with NS & A ; give over 15-30 proceedingss

5-7 mg/kg/day – in 2 to 3 divided doses


5-7 mg/kg/day in 2 to 3 doses

may necessitate 2-4 times IV/PO dosage

keep provenders 2 hour before and after a individual day-to-day dosage

Flush tubing good with 50mL unfertile H2O

* If Phenytoin degree available prior to lading dosage, use Equation 1: Therapeutic Dose Monitoring Of Sodium Health Essay Paper

Equation 1:

Loading Dose =

[ Vd ( Cp desired – Cp observed ) ] /FSA ( NB: Must change over Cp to metric units ie. mg/L by spliting SI units by 4 )


C. Monitoring

1 ) Phenytoin Serum Levels


Loading Dose:

2-4 hours station IV or 24 hours post PO burden

Care Dose:

steady province trough degrees ( 10-21 yearss ) or

compare two degrees drawn at 2-4 twenty-four hours intervals ( e.g. station lading dose degree and comparison to a follow-up degree in 2-4 yearss ) ; the care dosage must non alter between the degrees ; provides estimation of the accretion or lack of a fixed care dosage

Seizure Activity:

at the clip of a ictus, a phenytoin degree helps to gauge a threshold for ictus activity

2 ) Serum Albumin

Phenytoin is about 90 % protein edge. Reported degrees are based on entire diphenylhydantoin ( bound + free ) and degrees must be adjusted when serum albumen is reduced:

Equation 2: A

Cp normal =

Cp observed /A [ ( 0.02 x albumen ) + 0.1 ]


3 ) Nephritic Failure ( & lt ; 10mL/min, dialysis )

In patients with nephritic failure, uraemia increases the unbound fraction of diphenylhydantoin. These patients besides tend to hold low serum albumen. In general, purpose for curative degrees between 20-40 umol/L.


Diphenylhydantoin does NOT show a relative relationship between drug degrees and dosage. Due to zero order dynamicss, dose should NOT be increased by more than 50-100mg increases.


Hold dose until degrees are back within the curative scope so cut down dose as per above. As a general regulation, hold therapy 1 twenty-four hours for every 20umol/L over 80umol/L



Dose Related:

sleepiness, confusion, nystagmus, ataxy, slurred address, sickness, unusual behaviour, mental alterations, coma

( degrees & gt ; 200umol/L )

Non-Dose Related:

hirsuteness, acne, gingival hyperplasia, folate lack, osteomalacia, hypersensitivity reactions ( including Steven ‘s Johnson syndrome ) , SLE

A Optimum control without clinical marks of toxicity occurs more frequently with serum degrees between 10 and 20 mcg/mL, although some mild instances of tonic-clonic ( expansive mal ) epilepsy may be controlled with lower serum degrees of diphenylhydantoin. Therapeutic Dose Monitoring Of Sodium Health Essay Paper

Many research workers have studied the curative effects music has on hurting and anxiousness. Among the diverse countries of medical pattern that have improved with evidence-based pattern, music has its topographic point in health care. The intent of this paper is to show a reappraisal of the literature showing the improved patterns that the consequence of music has on hurting and anxiousness earlier, during and after a process, along with sum uping the consequences from the research. Besides, while sing each survey ‘s consequences and deductions, the following stairss towards seting such methods into pattern will be explored, every bit good as the short approachs of each survey ‘s consequences and design. Overall, this paper will cover the major strengths and failings of each survey while weaving their intents into a coherent and important literature reappraisal. In add-on, some possible schemes to assist better the quality of the result for patients and farther surveies in the hereafter will be addressed every bit good. Note all articles have quoted old research surveies on Music Therapy and related those thoughts to their findings.

Discussion of Identified Articles

The undermentioned key words were used to place articles for this literature reappraisal: music therapy, anxiousness and hurting, and inactive and active music therapy. Overall, the literature identified articles refering straight how music helps kids eight months to 20 old ages old undergoing medical or dental processs ( Klassen, 2008 ) ( Bekhus, 2009 ) , grownups having PICC or port-a-cath arrangement ( McDaniel, 2009 ) , patients undergoing same-day surgery ( Shertzer, 2001 ) , South Korean adult females holding gynaecological surgery ( Good, 2008 ) , Chinese patients holding C-clamp processs ( Chan, 2005 ) , and Turkish work forces holding urogenital surgery ( Arslan, 2007 ) . The broad assortment of patients take parting in each survey helps to supply an overall position ( cross culturally, ages, gender, length of clip, and type of process ) of how patients deal with hurting and anxiousness earlier, during and after their processs, every bit good as the effects that music has on them during their processs. Therapeutic Dose Monitoring Of Sodium Health Essay Paper

Synthesis of Current State of the Literature

In reexamining the literature sing the effects of music therapy, the bulk of the literature reports that a broad assortment of medical fortes have gained a great sum of information and cognition from their research through evidence-based pattern. The methods used by the bulk of research workers were designed around inactive music therapy techniques. Passive music therapy is defined as listening to music without the engagement of a music healer ( Klassen, Yuanyuan, Tjosvold, Klassen, & A ; Hartlilng, 2008 ) . With inactive music therapy, patients either listen to music being played in the environment/operatory, conveying their ain MP3 participants with their ain music, or they use music provided by the installation. Besides, during the bulk of surveies, patients enjoyed their music choices the best when undergoing painful processs. Active music therapy involves a healer, and the music is the medium for synergistic communicating ( Klassen et al. , 2008 ) . Besides, active therapy for kids is the usage of a distraction, such as reading a book to them, watching picture, speaking, or playing a game ( University of Iowa, 2007 ) . Earlier research of the curative effects of music has been studied and found to relieve anxiousness in different populations ( Chan et al. , 2005 ) . Music can ease hurting and anxiousness by traveling a patient ‘s witting thought off from the symptoms ( Klassen, Yuanyuan, Tjosvold, Klassen, & A ; Hartlilng, 2008 ) . Good ‘s ( 2008 ) survey revealed that 15 proceedingss of music therapy reduced hurting by 23 % for adult females after holding gynaecological surgery. Chan ‘s ( 2005 ) found that music therapy is effectual in cut downing hurting, bosom rate, systolic force per unit area, and respiratory rates of patients undergoing C-clamp process. Cohen ( 2001 ) besides found that patients that had music felt more in control and less anxiousness. Music had a important consequence on the patient ‘s anxiousness before processs and patients required less medicine because of it ( Arslan, 2007 ) . With McDaniel ‘s ( 2009 ) and Cohen ‘s ( 2001 ) survey patient ‘s anxiousness was decreased after the process.Therapeutic Dose Monitoring Of Sodium Health Essay Paper

Consistencies and Contradictions in the Literature

Each survey used different research designs to look into its job and note the factors which play major functions in a patients ‘ hurting and sensory receptors which register their hurting overall. The bulk of surveies used a quasi-experimental research design along with random control in order to outdo randomize and show an indifferent patient population of topics. The surveies utilizing these designs seemed to show the most believable information ; nevertheless, an issue of prejudice was presented when several research workers noted that they had selected topics based chiefly on their handiness instead than based on random assignment ( Burns & A ; Grove, 2009 ) . Besides, there was an issue with Chan ‘s ( 2005 ) survey sing the ways the research worker gathered informations. The issue was that same individual who provided the intercession besides collected the informations ; so there is a likely chance of important prejudice ( Chan et al. , 2005 ) . Another survey, ( Shertzer, 2001 ) , had lost informations because of the high work load in the PACU, so some of the information was non collected before patients were discharged. In order to account for their error and non lose valuable patient informations, the research workers implemented a follow-up questionnaire after the patients were discharged ( Shertzer & A ; Keck, 2001 ) . Besides, the McDaniel ( 2009 ) survey added a inquiry after the survey began to turn to whether or non the patients felt that music was a helpful beginning of intercession. McDaniel ‘s ( 2009 ) survey noted that inactive music therapy did small for the patients ‘ hurting and merely in the Port-a-cath patient ‘s anxiousness was significantly reduced.


For the kids in Klassen ( 2008 ) and Bekhus ( 2009 ) systematic reappraisal surveies, the measurings that were most used were observation, the Jadad graduated table, along with ego coverage if able. Out of 19 surveies reviewed, 16 of the surveies score a one and two others received a mark of two ( Klassen, 2008, Bekhus, 2009 ) . These tonss indicate that the quality is low and that there is inconsistent quality of patient oriented grounds. A Jadad graduated table is a method for measuring the quality of controlled clinical tests. Basic Jadad Score is assessed based on the reply to the following 5 inquiries. The maximal mark is 5 and inquiries are answered either yes or no:

1. ) Was the survey described as random? 1 or 0 ; 2 ;

2. ) Was the randomisation strategy described and allow? 1 or 0 ;

3. ) Was the survey described as double-blind? 1 or 0 ;

4. ) Was the method of dual blinding appropriate? ( Were both the patient and the assessor suitably blinded? ) 1 or 0 ;

5. ) Was there a description of dropouts and backdowns? 1 or 0 ( Jadad, 1996 ) .

Quality appraisal was based on Jadad Score, where the scope of mark quality is: 0-2 Low, 3-5 High ( Jadad, 1996 )

For the research surveies with grownup patients, the psychological measurings varied in each. Chan ( 2005 ) used the UCLA cosmopolitan hurting assessment tool, a hurting graduated table from 1-10 ; McDaniel ( 2009 ) and Shertzer ( 2001 ) , used the Numerical Rating Scale which is an 11 point graduated table from 0-10, ( NRS ) , Likert scale 1-5 for anxiousness, and questionnaires, Good ( 2008 ) used Visual Analog Scale ( VAS ) , and Arslan ( 2007 ) , State Trait Anxiety Inventory ( STAI ) . In several surveies, physiological effects were monitored at assorted times harmonizing to their standards normally earlier, during and after a process, such as, blood force per unit area, respiratory rate, pulsation, and oxygenation. The surveies by McDaniel ( 2009 ) , Chan ( 2005 ) , Shertzer ( 2001 ) , and Cohen ( 2001 ) included these measurings.Therapeutic Dose Monitoring Of Sodium Health Essay Paper


Merely one survey stated that music did non do a important difference in hurting but did do a important difference in anxiousness in their patients ( McDaniel et al. , 2009 ) . Klassen ( 2008 ) and Bekhuis ( 2009 ) , had jobs with low quality grounds so the consequences of the meta-analysis was viewed to be suggested but non confirmed to alter pattern. Five surveies, McDaniel ( 2009 ) , Chan ( 2005 ) , Arslan ( 2007 ) , Shertzer ( 2001 ) , and Good ( 2008 ) , had restrictions due to the sample size. These surveies, Chan ( 2005 ) , Arslan ( 2007 ) , Shertzer ( 2001 ) , and Good ( 2008 ) , recommend retroflexing the survey with a larger sample size and felt that it would be more utile to find the dependability of the consequences. Three surveies were performed outside of Western civilization, such as, Chan ( 2005 ) , China, Arslan ( 2007 ) , Turkey, and Good ( 2008 ) South Korea. Besides, the South Korean survey merely had females and the Turkish survey merely had work forces in their survey which bound ‘s the populations one can see utilizing such informations ( Arslan, 2007 ) ( Good, 2008 ) . With the overall input for those three surveies, their location in the universe and civilization poses a difficultly for relevant informations to be applied to Western populations. The Chinese survey had a limited choice of music where five of their choice were in Chinese, therefore doing limited participant pick ( Chan et al. , 2005 ) . In such surveies, kids pose a peculiar turn to data aggregation, because normally when kids are traveling through a process and their parents are with them. Therefore, for kids ‘s use of music therapy for anxiousness and hurting does non ever refer to all based on assorted environmental and relational factors ( University of Iowa, 2007 ) . At the University of Iowa, they are working on Web-based package which will rede nurses on the best manner to deflect kids from the processs that cause the hurting ( University of Iowa, 2007 ) . They are utilizing techniques, such as, holding a book read to the kid, holding them watch a picture, speaking, or even holding them play a game ( University of Iowa, 2007 ) .Therapeutic Dose Monitoring Of Sodium Health Essay Paper


No affair what their age, gender, or race, anxiousness and hurting influences the physiological and psychological reactions of patients ( Chan et al. , 2005 ) . The overall consensus is that music helps sooth the physiological and psychological response of the patient, which helps bring forth a more positive result for the patient ( Chan et al. , 2005 ) . By non supplying music therapy patients would endure needlessly ( Good, 2008 ) . Stress can detain or even halt the healing procedure, so any method to efficaciously battle such is contributing to the patient ‘s comfort and overall healing ( Cohen, 2001 ) . Besides for kids in the surveies, Klassen ( 2008 ) and Bekhuis ( 2009 ) concluded that inactive music therapy may be every bit effectual as active music therapy. In the University of Iowa ( 2007 ) survey felt that long-run wellness effects of doing it easier for kids to get by with hurting could be profound. As wellness attention professionals, we need to happen ways to assist our patients get through a process with less hurting and anxiousness. By researching and happening the best manner for step ining for our patients, we provide the best evidence-based pattern.



After reexamining the literature, several decisions can be made sing the effects music therapy has on patients before, during and after a process. Music is an effectual tool in either inactive or active therapy. By following and implementing patient-selected music hearing in the intervention country, such is a comparatively cheap manner to individualise patient attention and create feelings of trust between patient and health professional ( Cohen, 2001 ) . Overall this writer enjoyed larning about music therapy from such a assortment of research workers. This writer was surprised that there are many surveies that have occurred within the past decennary. However, what was found to be dissatisfactory was that the writer could non, even with the aid of the librarian, happen any article turn toing their inquiry of the usage of distraction to alleviate anxiousness and hurting, in the signifier of music therapy or another accelerator, to assist patients through a painful process. Based on the articles found and the consequences yielded, much more consistent research with mistakes more preemptively addressed demands to be conducted if the overall affects of music therapy on hurting and anxiousness is to be genuinely measured. Therapeutic Dose Monitoring Of Sodium Health Essay Paper