Tips against Ticks: What You Need To Know!

by: Brittany Thelemann, PharmD Candidate 2017, Drake University College of Pharmacy and Health Sciences

Do you have plans of hiking, golfing, or even hanging out in your backyard anytime soon? Then you need to be aware of ticks! While it is a good idea to take preventive measures against ticks year-round, it is important to be extra vigilant in warmer months (April-September) when ticks are most active. Here are some of the most important tips that you and your family should be aware of:

  • Avoid wooded and brushy areas with high grass and leaf litter
  • Mow the lawn frequently.
  • Walk in the center of trails.
  • Use repellents that contain 20 to 30% DEET on exposed skin and clothing for protection that lasts up to several hours. (Make sure to avoid the hands, eyes, and mouth!)
  • Use products that contain 0.5% permethrin on gear and clothing, such as boots, pants, socks and tents. Pre-treated clothing is also available and may have longer lasting protection.
  • Bathe or shower as soon as possible after coming indoors (preferably within two hours) to wash off and more easily find ticks on your body.
  • Conduct a full-body tick check with a mirror. Don’t forget to check under the arms, in and around the ears, inside the belly button, behind the knees, between the legs, around the waist, and especially in your hair!
  • Examine gear, children, and pets. Ticks can ride into the home then attach to a person later!
  • Tumble dry clothes in a dryer on high heat for 10 minutes to kill ticks on dry clothing after you come indoors.

How to Remove Ticks:


  • Use fine-tipped tweezers to grasp the tick as close to the skin’s surface as possible.
  • Pull upward with even pressure. Don’t twist or jerk the tick! (This can cause the mouth-parts to break off and remain in the skin). If this happens, remove the mouth-parts with tweezers.
  • After removing the tick, thoroughly clean the bite area and your hands with rubbing alcohol, an iodine scrub, or soap and water.
  • Dispose of a live tick by submersing it in alcohol, placing it in a sealed bag/container, wrapping it tightly in tape, or flushing it down the toilet– Never crush a tick with your fingers!
  • DO NOT use heat to make the tick detach from the skin!
  • DO NOT “paint” the tick with nail polish or petroleum jelly

Symptoms of a Tick Bite:

  • Rash
  • Fever
  • Fatigue
  • Chills
  • Muscle ache
  • Joint pain
  • Paralysis


Seek Medical Attention Immediately if you or a family member develops these symptoms!! Be sure to tell the doctor about your recent tick bite, when the bite occurred, and where you most likely acquired the tick. Not doing so may lead to serious illnesses such as Lyme’s Disease, Rocky Mountain Spotted Fever, STARI, Tularemia, and many others. Know the risks of tick bites and keep your family safe!

All information was taken from the CDC- Centers for Disease Control and Prevention,

What is Telepharmacy?

Defined simply, telepharmacy is the provision of pharmacy services at a distance. While used in countless ways across various pharmacy practice settings, the most relevant example to NuCara is telepharmacy in a community pharmacy practice.

As a leader in rural health care, telepharmacy is a natural fit to NuCara. We currently own and operate three telepharmacy sites and are providing the verification and counseling services for an additional four sites in Illinois. A telepharmacy operates just like a traditional community pharmacy, however the pharmacist verifies the prescriptions and counsels the patient through the use of technology. Patients will receive the same level of service at a NuCara telepharmacy as they do at any other NuCara Pharmacy.


Zearing, home to NuCara’s first pilot telepharmacy location in Iowa.

NuCara first entered the world of telepharmacy in 2013 with the opening of the second telepharmacy pilot in the state of Iowa in Zearing. Since then, we have welcomed Enderlin, North Dakota, to the NuCara family as well as a second Iowa pilot site in State Center.

With the recent legislation signed by Iowa Governor Branstad, we expect more telepharmacy services to be in our future. We have gathered excellent patient safety and have been working to provide additional pharmacist-provided clinical services such as immunizations and MTM into our telepharmacy sites.

Additionally, we are very excited about the “hybrid” telepharmacy model, which we define as having a pharmacist on site at least one day each week. This allows the efficiency of a telepharmacy, while providing regular access to an on-site pharmacist. NuCara has also used the same technology to provide quick and easy assess to other specialists, like respiratory therapists, to our patients in rural areas. As technology evolves, NuCara continues to be a pioneer in how to best serve our patients through innovation.

A New Perspective to Pharmaceutical Care

130826 Angela Thompson 2.jpg
Angela Thompson, PhD, PharmD, CGP, recently received her certification to be a Geriatric Pharmacist.

Licensure to practice the profession of pharmacy requires passing a licensure examination. This licensure exam covers a very broad range of topics and knowledge. However, the basic licensure examination does not ensure that the pharmacist has an in-depth knowledge of geriatric drug therapy.

With the aging of the baby boomer population, pharmacists are starting to look at treating their patients in a new way. What is different about older adults is the common presence of multiple diseases at the same time, along with multiple medications. Older adults also frequently have diminished kidney and liver function, which may require different doses or the use of different medicines than in younger adults.

Angela Thompson, Pharmacist at NuCara Pharmacy in Valley City, ND, recognized the need for further education and was recently certified as a Geriatric Pharmacist by the Commission for Certification in Geriatric Pharmacy. Thompson operates NuCara Long Term Care Pharmacy, located within 170 bed skilled care facility. NuCara is the onsite provider pharmacy and Thompson serves as the consultant pharmacist.

“The geriatric pharmacist knows that the focus must be on the total patient, looking at all of the diseases and all of the medicines to evaluate appropriateness of drug therapy,” says Thompson. “The geriatric pharmacist also knows that the elderly are subject to conditions, such as falls, delirium, and cognitive impairment, which are not usually a concern in younger adults.”

The contributions of the Certified Geriatric Pharmacist are especially important as the population continues to age. Drug therapy must be evaluated with respect to the potential for medications to cause or worsen these “geriatric syndromes.”

How a Certified Geriatric Pharmacist Can Help Reduce Risk for Medication-related Problems

The Certified Geriatric Pharmacist (CGP) has passed a comprehensive examination to demonstrate knowledge and expertise in the use of medicines in older adults. These pharmacists are entitled to put the initials “CGP” after their name. Almost 2,000 pharmacists have achieved the CGP credential. Some of these pharmacists, like Thompson, provide consultations to older adults.

Many older adults have complex medication regimens, involving multiple medications from multiple prescribers.  In many cases, a caregiver (such as a relative) may be providing assistance with managing the medications.  In these situations, CGP can be a valuable addition to the team. The CGP can:

  • Partner with you and other health professionals to help ensure appropriate use of medications
  • Help evaluate benefits and risks of the medications
  • Answer questions about the medications

Heart Health: Lowering Blood Pressure without Medications


By: Shanrae’l Vinel, MPH, Pharm D Candidate Class of 2016

Supervised By: By Pamela Wiltfang, Pharm.D., M.P.H., B.A., CHES, NuCara Pharmacist

About 1 in 3 Americans have hypertension (high blood pressure). Only about half of all people with high blood pressure have their condition under control. If left untreated, high blood pressure can lead to other health problems such as stroke, heart failure and kidney disease. A normal blood pressure is less than 120/80mmHg. People have high blood pressure when either their systolic blood pressure (the top number) or their diastolic blood pressure (bottom number) is above normal. Prehypertension is a stage when you are at risk for having high blood pressure. People who have high blood pressure may not be able to feel that their blood pressure is high. It is important to remember that high blood pressures can cause damage to your heart, blood vessels and kidneys even if you feel well. If a person can lower their blood pressure to normal just by making lifestyle changes, then they may not need medications.

  Systolic Blood Pressure

(Top Number)

Diastolic Blood Pressure

(Bottom Number)

Normal Less than 120 mmHg Less than 80 mmHg
Prehypertension 120 to 139 mmHg 80 to 89 mmHg
Hypertension Greater than 140 mmHg Greater than 90 mmHg

Risk Factors for High Blood Pressure

There are some things that can put you at risk for having high blood pressure.

  • Family History of High Blood Pressure
  • Race
  • Age
  • Other Chronic Conditions (Examples include diabetes and kidney disease)
  • Prehypertension
  • Unhealthy Diet
  • Physical Inactivity
  • Obesity
  • Tobacco Use
  • Too Much Caffeine
  • Too Much Alcohol

How to Lower Blood Pressure

People who have been diagnosed with prehypertension or hypertension can lower their blood pressure with a combination of medications and lifestyle changes. Lifestyle changes include: exercise, weight loss, improving your diet, and reducing your caffeine and alcohol consumption. The table shows how much each of these changes can lower your blood pressure.

Activity Blood Pressure Lowering
Weight Loss 5 – 20 mmHg
Exercise 4 – 9 mmHg
Sodium Reduction 2 – 8 mmHg
Improving Diet 8 – 14 mmHg
Reducing Caffeine Intake 5 – 10 mmHg
Reducing Alcohol Intake 2 – 4 mmHg
Smoking Cessation 5 – 20 mmHg


Adding 150 minutes of cardio exercise per week can help reduce blood pressure. The exercise can be divided into 30 minute intervals throughout the week. Cardio exercise includes activities such as walking, running, swimming, biking and dancing.


Your diet can be improved by gradually adding fruits and vegetables, eating more lean meats and eating lower fat dairy products. An example of a healthy diet is the DASH (Dietary Approaches to Stop Hypertension) diet:

Food Type Recommended Number of Servings Examples
Vegetable 4 to 5 Carrots, squash, cucumber, and lettuce
Fruit 4 to 5 Bananas, tomatoes, avocados, dates, tomatoes, raisins, cantaloupe, and oranges
Dairy 2 to 3 Low fat or fat free milk, yogurt, and cheese
Grains 7 to 8 Whole grain bread
Meat 2 or fewer Lean beef, poultry or seafood
Other proteins 4 to 5 Nuts, seeds, or beans
Fats 2 to 3 Fats and oils
Sugars 5 or fewer Pastries, candies, other sweets

Sodium Reduction

Sodium can raise blood pressure by forcing your body to retain water. This makes your heart and kidneys work harder and can make blood pressure medications less effective. Limit sodium intake to 2,300 milligrams or less. You can do this by reading food labels to figure out the sodium content of what you are eating, eating fewer processed foods and not adding salt to your food. It may be easier to ease into a reduced sodium diet gradually so that you can get used to your food tasting different.

Weight Loss

Improving diet and exercise can lead to weight loss. A healthy rate of weight loss is 1 to 2 pounds per week, which can be achieved by burning or cutting out 3500 calories per week. Large waist circumference has also been associated with heart disease. To reduce their risk, men should limit their waist circumference to less than 40 inches and women should limit their waist circumference to less than 35 inches.


Drinking caffeine containing beverages can cause spikes in blood pressure of 5 to 10 mmHg. Try to limit your caffeine consumption to 200 milligrams per day, which is about two 12oz brewed cups of coffee. To determine how much caffeine is in your beverages please read food labels on caffeine containing beverages such as soda or coffee. Some other sources of caffeine include flavored water, chocolate, tea, and ice cream.


Drinking too much alcohol can raise blood pressure and make medications less effective. Excess alcohol can also cause weigh gain, which can raise blood pressure. Men should limit themselves to 1 to 2 drinks per day. Women should limit themselves to one drink per day. One drink equals 12 ounces of beer, five ounces of wine or 1.5 ounces of 80-proof liquor.


Each time you smoke you cause dramatic spikes in your blood pressure (up to 20mmHg), which can stress your heart and other organs. Quitting smoking can reduce your risk of heart disease, lung disease, and cancer.

Please contact your doctor or pharmacist if you are interested in discussing these lifestyle changes.



Bad Habits Your Heart Hates

by: NuCara Intern, Lindsey GarnerDrake University, PharmD/MBA Candidate 2016


Heart shaped by hands

  1. Smoking

Smoking is a habit for some, but an addiction for others. It is the #1 preventable cause of death and illness in the United States. We know it can cause narrowing of blood vessels leading to your heart, which, coupled with the carbon monoxide in your blood stream, means decreased oxygen flow to your heart. You can end up with chest pain, heart attack, arrhythmias, or death. Aside from the thousands of unhealthy chemicals found in cigarettes, the nicotine in tobacco products causes a rise in blood pressure. See our post here for more information on how to quit.1

2. Putting off going to the doctor

Just because you didn’t have any health problems when you were 25, doesn’t mean you don’t have any now as a 40 year old. Many people don’t realize that over the course of 10-15 years their body has changed to develop high cholesterol, high triglycerides, or high blood pressure. Even though you don’t feel these things, you still need to see a doctor regularly to get them assessed! It’s time to make your yearly physical a priority.

3. Sleeping too much or not enough

Having an irregular sleep pattern is definitely an annoyance for some and inevitable for others (especially those with demanding jobs, kids, or sleep conditions), but not having a steady sleep routine can put undue pressure on your heart. The stress hormone Cortisol is regulated by your sleep schedule. If your sleep schedule is abnormal, your Cortisol level could remain unnecessarily high throughout the day and night.

  1. Drinking too much Alcohol

Drinking excessive alcohol puts additional calories and triglycerides into your body. Extra calories and higher triglycerides (sugary fats in the blood) can lead to obesity, high blood pressure, or diabetes. Binge drinking can cause arrhythmias (heart beats that are out of normal rhythm), which can lead to stroke. What’s considered excessive? For women the American Heart Association recommends no more than one drink per day, and men are allowed to have 2. One drink is one 12 oz. beer, 4 oz. of wine, 1.5 oz. of 80-proof spirits, or 1 oz. of 100-proof spirits.2

5. Ignoring your Belly Fat

Developing a “belly” with age isn’t supposed to be normal! The more fat you store in your midsection, the higher your risk for cardiovascular disease. Ask your doctor to assess your risk based on waist circumference and visceral fat (the fat between your midsection organs). Men who have a waist circumference greater than 40 inches and women with a waist circumference of greater than 35 inches are at higher risk of developing diabetes, hypertension, breast or colorectal cancer, and heart disease.

  1. Ignoring your High Blood Pressure

High blood pressure can be due to stress, eating a poor diet (especially one high in salt), lack of exercise, lack of sleep, excessive weight, drinking too much alcohol, smoking, and advancing age. Any of these sound familiar? Nearly everyone has at least one risk factor for high blood pressure, yet many people don’t remember the last time they got it checked. High blood pressure, while not usually a painful or bothersome diagnosis, can lead to damage in your heart. The longer you let it go unattended, the worse it will get. The good news is that there’s almost always a way to treat it without turning to medication. While medications do an excellent job of improving cardiac outcomes, changing your diet, exercising more, and getting more sleep can all lower your blood pressure.3

  1. Ignoring your Depression or Anxiety

Even though depression, anxiety, and mental health in general is getting much more help and attention than in years past, there are still many people who don’t think they “qualify” for help. Whether it’s due to cultural, familial, or personal ideas, acknowledging depression or anxiety is still stigmatized in some areas. Unfortunately, people with depression frequently have more biomarkers in their system that indicate a higher risk for cardiovascular events and coronary artery disease. While we’re still trying to figure out if depression comes first or follows a coronary event, the fact remains that the two together mean worse outcomes for the patient. That being said, don’t think that you aren’t important enough for treatment. Depression and anxiety can manifest in different ways for different people. Make sure to seek treatment! Your primary care provider or a specialized doctor can both be helpful.

  1. Pretending you don’t have time for exercise

We’re all guilty of this one — whether it’s pretending not to hear your alarm go off in the morning, or insisting that your day was just too long to put in an extra 30 minutes to go work out. As much as we try to convince ourselves that we can’t make time, a 30 minute walk, jog, or run is only 4% of your day! Like it or not, this is the one thing that you absolutely cannot continue to ignore. The more excuses you make, the harder it is to start. So, give yourself a kick start and make it happen!

  1. Acting like your dietary choices “aren’t that bad”

Yes they are, and you know it. If you’re eating more than 50% of foods that come from boxes, cans, or packaged on a shelf, then chances are that you’re eating an unnecessary amount of extra sugar, fat, and salt. The extra sugar can lead to insulin resistance, the extra fat can cause increases in triglycerides, and the salt can cause water retention that leads to high blood pressure. A majority of your food choices should come from complex carbohydrates (fruits, vegetables, legumes, and some whole grains), lean means (including fish), and healthy fats (olive oil, avocados, nuts and seeds). Everything you eat either helps or hurts your body, so consider that next time you stop for some fast food eats. Try keeping a food journal for a week, then tell me if your choices “aren’t that bad.” Bonus points can go to anyone who actually eats the recommended daily value of fiber (25 grams).

  1. Living on caffeine and energy drinks

Energy drinks are packed with caffeine, guarana, and sugar. Drinking even one energy drink can cause a modest spike in blood pressure. Drinking more than one per day is sure to elevate blood pressure, and put you at risk for heart beat irregularities. Drinking more than one per day on a regular basis is going to put your heart in toxic conditions. If you have a familial history of heart disease or arrhythmias, you’re at an even higher risk. Feeling any of the following after drinking one energy drink is a reason to go see a doctor, immediately: racing heart, skipping or jumping heartbeat, feeling jittery or anxious, or extended dizzy spells.

New Year’s Resolution: Healthy Eating/Living


A healthy lifestyle is one that includes healthy eating, regular physical activity, and balancing the number of calories you consume with the number of calories your body uses. According to the Dietary Guidelines for Americans 2010, a healthy eating plan:

  • Emphasizes fruits, vegetables, whole grains, and fat-free or low-fat milk products
  • Includes lean meats, poultry, fish, beans, eggs, and nuts
  • Is low in saturated fats, trans fats, cholesterol, salt (sodium), and added sugars
  • Stays within your daily calorie needs

Focus on foods you CAN eat instead of foods you CAN’T eat!

  • Fresh, Frozen, or Canned Fruits ― don’t think just apples or bananas. All fresh, frozen, or canned fruits are great choices. One caution about canned fruits is that they may contain added sugars or syrups. Be sure and choose canned varieties of fruit packed in water or in their own juice.
  • Fresh, Frozen, or Canned Vegetables ― try something new. You may find that you love grilled vegetables or steamed vegetables with an herb you haven’t tried like rosemary. When trying canned vegetables, look for vegetables without added salt, butter, or cream sauces. Commit to going to the produce department and trying a new vegetable each week.
  • Calcium-rich foods ― you may automatically think of a glass of low-fat or fat-free milk when someone says “eat more dairy products.” But what about low-fat and fat-free yogurts without added sugars? These come in a wide variety of flavors and can be a great dessert substitute for those with a sweet tooth.
  • A new twist on an old favorite ― if your favorite recipe calls for frying fish or breaded chicken, try healthier variations using baking or grilling. Maybe even try a recipe that uses dry beans in place of higher-fat meats. Ask around or search the internet and magazines for recipes with fewer calories ― you might be surprised to find you have a new favorite dish!

Some general tips for comfort foods:

  • It’s all about balancing comfort foods you love with healthier foods and physical activity
  • Eat them less often
  • Eat smaller amounts
  • Try a lower-calorie version. Use lower-calorie ingredients or prepare food differently.

For more ideas on how to cut back on calories, see Eat More Weigh Less(

Physical Activity

Regular physical activity is important for good health, and it’s especially important if you’re trying to lose weight or to maintain a healthy weight. It also helps to-

  • Reduce high blood pressure.
  • Reduce risk for type 2 diabetes, heart attack, stroke, and several forms of cancer.
  • Reduce arthritis pain and associated disability.
  • Reduce risk for osteoporosis and falls.
  • Reduce symptoms of depression and anxiety.

To maintain your weight: Work your way up to 150 minutes of moderate-intensity aerobic activity, 75 minutes of vigorous-intensity aerobic activity, or an equivalent mix of the two each week.

Moderate: While performing the physical activity, if your breathing and heart rate is noticeably faster but you can still carry on a conversation — it’s probably moderately intense. Examples include—

Moderate Physical Activity Approximate Calories/30 Minutes

for a 154 lb Person

Hiking 185
Light gardening/yard work 165
Dancing 165
Golf (walking and carrying clubs) 165
Bicycling (<10 mph) 145
Walking (3.5 mph) 140
Stretching 90

Vigorous: Your heart rate is increased substantially and you are breathing too hard and fast to have a conversation, it’s probably vigorously intense. Examples include—

Vigorous Physical Activity Approximate Calories/30 Minutes

for a 154 lb Person

Running/jogging (5 mph) 295
Bicycling (>10 mph) 295
Swimming (slow freestyle laps) 255
Aerobics 240
Walking (4.5 mph) 230
Weight lifting (vigorous effort) 220
Basketball (vigorous) 220


To lose weight and keep it off: You will need a high amount of physical activity unless you also adjust your diet and reduce the amount of calories you’re eating and drinking. Getting to and staying at a healthy weight requires both regular physical activity and a healthy eating plan.


New Year’s Resolution: I want to stop smoking

By Pamela Wiltfang, Pharm.D., M.P.H., B.A., CHES, NuCara Pharmacist

More people in the United States are addicted to nicotine, a drug found naturally in tobacco, than to any other drug. Research suggests that nicotine may be as addictive as heroin, cocaine, or alcohol. Tobacco use can lead to tobacco/nicotine dependence and serious health problems. Quitting smoking greatly reduces the risk of developing smoking-related diseases. Tobacco/nicotine dependence is a condition that often requires repeated treatments, but there are helpful treatments and resources for quitting.

Health Benefits of Quitting

Tobacco smoke contains a deadly mix of more than 7,000 chemicals; hundreds are harmful, and about 70 can cause cancer. Smoking increases the risk for serious health problems, many diseases, and death. Stopping smoking now can lead to the following health benefits:
• Lower risk for lung cancer and many other types of cancer.
• Reduced risk for heart disease, stroke, and peripheral vascular disease (narrowing of the blood vessels outside your heart).
• Reduced heart disease risk within 1 to 2 years of quitting.
• Reduced respiratory symptoms, such as coughing, wheezing, and shortness of breath.
• Reduced risk of developing some lung diseases (such as chronic obstructive pulmonary disease, also known as COPD, one of the leading causes of death in the United States).
• Reduced risk for infertility in women of childbearing age. Women who stop smoking during pregnancy also reduce their risk of having a low birth weight baby.

Ways to Help You Quit

Counseling and medication are both effective for treating tobacco dependence, and using them together is more effective than using either one alone.

• Brief help by a doctor (such as when a doctor takes 10 minutes or less to give a patient advice and assistance about quitting)
• Individual, group, or telephone counseling
• Behavioral therapies (such as training in problem solving)
• Treatments with more person-to-person contact and more intensity (such as more or longer counseling sessions)
• Programs to deliver treatments using mobile phones. For examples of apps that can be downloaded on your mobile phone, follow the link below:
Android: Apple:
• Nicotine replacement products:
o Over-the-counter (nicotine patch, gum, lozenge)
o Prescription (nicotine patch, inhaler, nasal spray)
• Prescription non-nicotine medications: bupropion SR (Zyban®), varenicline tartrate (Chantix®)

Helpful Resources

Quitline Services
Call 1-800-QUIT-NOW (1-800-784-8669) if you want help quitting. This is a free telephone support service that can help people who want to stop smoking or using tobacco. Callers are routed to their state quitlines, which offer several types of quit information and services. These may include:
• Free support, advice, and counseling from experienced quitline coaches
• A personalized quit plan
• Practical information on how to quit, including ways to cope with nicotine withdrawal
• The latest information about stop-smoking medications
• Free or discounted medications (available for at least some callers in most states)
• Referrals to other resources
• Mailed self-help materials
Online Help
• For information on quitting, go to the Quit Smoking Resources( page on CDC’s Smoking & Tobacco Use Web site.
• Read inspiring stories about former smokers and their reasons for quitting at CDC’s Tips From Former Smokers( Web site.