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Herbal product use and perioperative patients
Cheryl MacKichanThe article "Herbal product use and perioperative patients" is the basis for this AORN Journal independent study. The behavioral objectives and examination for this program were prepared by Rebecca Holm, RN, MSN, CNOR, clinical editor, with consultation from Susan Bakewell, RN, MS, BC, education program professional, Center for Perioperative Education. Participants receive feedback on incorrect answers. Each applicant who successfully completes this study will receive a certificate of completion. The deadline for submitting this study is May 31, 2007.
Complete the examination answer sheet and learner evaluation found on pages 963-964 and mail with appropriate fee to
AORN Customer Service c/o Home Study Program 2170 S Parker Rd, Suite 300 Denver, CO 80231-5711
or fax the information with a credit card number to (303) 750-3212.
You also may access this Home Study via AORN Online at http://www.aorn.org/journal/homestudy/default.htm.
BEHAVIORAL OBJECTIVES
After reading and studying the article on the effect of herbal product use on perioperative patients, the nurse will be able to
(1) explain how the historical use of herbal remedies affects herbal medicine practice today,
(2.) identify regulatory guidelines that affect marketing of herbal products,
(3.) discuss the process of herbal product preparation, and
(4.) describe the perioperative implications of herbs that are used preoperatively.
This program meets criteria for CNOR and CRNFA recertification, as well as other continuing education requirements.
A minimum score of 70% on the multiple-choice examination is necessary to earn 2.6 contact hours for this independent study.
Purpose/Goal: To educate perioperative nurses about the effects of herbal product use on perioperative patients.
The increased use of herbal products and the paucity of scientific data on these alternative medications present a special challenge when providing perioperative care. This is especially true for perioperative team members who may not be knowledgeable about alternative medication use in patients undergoing a surgical procedure. This group of patients may be at risk for herbal medication interactions with anesthetic agents and other medications during the surgical procedure. In the context of this literature review, the terms herbal medications, herbal products, herbal remedies, dietary supplements, and alternative medications are used interchangeably. The term health care provider includes physicians, advanced practice nurses, physician's assistants, and perioperative nurses.
ANALYSIS OF THE PROBLEM
Use of herbal products in the United States has increased as much as 380% in the past decade. (1) In 1997, approximately 15 million Americans (ie, one in five individuals) used herbal products or high-dose dietary supplements in combination with prescription medications. One in six patients may be taking herbal products in addition to prescribed treatments. (2) Studies of herbal product use in the preoperative patient population have found that more than 32% of perioperative patients use herbal preparations and other dietary supplements or both. (3-6)
Today, approximately 1,200 to 1,800 herbal products are marketed internationally. (7,8) In the United States, approximately $3 billion to $5 billion is spent on herbal products annually by consumers. (1,8-10) The World Health Organization (WHO) reports that approximately 75% of the world's population "depends on botanical medicines for their basic health care needs." (11) (p41) In its review of the literature, the WHO also reports that 121 prescription medications currently used worldwide are produced directly from plant extracts. Most recently, the discovery of an antineoplastic medication called paclitaxel, which is derived from the Pacific yew tree, underscores the importance of the role that plants play in modern pharmacotherapy. (12)
Awareness of herbal products has increased because of mass marketing via media advertisements. The main sources of information about herbal remedies for women who are 65 years of age and older are magazines, television, and newsletters. (13) Access to herbal remedies also has increased during the past decade. Many herbal products that, at one time, only were available in health food stores or from herbalists now are available in many pharmacies, as well as in grocery and retail stores. (14-16)
Today, consumers often attempt to diagnose their own ailments and seek treatments that are easier to obtain than conventional therapies. With the ease of access to herbal products, consumers can obtain information about herbs via word of mouth from friends and family members, by consulting a sales clerk in a nutrition or herbal store, and on the Internet. (2,14)
In studies that reported an increase in herbal product use, a large percentage of patients did not inform their health care providers about herbal product or dietary supplement use. (1,3,4,6) Health care providers who were not informed about herbal product use included primary care physicians and anesthesia care providers. (3,4,6) Not informing their health care providers about herbal product use puts patients at risk for avoidable herb-medication interactions that could be lethal. During routine preoperative assessment of patients awaiting surgery, health care providers must ask about use of herbal and dietary supplements.
HISTORICAL SIGNIFICANCE
Herbal remedies have been used for the prevention and treatment of disease and for healing purposes since before the beginning of human civilization. (12,15,16) Chinese texts written by the Yellow Emperor Huang Di detail use of herbal remedies that date back to 2,697 BC. (11) Chinese medicine today continues to incorporate these ancient traditions by using herbal remedies based on the concepts of yin and yang and qi energy. (16) Hippocrates, who trained with an Egyptian physician at the Alexandria School of Medicine from 466 to 377 BC, used herbal medicine in his practice and in the education of others. The Greek physicians' Dioscorides's Materia Medica, written in the first century AD, still is one of the world's greatest references on herbs. (11) Herbal preparations used in Europe and Asia for centuries now are considered an accepted part of medical practice in these countries. (8,15)
Many modern medications originate from plant sources. A century ago, most of the few effective medications available were plant based. For example, morphine, which is used to treat pain, is a derivative of the opium poppy. Digoxin, which is used to treat congestive heart failure, is derived from foxglove. Quinine and quinidine, which are used to treat malaria and cardiac arrhythmias, respectively, are derived from the willow bark of South American trees of the Cinchona genus. These early discoveries by scientists and herbalists, who experimented with botanical extracts, have enhanced the development of many important modern pharmaceuticals. (11,12,15)
LACK OF REGULATORY GUIDELINES
Currently, herbal products are marketed and sold as dietary supplements and, therefore, are not subject to regulation by the US Food and Drug Administration (FDA). Before 1994, all dietary supplements were regulated as food and were evaluated for safety before being placed on the market for consumer purchase. This regulation included herbs. In 1994, Congress passed the Dietary Supplement Health and Education Act (DSHEA), establishing new regulatory guidelines for dietary supplements. Under this act, herbs can be sold without FDA approval. (8,14,17-19) A dietary supplement is defined by DSHEA as containing one or more of the following ingredients:
* a vitamin;
* a mineral;
* an herb or botanical;
* an amino acid;
* a dietary supplement to enhance the diet by increasing dietary intake; or
* any concentrated metabolite, constituent, extract, or combination of any of the aforementioned ingredients. (14)
Dietary supplement products must be labeled and can be advertised as having healthful or nutritional properties, but they cannot claim therapeutic properties, such as prevention or treatment of disease; however, manufacturers can allude to a therapeutic use. (8,14,19) In March 1999, a new labeling regulation was implemented requiring that dietary supplements be labeled with a complete list of ingredients. Information such as medication interactions, side effects, contraindications, or warnings, however, is not required on the label of a dietary supplement. (19) The only way a dietary supplement can be withdrawn from the consumer market is if the FDA can prove that the product is unsafe. (8,14,19)
There currently are no federal regulations that control identification and purity of ingredients in herbal products, and there are no regulatory requirements or defined procedures for manufacturing herbal products. (8,14,17,19) Research to determine the safety and efficacy of herbal products has been published primarily in non-North American medical and botanical journals. (18) In the United States, there have been very few randomized clinical trials that can scientifically support or disprove the effectiveness of herbal products. (2,10-12) The German Commission E Monographs: Therapeutic Monographs on Medicinal Plants (20) is referenced by several authors as an accurate informational resource on herbs. (1,7,21,22) The German Commission E is a German government agency that regulates production of German herbal products. This government agency licenses manufacturers of herbal medicines based on demonstrated evidence of safety and effectiveness. (8,11,18,19)
HERBAL PREPARATIONS AND CONSUMER SAFETY
Lack of scientific research on herbs, combined with the lack of FDA regulation of herbal preparations, can give consumers a false sense of security about the safety of herbal products. (1,7,17) Although it generally is agreed that most medicinal herbs are safe, some are toxic and potentially may be lethal when used in combination with commonly prescribed medications. (12,16,17,23) Consumers also may be receiving information that is not accurate or complete. It often is difficult to evaluate herbal products because of the lack of manufacturer guidelines. Herbal products often are labeled natural, so consumers may equate this with being safe and harmless and neglect to read the actual botanical names or concentrations of herbal preparations. (14)
Another concern is that consumers often think that if a small amount of medication is good, then a larger amount is even better. Herbs that are considered safe may become toxic and potentially lethal when taken in larger-than-recommended amounts. In addition, herbal products differ in chemical concentration and preparation from one manufacturer to the next. Many environmental conditions affect the quality of herbs before processing. Some of these environmental factors include the use of pesticides on plants, the amount of rainfall or sunlight the plant receives, and how the herbs are dried and stored before production. (7,14,16,17,19) Adverse reactions to herbal preparations, however, seem to occur most often in herbs that are imported from areas outside North America and Europe. (16) Consumers who have existing allergies to any plants or pollens must consider these allergies when taking herbal remedies. (14) Some allergies can enhance adverse reactions and have potentially lethal consequences.
SOCIOECONOMIC AND DEMOGRAPHIC DATA
In the 1990s, alternative medicine use was not specific to any narrow segment of society. (1) An exploratory study that examined alternative medicine use determined that use was more common in women than men and less common among African Americans compared to other ethnic groups. (2) Participants aged 35 to 49 reported higher use of alternative medicines than those older than 49 and younger than 35. Herbal product use was most common in the western United States and more common among consumers with annual incomes greater than $50,000. Those surveyed were representative of the population distribution published by the US Bureau of the Census. (1)
In the same study, it was determined that consumers who used alternative medications came from a variety of socioeconomic backgrounds, and no differences in sociodemographic characteristics were identified. (2) Ethnicity was one identified difference, however. (24,25) Asian/Pacific Islanders used herbs 29% more than Caucasians and African Americans. One-fifth to one-half of the people of Asian/Pacific Island sociodemographic background in this study used herbal products. (24,25) Finally, older Americans who used alternative medicines came from all sociodemographic groups. (26)
INSURANCE COVERAGE FOR HERBAL THERAPIES
Insurance companies often do not cover herbal products or therapies. Insurance policies that do cover alternative therapies generally have high deductibles and copayments. These policies usually mandate low levels of capitation on the total amount that can be allocated for these services. Increased alternative therapy use in the United States, despite the lack of insurance coverage, is noteworthy. (1) Some authors believe that the rising cost of conventional medications has led patients to seek less expensive alternatives. (1,12,14)
HERBAL MEDICINE PROVIDERS
Research literature today indicates that if consumers are going to use alternative therapies, they do so by seeing specialists in the area of interest. Herbal medicine providers often are known as herbalists. (1,14,16) Training programs vary, and, currently, there is no guarantee of a provider's competence, whether in the United States or internationally, particularly because standards and regulations have been inconsistent for some time. (16) Herbalists generally use unpurified plant extracts, which contain many constituents. Herbalists claim that herbs used together work synergistically and that toxicity is reduced when whole plants are used instead of active ingredients, a process known as buffering. This differs from conventional pharmaceuticals because conventional medications generally are not dispensed as polypharmocological preparations. (16)
Herbalists focus on treating chronic conditions and improving well-being. Like conventional health care providers, herbalists obtain extensive histories and perform comprehensive physical examinations. In addition, they typically assess everyday body processes, such as appetite, digestion, defecation, urination, and sleep. Herbalists tend to treat their patients using these body functions as indicators of underlying causes of chronic illnesses. Follow-up appointments are similar to those used in conventional medicine. Herbalists tend not to treat musculoskeletal or acute mental disorders. (16)
Many herbalists have some formal training. Currently, the American Herbalists Guild is the only peer-review organization for herbalists in the United States. This organization maintains a record of registered members who have been evaluated and recognized in the field of herbal medicine. The organization offers a course consisting of 1,200 didactic and 400 clinical hours. Credentialing and certification still are nonexistent in the United States and internationally. Typically, herbalists have solo practices or practice in complementary medicine clinics. (27)
MOST COMMONLY USED HERBAL PRODUCTS
Eight of the most commonly used herbal products may have adverse side effects and implications for the care of perioperative patients. (7) Effects of herbal products include
* direct interactions (ie, intrinsic pharmacological effects);
* pharmacodynamic interactions (ie, alteration of the action of conventional medications at effect or sites); and
* pharmacokinetic interactions (ie, alteration of absorption, distribution, and metabolism; elimination of conventional medications).
Bleeding, cardiovascular instability, and hypoglycemia are direct pharmacological effects that may result from the use of these herbs. Pharmacodynamic interactions that are neither well understood nor documented may occur because of herb-medication interactions. Pharmacokinetic herb-medication interactions, such as increased metabolism caused by several medications used in the perioperative period, have potentially lethal consequences. (7) Table 1 contains an overview of the eight most commonly used herbal products, indications for use, and related perioperative issues.
INFORMATION REGARDING USE OF HERBAL MEDICINE
Pharmacists are in a unique position to answer questions concerning herbal preparations. A study of pharmacists' knowledge, however, found that "scores measuring pharmacists' knowledge of herbal products were relatively low." (9) (p713) The pharmacists in this study were not well informed about herbs and their adverse effects, potential herbal-medication interactions, or precautions. Pharmacists who were able to address issues concerning herbs had previous education or continuing education about herbal therapies. (9)
Several researchers have determined that people are less likely to inform their own physician or health care provider about use of herbal products. (1,3,13,28) In one study, 70% of patients who used alternative therapies did not report them to their physicians. (1) Another study, which investigated herbal product use among patients in family practice facilities in Oregon, discovered that only 53% of patients informed their physicians about alternative medication use. (24) Fifty-seven percent of patients did not report their use of herbal products to health care providers.
Reasons patients cite to explain why they do not tell their health care provider are many. (26)
* Often consumers do not consider herbal products as medications.
* Herbal products are relatively inexpensive.
* Patients do not need a prescription to purchase herbal products.
* Many herbal products are marketed as natural; therefore, consumers believe the products to be safe.
* Providers do not ask their patients about herbal product use; thus, acknowledgement of use is absent or ignored. (1,8,14,18,29)
Providers may fail to inquire about herbal use because they are not informed about the widespread use of herbs; however, consumers may perceive the lack of inquiry to mean the topic is unimportant or taboo.
Most herb and herbal preparation research has been conducted in Germany because that medical and social culture is accepting of herbal medicine therapy. Herbal medicines largely are unregulated in the United States, whereas in Germany, herbal products are evaluated and regulated by the German Commission E. (8,11,18,19)
Reports of serious adverse reactions or side effects from herbal products are rare in comparison to pharmaceutical medications. An estimated 106,000 deaths occur each year in hospitalized patients because of adverse reactions to appropriately prescribed pharmaceutical medications. (30) Many of the most commonly used herbal products usually are harmless if taken as recommended in appropriate doses. European studies that monitored thousands of people taking ginkgo biloba, St John's wort, and other commonly prescribed herbal products determined that the adverse effects of these medications primarily are mild. Side effects were described as infrequent dermatological reactions or gastrointestinal distress. These adverse effects were seen in less than 3% of the population and occurred at the same rate as in placebo groups. (19) The reportedly low incidence of side effects from herbal products may reflect several factors, including the weaker pharmacological activity of herbal products, the lack of an established reporting system for adverse reactions to herbal products, and overall less consistent use of herbs by patients. (11,16,19)
HERBAL PRODUCT USE AND PERIOPERATIVE PATIENTS
The significant increase in herbal product use in the United States, combined with the increase in consumer interest in alternative and herbal therapies in the past decade, has important implications for perioperative patients. Scientific evidence is not available to clearly show the potential interactions between herbal and modern pharmaceuticals. One area of concern is the interaction of herbal products with anesthetic agents. Patients who have not informed health care providers about their herbal product use are in danger of experiencing potentially life-threatening adverse reactions or herb-medication interactions when anesthesia is administered during surgical procedures. For the perioperative patient, "the prevention, recognition, and treatment of complications begin with explicitly eliciting and documenting a history of herbal medicine use." (7) (p208)
Conclusions drawn from authors discussing herbal product use suggest that health care providers in every setting must be familiar with the scientific literature on herbal medicine and other alternative therapies. This knowledge will help providers ask appropriate, nonjudgmental questions about product names, dosages, frequency, side effects, and the client's perception of effectiveness regarding herbal product use when obtaining patient histories. (31) Being educated and well informed about herbs and herbal products, including having knowledge of current research, allows health care providers to answer patients' questions and address concerns. (4,5,7,11,18) Although, information is not yet available regarding all potential side effects and interactions from herbal products, providers can anticipate possible problems so care can be planned accordingly. (31)
Currently, it is recommended that use of herbal products be discontinued two to three weeks before surgery. The American Society of Anesthesiologists does not have an official standard, but it suggests this period of time as a guideline. (21) This may be an impossible expectation in practice considering the number of nonelective surgical procedures performed each year. (7) Being knowledgeable about the most commonly used herbal products and being able to recognize and treat complications is a priority. Discontinuation of herbal products before surgery does not ensure that patients will be free of the risk of complications during the procedure. Complications still may occur in the perioperative and postoperative periods. More knowledge, therefore, is needed to recognize problems that may arise.
Guidelines for preoperative assessment and patient education about herbal products have been proposed. These include
* avoiding herbal remedies if nursing or pregnant;
* checking facts about herbal product claims with a qualified health care professional;
* discontinuing use of herbal products if any untoward effect or unusual symptom occurs and reporting this to a health care provider;
* discussing herbal product use with all health care providers;
* purchasing herbal products that have been standardized in terms of known effects for a given dose;
* reading the labels of herbal products carefully;
* using caution when giving herbal products to children and older adults; and
* using only recommended products that are labeled with the
* scientific name of the herb;
* manufacture date;
* expiration date;
* lot number;
* proof of adherence to good manufacturing practice (ie, standards established for food processing);
* proof that the product has undergone scientific testing; and
* the address of the supplier. (18) (p183)
Three research-based reports are available regarding herbal products and preoperative surgical patients. These reports are descriptive studies that used self-report questionnaires about herbal product use before surgery. The conclusions drawn from these research reports indicate that herbal product use among preoperative patients is common, with 22% to 73% of patients reporting alternative medicine use. (3-6) Herbal products may prolong coagulation time, affect blood pressure, act as a sedative, affect cardiac function, or affect electrolytes. (5) About 50% of patients report discontinuing use before surgery. (4) This implies that the other 50% did not discontinue herbal product use before surgery, putting them at risk for complications. Surgery was cancelled for one patient with prolonged clotting times who had taken ginkgo biloba for several weeks before surgery. (4)
Reasons cited by patients for taking herbal products include
* self-prescribed to improve general health,
* recommendation from a friend or family member, and
* recommendation of a health care provider or media sources. (4,6)
Understanding reasons for taking herbal products may help health care providers tailor preoperative teaching so patients understand the importance of reporting use and, in many instances, discontinuing use before surgery.
It is evident that herbal medicine research, as it relates to implications for perioperative patients, is just beginning. It is important for clinicians to understand how herbal products function and how herb-medication interactions affect the perioperative patient.
TABLE 1
Commonly Used Herbal Products
Herb Perioperative
(Scientific name) Indications for use concerns/instructions
Echinacea (1-3)
(Echinacea * Prevents and treats * May cause allergic
angustifolio, bacterial, viral, reactions
E purpura, E pallida) and fungal infections * Decreases
effectiveness of
immunosuppressants
* May cause
immunosuppression
Ephedra (1,4-6)
(Ephedra sinica, * Increases energy * May cause insomnia,
ma Huang) * Acts as an appetite tachycardia,
suppressant headache,
* Acts as a irritability,
bronchodilator restlessness,
nausea, cardiac
arrhythmias,
myocardial
infarction, cardiac
arrest, seizure,
stroke, or death
Garlic (1-3,5,7)
(Allium sativum) * Lowers cholesterol * Inhibits platelet
* Reduces blood aggregation
pressure and thrombus * Prolongs bleeding
formation and clotting times
* Acts as an * Discontinue seven
antibacterial and days before surgery
antimycotic
Ginkgo (1,3,5,6,8,9)
(Ginkgo biloba) * Treats cognitive * Decreases blood clot
disorders, peripheral formation
vascular disease, * Increases risk of
vertigo, and tinnitus bleeding
* Inhibits platelet
aggregation
* Discontinue at least
36 hours before
surgery
Ginseng (1,3,6)
(Panax) * Treats hemoptysis, * Inhibits platelet
gastric disturbances, aggregation
and vomiting * Increases risk of
* Protects against bleeding
stress * Causes hypoglycemia
* Combats weakness and edema
* Potential
interaction with
warfarin
* Potential
interaction
with stimulants
* May cause
hypertension or
tachycardia
* Discontinue seven
days before surgery
Kava (1,5,10)
(Piper methysticum * Acts as an * Possibly potentiates
rhiszoma) antispasmodic and any substance that
anticonvulsant by its affects the central
central muscle nervous system (CNS)
relaxation effects (ie, anesthetics,
* Causes hypnosis, barbiturates,
sedation, and benzodiazepines)
analgesia * Discontinue at least
* Acts as a 24 hours before
psychotropic surgery
NOTES
(1.) D M Eisenberg et al, "Trends in alternative use in the United States, 1990-1997: Results of a follow-up national survey," JAMA 286 (November 1998) 1569-1575.
(2.) E M Johnson et al, "Use of herbal therapies by adults seen in an ambulatory care research setting: An exploratory survey," The Journal of Alternative and Complementary Medicine 6 (October 2000) 429-435.
(3.) A D Kaye et al, "Herbal medications: Current trends in anesthesiology practice--A hospital survey," Journal of Clinical Anesthesiology 12 (September 2000) 468-471.
(4.) J M Leung et al, "The prevalence and predictors of the use of alternative medicine in presurgical patients in five California hospitals," Anesthesia and Analgesia 93 (August 2001) 1062-1068.
(5.) CL Norred, S Zamudio, S K Palmer, "Use of complementary and alternative medicines by surgical patients," AANA Journal 68 (February 2000) 13-18.
(6.) L C Tsen et al, "Alternative medicine use in surgical patients," Anesthesiology 93 (April 2000) 148-151.
(7.) M K Ang-Lee, J Moss, C Yuan, "Herbal medicines and perioperative care," JAMA 286 (July 2001) 208-216.
(8.) K Flanagan, "Preoperative assessment: Safety considerations for patients taking herbal products," Journal of PeriAnesthesia Nursing 16 (February 2001) 19-26.
(9.) Z G Chang et al, "Pharmacists' knowledge and attitudes toward herbal medicine," The Annals of Pharmacotherapy 34 (June 2000) 710-715.
(10.) K B Keller, L Lemberg, "Herbal or complementary medicine: Fact or fiction?" American Journal of Critical Care 10 (November 2001) 438-443.
(11.) B Barrett, D Kiefer, D Rabago, "Assessing the risks and benefits of herbal medicine: An overview of scientific evidence," Alternative Therapies 5 (July 1999) 40-49.
(12.) N H Mashour, G I Lin, W H Frishman, "Herbal medicine for the treatment of cardiovascular disease: Clinical considerations," Archives of Internal Medicine 158 (November 1998) 2225-2234.
(13.) S Yoon, C H Horn, "Herbal products and conventional medicines used by community-residing older women," Journal of Advanced Nursing 33 (January 2001) 51-59.
(14.) C Brumley, Herbs and the perioperative patient," AORN Journal 72 (November 2000) 785-796.
(15.) B B Turkoski, "Common herbal remedies," Orthopedic Nursing 19 (January/ February 2000) 83-89.
(16.) A Vickers, C Zollman, R Lee, "Herbal medicine," Western Journal of Medicine 175 (August 2001) 125-128.
(17.) C Mar, S Bent, "An evidenced based review of the 10 most commonly used herbs," Western Journal of Medicine 171 (September 1999) 168-171.
(18.) J M Murphy, "Preoperative considerations with herbal medicine," AORN Journal 69 (January 1999) 173-183.
(19.) M D Rotblatt, "Herbal medicine: A practical guide to safety and quality assurance," Western Journal of Medicine 171 (September 1999) 172-175.
(20.) M Blumenthal ed, German Commission E Monographs: Therapeutic Monographs on Medicinal Plants (Austin, Tex: American Botanical Council, 1998).
(21.) "Considerations for anesthesiologists: What you should know about your patients' use of herbal medicines," American Society of Anesthesiologists, http://www.asahq.org /patientEducation/herbPhysician.pdf (accessed 11 March 2004).
(22.) T Fleming ed, PDR for Herbal Medicines, second ed (Montvale, NJ: Medical Economics, 2000).
(23.) M C Lin et al, "State of complementary and alternative medicine in cardiovascular, lung, and blood research: Executive summary of a workshop," Circulation 103 (April 2001) 2038-2041.
(24.) N C Elder, A Gillcrist, R Minz, "Use of alternative health care by family practice patients," Archives of Family Medicine 6 (March/April 1997) 181-184.
(25.) O L Hung et al, "Herbal preparation use among urban emergency department patients," Academic Emergency Medicine 4 (March 1997) 209-213.
(26.) D F Foster et al, "Alternative medicine use in older Americans," The Journal of American Geriatrics Society 48 (December 2000) 1560-1565.
(27.) A Vickers, C Zollman, "ABC of complementary medicine: Herbal medicine," British Medical Journal 319 (October 1999) 1050-1053.
(28.) J Gulla, A J Singer, "Use of alternative therapies among emergency department patients," Annals of Emergency Medicine 35 (March 2000) 226-228.
(29.) D M Eisenberg, R C Kessler, C Foster, "Unconventional medicine in the United States: Prevalence, cost, and patterns of use," The New England Journal of Medicine 328 (January 1993) 246-252.
(30.) J Lazarou, B H Pomeranz, P N Corey, "Incidence of adverse drug reactions in hospitalized patients: A meta-analysis of prospective studies," JAMA 279 (April 1998) 1200-1205.
(31.) J Lefever Kee, E R Hayes, Pharmacology: A Nursing Process Approach, fourth ed (Philadelphia: Saunders, 2002) 168-184.
Examination
Herbal product use and perioperative patients
1. One of the world's greatest references for herbs is the
a. Dioscorides's Materia Medica.
b. Internet.
c. German Commission E Monographs.
d. Physician's Desk Reference.
2. Quinine is derived from
a. foxglove.
b. opium poppies.
c. sweet pea blossoms.
d. willow bark.
3. Under the Dietary Supplement Health and Education Act of 1994, new regulatory guidelines for dietary supplements require US Food and Drug Administration approval for the sale of herbs.
a. true
b. false
4. A new labeling regulation implemented in March 1999 requires that dietary supplements be labeled with
1. a complete list of the ingredients.
2. contraindications.
3. medication interactions.
4. side effects.
5. warnings.
a. 1
b. 2 and 3
c. 1, 4, and 5
d. 1, 2, 3, 4, and 5
5. Environmental factors that can affect the quality of herbs before processing include
1. amount of rainfall received.
2. how the herbs are dried and stored before production.
3. nutrient content of the soil.
4. pesticide use.
5. quantity of sunshine received.
a. 1 and 3
b. 1, 2, 4, and 5
c. 2, 3, 4, and 5
d. 1, 2, 3, 4, and 5
6. Buffering is believed to be a process that reduces toxicity of herbal products by
a. adding sodium bicarbonate as a buffering agent.
b. containerizing data regarding toxic interactions.
c. using whole plants instead of active ingredients.
7. Examples of direct pharmacological effects include
1. bleeding.
2. cardiovascular instability.
3. hypoglycemia.
4. increased metabolism.
a. 1 and 2
b. 3 and 4
c. 1, 2, and 3
d. 1, 2, 3, and 4
8. Which herbs should be discontinued at least seven days before surgery because they inhibit platelet aggregation?
a. garlic and ginseng
b. garlic and kava
c. ginkgo and ephedra
d. ginkgo and valerian
9. Which of the following herbs are used to treat depression?
a. kava and ginkgo
b. ginkgo and St John's wart
c. valerian and ephedra
d. valerian and St John's wort
10. When educating patients about herbal product use, ensure that only recommended herbal products are used that are labeled with
1. proof of good manufacturing practice.
2. proof of scientific testing.
3. the lot number.
4. the manufacture and expiration dates.
5. the scientific name of the herb and address of the supplier.
a. 2 and 4
b. 1, 3, and 5
c. 2, 3, 4, and 5
d. 1, 2, 3, 4, and 5
Answer Sheet
Herbal product use and perioperative patients
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Learner Evaluation
Herbal product use and perioperative patients
Objectives
To what extent were the following objectives of this Home Study Program achieved?
1. Explain how the historical use of herbal remedies affects herbal medicine practice today.
2. Identify regulatory guidelines that affect marketing of herbal products.
3. Discuss the process of herbal product preparation.
4. Describe the perioperative implications of herbs that are used preoperatively.
Content
5. Did this article increase your knowledge of the subject matter?
6. Was the content clear and organized?
7. Did this article facilitate learning?
8. Were your individual objectives met?
9. How well did the objectives relate to the overall purpose/goal?
Test Questions/Answers
10. Were they reflective of the content?
11. Were they easy to understand?
12. Did they address important points?
Learner Input
13. Will you be able to use the information from this Home Study in your work setting?
a. yes b. no
14. I learned of this Home Study via
a. the Journal I receive as an AORN member.
b. a Journal I obtained elsewhere.
c. the AORN web site.
d. SSM Online.
15. What factor most affects whether you take an AORN Journal Home Study?
a. need for contact hours
b. price
c. subject matter relevant to current position
d. number of contact hours offered
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AORN Home Study
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Purpose/Goal: To educate perioperative nurses about the effects of herbal product use on perioperative patients.
Cheryl MacKichan, RN, BSN, CCRN, is a certified RN anesthetist intern at Bailey University/Decatur Memorial Hospital, Decatur, Ill.
Jacklyn Ruthman, RN, PhD, is an assistant professor at Bradley University, Peoria, Ill.
COPYRIGHT 2004 Association of Operating Room Nurses, Inc.
COPYRIGHT 2004 Gale Group