#1 Patient education materials on anticonvulsant drug therapy - Shelly Flynn, RN, MA, CPNP and Pediatric Neurology Staff

#2 Tatooing and body piercing education materials - Barbara Freyenberger, RN

Iowa Health Book: Pediatrics
Anticonvulsant Drug Therapy
Shelly Flynn, RN, MA, CPNP and Pediatric Neurology Staff
Pediatric Neurology
Peer Review Status: Internally Peer Reviewed
Creation Date: October 1998
Last Revision Date: October 1998

The Purpose of Anticonvulsant Drug Therapy
Anticonvulsant medication is used to treat children who have had seizures and are at risk to have more seizures. There are now a number of drugs available for this purpose and the overall efficacy of anticonvulsant drug therapy is good. With proper use of medication, 75-80% of children with seizures will have significantly reduced numbers of seizures or no seizures. There remain however, 20-25 percent of children with seizures who continue to have seizures despite treatment with medication. Among these patients, some will eventually have some improvement by using different medications (alone or in combination) and different dosages. In such instances, our approach is to give an amount of medication that will bring about the best possible control of seizures, but with a minimum of side effects.
Choice of Drugs
Several factors determine which anticonvulsant drug is chosen for treatment. These factors include: the type of seizure a child has, the age of the child, the individual preference of the physician, and the cost of the medication. The drug chosen is the one predicted to be the most effective and most safe for the patient. A single drug is preferred whenever possible although some children require two or more drugs in combination. We generally prefer to use tablets or capsules rather than the liquid preparations because they allow more accurate dosing and are more convenient than liquids.
How Anticonvulsant Drugs Are Given
When using liquid medication, use a calibrated dropper, medicine syringe or measuring spoon to insure that you are giving your child an accurate amount of medication. Many of the tablets are scored. A scored tablet has a line in the center of it and can be cut in half if needed.
The frequency with which a drug is administered is partly determined by how long it lasts in the body. Drugs that last longer (such as Phenobarbital) can be given once or twice a day. Drugs that are metabolized quickly need to be given more frequently, sometimes 3-4 times a day. The dosing frequency may need to be adjusted for an individual child, since absorption and metabolism are not the same in everyone.
Most children who take medications three times a day do not need to take the medicine at school. The child can take the medicine before school, after school and at bedtime. A drug prescribed twice a day is taken in the morning and atbed time or dinner time. It is not necessary to be absolutely precise about the exact time of day when these medications are administered. Bedtime can be 8 pm or 9:30 pm and it is entirely acceptable for this to vary in a given child from day to day. What is important is that the child receive the total daily dose that is prescribed at spaced intervals.
What You Need To Know About Anticonvulsant Drugs
When your child is prescribed an anticonvulsant medication, you should understand the following: the name of the drug, the number of milligrams (mgs) in the capsule, tablet, or teaspoon of liquid preparation, how often the drug is to be taken, and the common side-effects or toxic effects of the drug or drugs. The types of side-effects include "allergic" and toxic effects. Allergic reactions are unpredictable, usually occur shortly after starting the medication and are not related to the dose of medication. Toxic effects usually result from excessive dosage and high serum levels of the drug. One further concern is the possibility of adverse effects upon the fetus when anticonvulsant drugs are taken during pregnancy. This matter should be discussed with the physician when the woman taking these medications contemplate spregnancy.
Side-effects of anticonvulsant drugs are usually not serious and are reversible once the dose is reduced or the drug is discontinued. Drugs with a relatively high likelihood of more serious side-effects are usually not prescribed unless the safer medications are not effective in controlling the seizures. Accidental ingestion of large quantities of any of these medications by small children can result in severe intoxication or even death. For this reason, all medications should be kept in a safe place, well out of the reach of young children.
The quantity of the drug that is present in the blood (the plasma level) can often be determined by a laboratory test. When control of seizures is less than optimal and the plasma level is found to be below the therapeutic range, the physician can then safely increase the dosage. Determination of the plasma level is also valuable when the child develops symptoms that suggest drug toxicity. Identification of a plasma level in the toxic range in such a child usually indicates a need for reduction of the dosage. How often the plasma level should be obtained on a child taking anticonvulsant drugs is variable and depends on several factors. In those patients on low dosages of a drug whose seizures are well controlled, plasma levels are needed only one to two times per year. Conversely, when a child requires a high dosage, or is on multiple drugs, o rseizures are poorly controlled, plasma level monitoring at frequent intervals is sometimes necessary.
Some anticonvulsant medications have the potential to decrease the white blood cell count. Certain other antiepileptic drugs can affect liver and/or kidney function. While problems with blood counts, liver, or kidney function are rare, blood samples from your child may need to be obtained on a periodic basis to make sure these organs are functioning normally. Whether your child needs to be monitored for any of these problems depends on the medication being taken. If your child becomes ill, be sure that the physician knows what medicines he or she is taking.
All anticonvulsants act through their effect on the brain, since seizures arise from the brain. As a result, any anticonvulsant can lead to changes in personality, behavior or learning ability. There is individual variation in response to a drug. If your child has a significant worsening of behavior or learning that lasts for more than about 4-6 weeks after a new medication is started you should notify the neurologist.
How Long To Continue Drug Treatment
Basically, drug therapy is continued as long as the child remains susceptible to seizures. Many children do "outgrow" their predisposition to have seizures. This is more commonly seen in otherwise normal children, whose electroencephalograms (EEG) have been normal or only mildly abnormal, whose seizures occurred infrequently and were promptly controlled with drug therapy. Under such circumstances, the medication is often discontinued after about 2 years without seizures. Other children, for example those with brain injury, may go many years between seizures on drug therapy, but still are clearly susceptible to future attacks and the medication will be continued. In the final analysis,the drug treatment is stopped when it is determined that the child has a relatively low probability of having more seizures. This is never a certainty and is always a judgement matter. In determining when to stop the anticonvulsant, you and the physician will weigh the benefit of stopping a daily medication (with potential side-effects) against the risk of recurrent seizures. When the medication is stopped, the doses are gradually tapered over 2-4 weeks rather than stopped abruptly. Abrupt discontinuation of antiepileptic medication can lead to status epilepticus (prolonged seizures).

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Iowa Health Book: Dermatology
Tattooing and Body Piercing:
Decision Making for Teens
Barbara Freyenberger
Peer Review Status: Internally Peer Reviewed by Joann Eland, PhD, RN
Creation Date: November 1998
Last Revision Date: November 1998

How long has this been going on? A long, long time!
History of tattooing and body piercing
Throughout history tattooing and body piercing have been practiced by many cultures. The body of a 4,000 year old tattooed man was discovered in a glacier on the Austrian border in 1992. Egyptians in the period from 4000-2000 B.C. identified tattooing with fertility and nobility. During the 17th and 18th centuries, European sailors traveling through the Polynesian islands saw extensive tattooing on both men and women. Since the 5th century B.C. the Japanese have used tattooing for ornamental, cosmetic, and religious purposes as well as for identification and punishment of criminals. In the late nineteenth century, tattooed royalty in England and European countries were fashionable. Lady Randolph Churchill (Winston's mother) had a snake tattooed around her wrist.
Like tattooing, body piercing has been practiced in many cultures for many centuries. Body piercing was often identified with royalty and portrayed courage and virility. Egyptian Pharaohs pierced their navels as a rite of passage. Roman soldiers pierced their nipples to show their manhood. Mayans pierced their tongues as a spiritual ritual, and both sexes of Victorian royalty chose nipple and genital piercing.
In recent times tattoos have been most common among motorcyclists, criminals, gang members, individuals with psychiatric problems, and military personnel. Members of these groups often obtained tattoos to show loyalty to their group. Today the number of musicians and sports stars who are tattooed or body pierced has skyrocketed. Cher and Dennis Rodman are two of the most outspoken stars wearing tattoos. Many of these figures serve as role models for teenagers.

So you are thinking about getting a tattoo or body piercing?
You might want to know:
· Unsterile tattooing and piercing equipment and needles can spread serious infection, hepatitis, tetanus, or possibly even HIV.
· Asking a friend to apply a tattoo may ruin a friendship if the tattoo doesn't look like you thought it would.
· Tattoo removal is very expensive. A tattoo that costs $50 to apply may cost over $1000 and more to remove.
· The law in many states prohibits the tattooing of minors.
· Tattoos are not easy to remove and in some cases may cause permanent discoloration. Think carefully before getting a tattoo. You can't take it back if you don't like it.
· Some people are allergic to the tattoo dye. Their body will work to reject the tattoo.
· Blood donations cannot be made for a year after getting a tattoo, body piercing, or permanent makeup.
Questions to ask friends
First:
· Talk to your friends or others who have been tattooed or pierced
· Ask them about their experience, the cost, pain, healing time, etc.
· Ask them what they would do if they had a chance to do it over again.
Second:
· Understand that you do not have to tattoo or pierce your body to belong.
· Remember that you are directly involved in decisions that effect your health and body.
· You can always change your mind or wait if you are not sure.
Third:
· If you decide to have a tattoo or body piercing, never tattoo or pierce your own body or let a friend do it because of potential complications.

How to choose a tattooist or piercing artist?

Visit several piercers or tattooists. The work area should be kept in a clean and sanitary condition and have good lighting. If they refuse to discuss cleanliness and infection control, go somewhere else.
Consent forms (which the customer must fill out) should be handled before tattooing. Reputable piercing and tattoo studios will not serve a minor without signed consent from parents. Check the laws in your state about tattooing of minors if you are under 18.
The tattooist/piercer should have an autoclave - a heat sterilization machine used to sterilize equipment between customers. Most tattooists/piercers are proud of their sterilization equipment.
Packaged, sterilized tattoo needles should be used only once and then thrown away in a special biohazard container.
Leftover tattoo ink should be thrown away after each procedure. Ink should never be poured back into the bottle. Needles should never be inserted into the bottle.
Immediately before tattooing/piercing, the tattooist/piercer should wash and dry his or her hands and put on latex gloves. The gloves should be worn at all times during the tattoo or piercing procedure. If the tattooist/piercer leaves the procedure and touches other objects such as the phone, new gloves should be used.
A piercing gun should not be used because it cannot be sterilized properly. Only jewelry made of a non-corrosive metal, such as surgical stainless steel, niobium, titanium, or solid 14K gold is safe for a new piercing. Gold-plated jewelry should not be used.

Does it hurt?
Tattoo procedure

Adolescents can acquire either a "professional" or amateur tattoo depending upon the law in their state. Typically, the "professional" tattoo is applied by an unlicensed artist using non FDA-approved pigments at a studio. It may have been applied with or without consent from their parent or guardian. Tattoo artists use an electrically powered, vertical vibrating instrument to inject the tattoo pigment 50 to 3,000 times per minutes into the second layer of the skin(dermis), at a depth of 1/64 to 1/16 of an inch. A single needle outlines the tattoo and the design is then filled in with five to seven needles in a needle bar. State regulations of tattooing range from prohibition of tattooing to no regulation at all. In some states with no regulation, local cities set up their own standards. The law for each specific state may be obtained from state, county, or local health departments.
The second method of obtaining a tattoo is from an amateur. More frequently teens obtain their tattoos from friends or self-inflict their own tattoos. These tattoos are done in unclean conditions using objects such as pencils, pens, straight pins, or needles. Pigments injected include India ink, carbon, soot, mascara, charcoal, and dirt. These tattoos are often placed on easy-to-reach parts of the body such as thighs, ankles, forearms, backs of hands and the tops of fingers.
Both types of tattooing carry the risk of catching a blood-borne disease or infection. Needles must be sterilized before use and should not be reused. Leftover dye should not be returned to the bottle after use and the needles should not be placed directly into the bottle. The tattooist should wear latex gloves and should change gloves if the tattooing procedure is interrupted for other activities such as answering the phone or leaving the room.

Body piercing procedure
Teens obtain body piercings by either a studio piercer or an amateur. Earlobe and ear cartilage are the most frequently pierced sites. Other body parts pierced include eyebrow, lip, nose, tongue, nipple, navel, and various genital sites. A hollow needle is passed through the body part followed by the insertion of the body jewelry in the hole. A small amount of bleeding may occur as a result of the piercing. A piercing gun should not be used because it crushes the tissues that are pierced and it cannot be properly resterilized.
The type of jewelry inserted will depend on the body part. For example, a short barbell in the tongue will lead to problems when the tongue starts to swell. The type of jewelry used must accommodate the swelling that follows the piercing procedure. Piercers recommend non-toxic metals such as surgical steel, 14K gold, niobium, or titanium to avoid infections and allergic reactions.
Healing times for body piercing will vary with the site.

Ear lobe 6 to 8 weeks
Ear cartilage 4 months to 1 year
Eyebrow 6 to 8 weeks
Nostril 2 to 4 months
Nasal septum 6 to 8 months
Nasal bridge 8 to 10 weeks
Tongue 4 weeks
Lip 2 to 3 months
Nipple 3 to 6 months
Navel 4 months to 1 year
Female genitalia 4 to 10 weeks
Male genitalia 4 weeks to 6 months
How do I take care of a new tattoo?
Tattoo site care

Tattoo site care is similar to skin care used for a minor burn. The area must be kept clean and moisturized until the tattoo has healed.
Guidelines for skin care of new tattoos:
1. Keep the tattoo covered with the bandage for 2 - 12 hours or overnight. Touch the area as little as possible and do not allow others to touch the new tattoo.
2. Remove the bandage by first wetting the gauze in the shower. Do not rebandage the tattoo.
3. Wash the tattoo with antibacterial soap such as (Dial or Lever 2000) and water to remove all Vaseline and blood. Rinse thoroughly and pat dry with a soft towel. Do not use alcohol or peroxide. They dry out the tattoo.
4. With clean hands, apply a light coat of an antibiotic ointment such as (Neosporin, Bacitracin, or Mycitracin) at least three times a day. Rub it into the tattoo like lotion. The scab will stay soft and won't get hard and crack. Antibiotic ointment can be purchased at any drug store. Ask the pharmacist if you have questions and especially if you are allergic to antibiotics. Do not apply Vaseline or petroleum jelly. It has no healing abilities and will cause a heavy scab to form and the tattoo will become dull.
5. If a rash occurs, stop using the antibiotic ointment and use A and D Ointment or your regular hand lotion.
6. After five days you may stop using an antibiotic ointment and switch to a gentle body lotion such as (Dermassage Lotion or Curel). The brand you use should be a cream-based moisturizer and not greasy. Do not use lotions with perfumes and color additives. Within 7 - 10 days your tattoo should stop feeling tender. Continue to apply the lotion for at least two weeks.
7. Avoid exposure to direct sunlight for four weeks. Five minutes of direct sunlight on any part of the a healing tattoo may trigger an allergic reaction. A strong water proof sun screen (30 spf) is recommended forever.
8. Do not use a tanning bed during the healing process. Even after the tattoo has healed, always wear a bandage over the tattoo in a tanning bed.
9. Soaking in a hot tub, swimming, or taking hot baths can ruin a tattoo. Avoid these activities until the peeling has stopped.
References:
1. http://rapid13.org/tattoo/tat.html
2. Korn, Kenneth, (1996). Body Adornment and tattooing, clinical issues and state regulation. Physician Assistant, 20(5), 85-100.

Body Piercing Site Care

The area around the new piercing must be kept clean and allow the body to heal around the jewelry. Piercing sites that are covered by clothes such as nipple, navel, or genital piercings may become infected because of perspiration and rubbing of clothing. Piercers stress the importance of not fingering the jewelry to prevent infection.
Guidelines for care of new piercing sites:
1. Clean the piercing area with an antibacterial soap such as (Jergens, Dial, Lever 2000) twice a day. This is enough to keep the piercing clean and allow the body to heal. Gently wash the area surrounding and including the piercing with the soap. Remove all crusty formations from the piercing and jewelry. Rinse off the soap, making sure that all the soap and crust formations are gone.
2. Salt water soaks are good to loosen up crusty formations. You can make salt water by adding 1/4 teaspoon of salt to one cup of clean water.
3. You do not need strong cleaning agents if the area is infection-free. Do not use alcohol or Peroxide to clean the area at any time. They will dry out your skin. Betadine (TM) will discolor gold jewelry.
4. Wash your hands with soap before touching or cleaning the pierced part during the healing process. Don't let anyone else touch the pierced part during the healing period.
5. Avoid contact with other people's body fluids. (saliva, sweat, etc.). Even your own sweat may irritate the piercing. Be sure to rinse the area after all exercise to remove all sweat.
6. Always wear clean clothing and change bed-sheets every week during healing. If the piercing is an ear piercing, clean your telephone and sun or eye glasses with Lysol spray or alcohol. Wash the part of eye glasses that touch your ear with soap and water.
7. Check any threaded jewelry in your mouth (such as barbells) twice a day to make sure the ends are tight. You may swallow the barbell or damage a tooth if it comes loose.
8. For ear and cartilage piercings, avoid make-up and powders around your face and neck during the healing process. Cover the pierced part with a tissue when using hair spray.
9. No tight clothes. For navel piercing, don't wear large belts, stockings, body suits, and do not sleep on your stomach. Good air circulation is important for healing.
10. Be careful where you swim. Avoid public pools and hot tubs until the piercing has healed.
11. For mouth care following tongue or lip piercing, choose an antibacterial mouthwash that does not contain alcohol and rinse your mouth after all meals and snacks. If you notice bad breathe and an off-colored tongue the mouth wash may have killed the mouth's own bacteria. If this happens switch to salt water rinses instead of mouthwash.
References:
1. Armstrong, M.L. (1996). You pierced what? Pediatric Nursing, 22(3), 236-238.

What can go wrong?
Tattoo troubles
Tattooing carries the risk of acquiring HIV (although none has been reported), Hepatitis B and C, and tetanus. Years ago, other infections such as TB and syphilis had been reported due to use of fluids such as urine and saliva in the tattooing process. Blood cannot be donated for one year after a person has obtained a new tattoo. If the tattoo was obtained at a studio, the tattooist may provide instructions for the care of the new tattoo. Without proper cleaning and protection from sun, the new tattoo may become a source of infection and the body may work to reject the tattoo. Hypersensitivity to a pigment may result in an allergic response. Tattoo-mediated severe allergic contact dermatitis (severe skin irritation) has been reported with the use of certain pigments. Also reported are sarcoid-like granulomas (large thick scars) developing at the site of the tattoo. Iron oxide used in some eyeliner tattoos has caused tissue injury when the person had a special x-ray study called magnetic resonance imaging (MRI testing).

Piercing problems
Complications from body piercings relate to the body part pierced. Ear cartilage piercings do not heal as quickly as lobe piercings because of the different type of tissue and pressure on the piercing area during sleep. Tongue piercings initially swell a large amount but heal quickly because of the tongue's great blood supply. Nipple piercings may burrow through some of the milk-producing ducts and cause infection or problems if a woman wishes to breast feed an infant later in her life. Navel piercings become infected easily because tight-fitting clothes do not allow enough air to circulate and allow moisture to collect around the piercing site. The teen may have healing problems if the selected jewelry is not the correct jewelry for the pierced area. If the jewelry is too thin or too heavy, the body may reject the jewelry and work to expel it like a splinter. If the jewelry is too small in diameter, the jewelry may cut off the blood supply and cause a lot of swelling and pain.
I've changed my mind. Now what do I do?
Tattoo Removal

Until the recent development of the Q-switched lasers, tattoos were removed by destroying the epidermis and dermis (first and second layers of skin), depending on the depth of the tattoo. Salabrasion, the removal of the tattoo by rubbing salt into the tattoo,and dermabrasion, the scrapping of the skin down to the dermis (second layer of skin) to remove the tattoo, both left extensive scarring at the site. The carbon dioxide laser removed the top layers of skin to expose the tattoo. The tattoo particles were then removed with chemicals such as urea. This method also resulted in scarring.
Three Q-switched lasers are designed for tattoo removal. The Q-switched ruby laser is used in removing blue-black and green pigments. The Q-switched Nd-YAG laser removes blue-black and red pigments. The Q-switched alexandrite laser removes blue-black pigments. The Q-switched laser radiation enters the skin layer where the tattoo granules reside. The energy of the laser breaks down the fibrous capsule around the pigment Waste products from this reaction are either scattered into the air or removed by the body's elimination system. The procedure is slightly painful with the sensation described as the snap of a thin rubberband or specks of hot bacon on the skin. Local anesthetics may be used to reduce the pain during the procedure. The removal of a "professional" tattoo may require 5 to 6 treatments and the removal of an amateur tattoo may require 2 to 4 treatments. The number of treatments depends on the amount and type of ink or pigment used and the depth of the ink in the skin. Dark (blue/black) inks and red inks fade the best. Oranges and purples usually respond well. Green and yellow inks are the most difficult to remove. The cost of laser removal is quite expensive and not covered by insurance. A tattoo that costs $50 to $100 to obtain may cost $1200 to $1500 to remove by laser.