NUR 120 (UNIT 4) Medications for Cardiac Disorders 1.1 - 9.1

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Mrs Gulledge Nur 120 CCTC Spring 2012

Thiazide Diuretics actions:

- Keeps chloride and the sodium in the tubule to be excreted in the urine (wastes Na and Cl), thus preventing the reabsorption of both in the vascular system

- Blocks reabsorption of bicarbonate (urine will be more base)

Thiazide Diuretics Drug-Drug

- cholestyramine or colestipol
- digoxin toxicity increases
- Decreases effectiveness antidiabetic agents (may need to adjust the dose)
- Increases quinine (malaria tx) toxicity & lithium (antipsychotic) toxicity

Thiazide Diuretics Contras

- Allergy to thiazides or sulfonamides
- Fluid and electrolyte imbalances, and renal and liver disease
- Bipolar disorders

Thiazide Diuretics cautions

- Gout
- Systemic lupus erythematosus
- Diabetes
- Hyperparathyroidism
- Pregnancy (B, C) and lactation

Hydrochlorothiazide: Indications

- Adjunctive therapy for edema associated with CHF, cirrhosis, corticosteroid or estrogen therapy, and renal dysfunction; treatment of hypertension as monotherapy or in combination with other antihypertensives

Hydrochlorothiazide: Actions

- Inhibits reabsorption of sodium and chloride in distal renal tubules, increasing the excretion of sodium, chloride, and water by the kidneys

Hydrochlorothiazide: AE/SE

- Dizziness, vertigo, orthostatic hypotension, nausea, anorexia, vomiting, dry mouth, diarrhea, polyuria, nocturia, muscle cramps or spasms (build up of Ca leads to muscle spasms), headaches, decreased calcium excretion, hypokalemia, increased blood glucose levels, urine slightly alkalinized (HCO3 loss), dysrhythmias
(urine more alkaline -- increase risk of infection)

Theo is for REAL but don't give it to a BEAR

Theo = Thiazide

Renal (physical) dysfunction
Edema
Adjunct to hypertension
Liver Disease

Bi-polar
Electrolyte imbalance
Allergy to sulfonimides/Thiazide
Renal (chemical) Disease/Liver Disease

Heparin

- Normally found in mast cells
- Enhances inhibitory action of antithrombin III, interferes w/ conversion of prothrombin to thrombin (prolongs coagulation time)
- Inactivated by stomach acids - can not be given orally
- Administer IV or SC - avoid IM, do NOT massage or aspirate - SC site
- Antidote: 1% Protamine sulfate
- Labs - APTT or PTT
- Side effect - bleeding (hemorrhage)
- Pregnancy category B

Heparin: Indications

- Prevention and treatment of venous thrombosis and pulmonary emboli; treatment of atrial fibrillation with embolization; diagnosis and treatment of DIC; prevention of clotting in blood samples and heparin lock sets

Heparin: Actions

- Inhibits thrombus and clot production by blocking the conversion of prothrombin to thrombin and fibrinogen to fibrin

Heparin: AE/SE

- Loss of hair, bruising, chills, fever, osteoporosis, suppression of renal function (with longterm use)

Heparin Patient/Family Teaching

- Avoid activities that may result in injury
- NO contact sports
- Immediately report bleeding problems
- Menstruation may be increased
- Avoid smoking and alcohol
- Do not take other drugs or supplements
- Learn subcutaneous injection techniques
- Inform dentist prior to procedures
- Use soft toothbrush
- Use electric razor

Heparin Nursing Considerations:

- Baseline blood tests - whole blood clotting time 2.5 to 3 times control
- Monitor aPTT (activated partial thromboplastin time) 1.5 to 3 times control value
- Collect blood for testing 30 minutes prior to dose
- Monitor for signs of bleeding
- Apply firm pressure x 10 minutes for needle sticks & discontinuing IV site
- Reduce risk of trauma
- Antidote: protamine sulfate - administer slowly
- Not to exceed 50mg IV in 10 minutes

Heparin (memory)

Low-Molecular Weight Heparins Actions

- Inhibit thrombus and clot formation by blocking factors Xa and IIa
- Block angiogenesis, the process that allows cancer cells to develop new blood vessels
- Do not greatly affect thrombin, clotting, or prothrombin times; therefore cause fewer systemic adverse effects
- Indicated for prevention of clots and emboli formation after certain surgeries or prolonged bed rest
- Administer for 7 to 14 days postoperative

Low molecular weight heparin: enoxaparin (Lovenex), dalteparin (Fragmin), tinzaparin (Innohep)

- Inhibits coagulation factor X
- Administered SC in anterolateral or posterolateral abdominal wall (love handles)
- Never aspirate or massage site
- Dose based on weight, not labs
- Adverse effect: bleeding, same as heparin
- Antidote: Protamine sulfate

Warfarin (Coumadin) general info

- Oral route
- 99% protein bound
- Does NOT dissolve clots - prevents clots
- Adverse effects: bleeding, hypotension, wheezing, rash, hair loss, swelling of face, lips, tongue, prolonged & painful erections
- Teratogenic - pregnancy category D
- Takes several days to reach maximum effect
- Genetic marker for metabolism

warfarin (Coumadin) Nursing Considerations

- Monitor Prothrombin Time (PT) 1.5 to 2.5 times control value and International Normalized Ratio (INR) of 2 - 3
- Monitor urine, stool, liver function, and blood
- Monitor risk groups for nonadherence
- Antidote: Vitamin K
- Schedule regular periodic blood tests

warfarin (Coumadin) Patient/Family Teaching

- Minimize risk of injury
- Use same brand and take at same time
- Avoid high-fat diet, moderate vitamin K foods
- Avoid excessive alcohol
- Extra precautions to avoid pregnancy
- Notify all physicians, dentists, podiatrists if taking
- Wear MedicAlert bracelet
- Report: red or black stools, red or orange urine, nosebleeds, - severe headaches, stomach pains, bruising, excessive bleeding, unusually heavy menstrual periods

Warfarin Sodium (Coumadin) (memory)

Anticoagulants: heparin, LMWH

- SQ or IV
- Prevents the formation of clots
- Prolongs clotting time
- Antidote: protamine sulfate
- Labs: PTT and WBCT

Anticoagulants: warfarin (Coumadin)

- PO
- Prevents the formation of clots
- Prolongs clotting time
- Antidote: Vitamin K
- Labs: PT and INR
- Teratogenic

Bleeding Precautions (memory)

Aspirin: Indications

Reduction of risk of recurrent TIAs or strokes in males with a history of TIA due to fibrin or platelet emboli; reduction of death or nonfatal MI in patients with a history of infarction or unstable angina; MI prophylaxis; also used for its anti-inflammatory, analgesic, and antipyretic effects

Aspirin: Actions

Inhibits platelet aggregation by inhibiting platelet synthesis of thromboxane A2

Aspirin: AE/SE

Acute aspirin toxicity with hyperpnea, possibly leading to fever, coma, and cardiovascular collapse; nausea, dyspepsia, heartburn, epigastric discomfort, GI bleeding, occult blood loss, dizziness, tinnitus, difficulty hearing, anaphylactoid reaction

Antiplatelet Drugs Nursing Considerations

- Monitor lab tests - complete blood count (CBC), clotting times
- Observe for bleeding - bruising, use pressure dressings & ice
- Watch for hypersensitivity (allergy)
- Minimize bleeding risk
- Use soft toothbrush, electric razor, no contact sports
- Elevate head of bed and keep limb straight when femoral artery access is used

Antiplatelet Drugs Patient/Family Teaching

- Immediately report unusual bleeding
- Do not use other medications or other OTC medications or herbal supplements
- Teach to use electric razor, soft toothbrush
- No contact sports
- Wear MedicAlert bracelet

Nitroglycerin: Indications

Treatment of acute angina, prophylaxis of angina, intravenous treatment of angina unresponsive to beta-blockers or organic nitrates, perioperative hypertension, congestive heart failure (CHF) associated with acute MI; to produce controlled hypotension during surgery

Nitroglycerin: Actions

Relaxes vascular smooth muscle with a resultant decrease in venous return and decrease in arterial blood pressure, reducing the left ventricular workload and decreasing myocardial oxygen consumption

Nitroglycerin: AE/SE

Hypotension, headache, dizziness, tachycardia, rash, flushing, nausea, vomiting, sweating, chest pain

Nitrates Nursing Considerations

- Administer 1 tab SL every 5 min x 15 min
- No relief call health care provider
- Store dark vial
- Tablet should burn or "fizzle"
- Instruct not to swallow tablets
- Instruct not to chew/crush sustained-release
- Wear gloves for transdermal patch (can cause headache die to vasodilation)
- Spray translingual spray under tongue, not inhaled
- Wean off over 4-6 weeks

Nitrates Patient/Family Teaching

- Take at earliest sign of anginal pain
- Slow position changes
- Call 911 if pain unrelieved by 3 tablets - 5 minutes apart - over 15 minutes
- Take 5 -10 minutes prior to exercise
- Remove patches at bedtime, apply in AM
- Report blurred vision, dry mouth, chest pain, fainting
- Avoid alcohol, coffee, cigarettes
- Wear medic-alert bracelet
- Store in dark container, replace every 3 months (lose potency really quickly)
- Dress appropriately in cold weather - wear mask (cold gives chest pains - teach to stay in when very cold)

Nitroglycerin (memory)

Antihypertensive Drugs (memory)

ACE Inhibitor (memory)

ACE Inhibitor method of action

Decrease in blood flow (kidneys) signals --> release of renin --> angiotension --> enzyme --> angiotensen II --> increase in peripheral resistance --> increase in BP

ACE Inhibitors block the enzyme and stops the process which leads to a reduction in BP

Angiotensin-Converting Enzyme Inhibitors (ACE) Actions

Blocks ACE from converting angiotensin I to angiotensin II, leading to a decrease in blood pressure, a decrease in aldosterone production, and a small increase in serum potassium levels along with sodium and fluid loss

Angiotensin-Converting Enzyme Inhibitors (ACE) Contras

- Allergies
- Impaired renal function
- Pregnancy (birth defects) and lactation

Angiotensin-Converting Enzyme Inhibitors (ACE) Caution

HF (don't want to slow down the heart too much)

ACE Inhibitors Nursing Considerations

- Assess blood pressure prior to administration
- Hold for BP 90-100/60 (Have to have BP before giving drug)
- Administer on an empty stomach 1 hour before or 2 hours after meals
- Watch for "first dose phenomenon"
- Prevent dehydration
- Decrease dose for renal failure
- Dry, hacking cough is a common adverse effect

Angiotensin II Receptor Blockers: Indications

Alone or as part of combination therapy for the treatment of hypertension; treatment of diabetic nephropathy with an elevated serum creatinine and proteinuria in patients with type 2 diabetes and hypertension

Angiotensin II Receptor Blockers: Actions

Selectively blocks the binding of angiotensin II to specific tissue receptors found in the vascular smooth muscle and adrenal glands; blocks the vasoconstriction and release of aldosterone associated with the renin-angiotensin system

Angiotensin II Receptor Blockers: AE/SE

Dizziness, headache, diarrhea, abdominal pain, symptoms of upper respiratory tract infection, cough, back pain, fever, muscle weakness, hypotension
(Liver and kidneys must be in good working order)

Angiotensin II Receptor Blockers Nursing Considerations

- Can take with food (irritating to GI tract)
- Prevent dehydration
- Do not use if pregnant or breastfeeding
- Use barrier contraceptives
- Discontinue immediately if pregnant
- Watch for syncope, cough, alopecia (hair loss)

Beta Blockers Mnemonic

B = Bronchospasms - do NOT give to patients with bronchoconstrictive diseases
E = Elicits decrease in cardiac output & contractility
T = Treat hypertension
A = AV conduction decreases - treats arrhythmias
Do NOT discontinue abruptly - causes rebound angina, confusion in elderly, psychosis

Beta Blockers Indications

Treatment of cardiac arrhythmias, especially supraventricular tachycardia; treatment of ventricular tachycardia induced by digitalis or catecholamines

Beta Blockers Action

Competitively blocks beta-adrenergic receptors in the heart and kidney; has a membrane-stabilizing effect and decreases the influence of the sympathetic nervous system

Beta Blockers AE/SE

Bradycardia, CHF, cardiac arrhythmias, heart blocks, cerebrovascular accident (CVA), pulmonary edema, gastric pain, flatulence, nausea, vomiting, diarrhea, impotence, decreased exercise tolerance, antinuclear antibody (ANA) development

Beta Blockers Nursing Considerations

- Monitor BP, Pulse, and Respiratory status (you will want to know if the lings are filling up c fluid)
- Obtain medical history
- * asthma, COPD
- smoking - drugs cause loss of bronchodilation
- diabetics - monitor blood glucose frequently (due to the tendency of B blockers to increase blood glucose levels)
- Wean off drug over 2 weeks
- Teach to change positions slowly
- Explain change in sexual function
- Review laboratory tests:
- kidney, liver, electrolytes

Calcium Channel Blockers Indications

Treatment of essential hypertension

Calcium Channel Blockers Actions

Inhibits the movement of calcium ions across the membranes of cardiac and arterial muscle cells, depressing the impulse and leading to slowed conduction, decreased myocardial contractility, and dilation of arterioles, which lowers blood pressure and decreases myocardial oxygen consumption

Calcium Channel Blockers Contras

Allergy, heart block or sick sinus syndrome (don't want to decrease it if it is already too slow), renal or hepatic dysfunction, pregnancy, and lactation

Calcium Channel Blockers AE/SE

Dizziness, light-headedness, headache, peripheral edema, bradycardia, atrioventricular block, flushing, nausea

Calcium Channel Blockers Nursing Considerations

- Monitor BP, Pulse, cardiac status (are there any arrhythmias? listen to the apical and feel the radial pulse at the same time)
- Grapefruit juice increases drug to toxic level (interferes c P-450 enzyme system which is the livers system to detoxify drugs)
- Take 1 hour before or 2 hours after meals
- Prevent dehydration
- Wean off drug
- Do not use in pregnancy or breastfeeding
- African Americans respond better to CCBs

B1 and B2 Blocker Actions (memory)

Beta Blocker Actions (memory)

Beta Blocker AE/SE (memory)

Cardiac Glycosides overview

- Slows heart rate (- chronotropic)
- Increases force of myocardial contraction (+ inotropic)
- Decreases conduction velocity through the AV node (- dromotropic)
- Increases cardiac output and renal perfusion
- Increases urine output and decreased blood volume

Cardiac Glycosides Indication Digoxin:

Treatment of CHF, atrial fibrillation

Cardiac Glycosides Digoxin: Actions

Increases intracellular calcium and allows more calcium to enter the myocardial cell during depolarization; this causes a positive inotropic effect (increased force of contraction), increased renal perfusion with a diuretic effect and decrease in renin release, a negative chronotropic effect (slower heart rate), and slowed conduction through the atrioventricular (AV) node

Cardiac Glycosides Digoxin: AE/SE

Headache, weakness, drowsiness, visual disturbances, arrhythmias, GI upset
digoxin (Lanoxin, Lanoxicaps)

Cardiac Glycosides Patient/Family Teaching

- Take radial pulse daily report <60 or >110 (at >110 drug levels are either getting too toxic or not working)
- Immediately report adverse effects
- Check weight daily, report gain 2 lb in 2 days
- Administer before or after meals - not with food
- Diet - eat high K+ foods (wastes K+)
- Take as prescribed
- Do not take any OTC medications, esp. antacids (antacids interfere with absorption)
- Do not switch brands
- Do not breastfeed

Cardiac Glycosides Nursing Considerations

- Take apical pulse for 1 minute before administration.
- Withhold medication if apical pulse below parameters
(Adult = 60, Child = 70, Infant = 90, newborn = 100)
- Administer loading or "digitalizing" dose
- Narrow therapeutic index
(0.5 - 2.0 ng/ml - toxic > 2.0 ng/ml)(must follow c labs to monitor)
- Monitor lab values - K+
- Monitor I & O, daily weight
- No IM injection, administer IV slowly over 5 minutes
- Antidote: Digoxin Immune Fab, Digibind, Digifab

Cardiac Glycosides: Lizzy Dizzy (memory)

Loop Diuretics: furosemide (Lasix)

Most commonly used; less powerful than new drugs; larger margin of safety for home use

Loop Diuretics Furosemide: Indicaitons

Treatment of edema associated with CHF, acute pulmonary edema, hypertension

Loop Diuretics Furosemide: Actions

Inhibits the reabsorption of sodium and chloride from the proximal and distal renal tubules and the loop of Henle, leading to a sodium-rich diuresis

increase risk of hyponatremia

Loop Diuretics Furosemide: AE/SE

Dizziness, vertigo, paresthesias, blurred vision, orthostatic hypotension, thrombophlebitis, photosensitivity, rash, urticaria, nausea, anorexia, vomiting, constipation, glycosuria, urinary bladder spasm, leukopenia, anemia, thrombocytopenia, muscle cramps, and spasms,
hypokalemia, hypocalcemia, tachycardia, metabolic alkalosis, ototoxicity (8th cranial nerve damage -> tinnitus --> deafness)

Nursing Considerations - Potassium Wasting Diuretics

- Measure BP, P before taking & regularly
- Monitor: daily weight (report 3 lb increase)(same scale, same time, same clothing),
- I & O, skin turgor, lung sounds, heart sounds
- Rise slowly
- Administer early in day, bathroom access
- Provide K+ diet
- Take with meals, milk to decrease GI upset
- Monitor electrolytes - K+, Ca +, glucose
- Adequate fluid intake - fluid rebound - page 816
- Avoid extravasation if given IV

Potassium Rich Foods:

Avocados, Bananas, Broccoli, Cantaloupe, Dried fruits Grapefruit, Lima beans, Nuts, Navy beans , Oranges, Peaches, Potatoes, Prunes, Rhubarb, Sanka coffee, Sunflower seeds, Spinach, Tomatoes, Watermelon

normal potassium levels:

3.5 - 5 mg/dL

What is the most effective way for the nurse to evaluate effectiveness of diuretics?

pt's weight

Xanthines (Aminophylline is IV form
Theophylline in oral form): Actions

- Direct effect on the smooth muscles of the resp tract, both in the bronchi and in the blood vessels. Used for apnea and bradycardia in premature infants
- Used for Cheyne-Stokes respirations

Xanthines (Aminophylline is IV form
Theophylline in oral form): Indications

symptomatic relief of bronchial asthma & reversible bronchospasm asstd c bronchitis & emphysema

Xanthines (Aminophylline is IV form
Theophylline in oral form): Caution/Contras

GI problems, coronary disease, respir dysfunction, renal or hepatic disease, alcoholism, or hyprthyroidism
sml thera margin: 10 - 20 mcg/mL

Xanthines (Aminophylline is IV form
Theophylline in oral form): Drug-Drug

- Many drugs interact with xanthines
- Nicotine increases the metabolism of Xanthines

Xanthines (Aminophylline is IV form
Theophylline in oral form): AE/SE

Irritability, restlessness, dizziness, palpitations, life-threatening arrhythmias, loss of appetite, proteinuria, respiratory arrest, fever, flushing, GI upset, seizures, brain damage, death

Xanthines (Aminophylline is IV form
Theophylline in oral form): PT/NC

- Advise NO smoking
- Administer oral drug with 8 oz water or food or milk (GI upset)
- Decrease caffeine use
- Excessive charcoal-broiled foods decrease effectiveness
- Provide rest periods and quiet environment
- Treat headaches
- Periodic blood tests to monitor serum theophylline levels
- Avoid OTC medications

Narcotic Agonist Morphine: Indication

Relief of moderate to severe acute or chronic pain; preoperative medication; component of Brompton's cocktail for severe chronic pain; intraspinal to reduce intractable pain

Narcotic Agonist Morphine: Actions

Acts as an agonist at specific opioid receptors in the CNS to produce analgesia, euphoria, and sedation

Narcotic Agonist Morphine: AE/SE

Light-headedness, dizziness, sedation, nausea, vomiting, dry mouth, constipation, ureteral spasm, respiratory depression, apnea, circulatory depression, respiratory arrest, shock, cardiac arrest

Morphone (memory)

Statins: HMG-CoA Reductase Inhibitors: Actions

Inhibits HMG-CoA reductase enzyme (controls production of cholesterol), decreases serum cholesterol levels, LDLs, and triglycerides, increases HDL levels

*help decrease intermittent claudication pain*

Statins: HMG-CoA Reductase Inhibitors: Contraindications

Allergy to drug or fungi
Active liver disease or history of alcoholic liver disease
Pregnancy (Category X) or lactation

Statins: HMG-CoA Reductase Inhibitors: Caution

Impaired endocrine function

Statins: HMG-CoA Reductase Inhibitors: AE/SE

GI symptoms: flatulence, abdominal pain, cramps, nausea, vomiting, and constipation
CNS: headache, dizziness, blurred vision, insomnia, fatigue, cataracts
Liver failure

Rhabdomyolysis (injury to glomerulus causing renal failure) the breakdown of muscle fibers that leads to the release of muscle fiber contents (myoglobin) into the bloodstream.

Statins: HMG-CoA Reductase Inhibitors: Drug-Drug

erythromycin, cyclosporine, gemfibrozil, niacin, antifungal drugs cause increased risk of rhabdomyolysis
digoxin or warfarin = increases toxicity
Increases estrogen levels w/ oral contraceptives
Grapefruit juice = increased serum levels & toxicity of inhibitor

Statins: HMG-coA Reductase Inhibitors Nursing Considerations

Obtain baseline lipid values
Monitor LDL and serum cholesterol levels
Assess lipid lab tests within 2 - 4 weeks of initiation of therapy or change in dose
Exercise program for 3 - 6 months prior to taking
Obtain baseline weight
Assess for signs of rhabdomyolysis (breakdown of muscle fibers resulting in the release of muscle fiber contents (myoglobin) into the bloodstream - can lead to kidney damage)
Observe for digoxin and warfarin toxicity
Withhold if serious medical condition
Discontinue if liver function tests 3 times normal - AST & ALT

Statins: HMG-CoA Reductase Inhibitors Patient/Family Teaching

Take in evening (bedtime) with food
Maintain cholesterol-lowering diet
Avoid grapefruit/grapefruit juice
Avoid drug interactions
Counsel about pregnancy and lactation
Use barrier method of contraception
Restrict/eliminate alcohol intake
Periodic eye exams

Vasodilators: Indications

Hypertensive crisis, maintenance of controlled hypotension during anesthesia, acute CHF

Vasodilators: Actions

Acts directly on vascular smooth muscle to cause vasodilation and drop of blood pressure; does not inhibit cardiovascular reflexes and tachycardia; renin release will occur

Vasodilators: AE/SE

Apprehension, headache, retrosternal pressure, palpitations, cyanide toxicity, diaphoresis, nausea, vomiting, abdominal pain, irritation at the injection site

Vasodilators Nursing Considerations

- Light sensitive
- Monitor for cyanide toxicity - see page 687
Suppresses iodine uptake - hypothyroidism
Monitor BP closely during administration
Prevent dehydration

clopidogrel (Plavix) Patient/Family Teaching

Immediately report unusual bleeding or bruising
Know it may take longer to stop bleeding
Do not stop taking drug
Do not use NSAIDs including ASA, other OTC medications, or herbal supplements
Inform dentist and other care providers prior to procedures
Evaluate unexplained fever/infection

clopidogrel (Plavix) is a

Platelet Aggregation Inhibitor
- stops platelets from sticking together

clopidogrel (Plavix) (memory)

pentoxifylline (Trental) is a

blood viscosity reducing agent

pentoxifylline (Trental)

used to improve blood flow in patients with circulation problems to reduce aching, cramping, and tiredness in the hands and feet. It works by decreasing the thickness (viscosity) of blood. This change allows your blood to flow more easily, especially in the small blood vessels of the hands and feet.

*Management of symptomatic peripheral vascular disease (intermittent claudication)*

pentoxifylline (Trental) AE/SE

CNS: agitation, dizziness, drowsiness, headache, insomnia, nervousness.
EENT: blurred vision.
Resp: dyspnea.
CV: angina, arrhythmias, edema, flushing, hypotension.
GI: abdominal discomfort, belching, bloating, diarrhea, dyspepsia, flatus, nausea, vomiting.
Neuro: tremor.

pentoxifylline (Trental) Nursing Considerations

- Assess patient for intermittent claudication prior to and periodically throughout therapy
- Monitor blood pressure periodically in patients on concurrent antihypertensive therapy

pentoxifylline (Trental) Patient Teaching

- Consult health care professional before discontinuing medication, because several weeks of therapy may be required before effects are seen
- May cause dizziness and blurred vision. Caution patient to avoid driving and other activities requiring alertness until response to medication is known
- Advise patient to avoid smoking, because nicotine constricts blood vessels
- Instruct patient to notify health care professional if nausea, vomiting, GI upset, drowsiness, dizziness, or headache persists

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