Exam 4 Drugs Flashcards
Turmeric
Anti-inflammatory herb
Uses:
-Arthritis, chronic pain due to inflammation, joint health, etc.
Concerned about:
-Bleeding: antiplatelet activity
Contraindications
-With anticoagulants
St John’s Wort
Improved mood, antibiotic, antiviral
Uses:
-Depression, anxiety, insomnia
Contraindications:
-Nearly every medication
Ginko
Improve cognitive function, vasodilator
Uses:
-Improve memory and increase circulation to the brain
Contraindications:
- Antiplatelets
- Anticoagulants
Garlic
Diuretic, anthelmintic, positive circulatory effect
Uses:
-Fighting colds, lowering BP, diabetes
Caution:
- Potentiates anticoagulation/antiplatelets
- Lowers blood sugar
- Diuretic
Contraindications:
-Any drug that also have these effects
Black Cohosh
Stimulates estrogen receptors
Uses:
-Menopause (hot flashes), hormone imbalances
Contraindications
-Pregnancy
maybe worry about a blood clot
Valerian Root
Sedative effects
-Increases GABA, nature’s Benzodiazepine
Uses:
-Insomnia, anxiety
Can cause withdrawal effects
-Needs to be tapered off
Kava
Uses:
-Anxiety, depression, seizures, insomnia
Caution
-Hepatotoxicity
Use caution with all medications
Herbal Therapies Nursing
- Be respectful to individuals and cultures (ask & learn, know & document)
- Be familiar with commonly used herbs
- Ask about all herbal remedies, frequency, reason for taking, and effects
- Educate that herbs can interfere or be toxic when combined with Western medicines
- Inform your doctor if you are using herbs
- Stop taking herbs when starting a new medication (some need tapering off)
- Avoid during pregnancy and lactation
- Avoid giving them to infants & children
NSAIDs
Acetylsalicylic acid (ASA) aspirin: 1899 -Not included in FDA black box warning
Ibuprofen: PO (1969), IV (2009)
-IV gtt., never IV push or give IM
Naproxen: PO (1999), Topical
Ketorolac: IV, IM, PO (1989), nasal (2010)
Combinations: ibuprofen/hydrocodone, ibuprofen/oxycodone, ibuprofen/acetaminophen, ASA/hydrocodone, ASA/oxycodone
Category Class:
- Anti-inflammatory
- Analgesic
- Antipyretic
MOA:
-prevents prostaglandins production by inhibiting COX
Problem with MOA:
- prostaglandin => increase circulation to brain, kidney, coronary arteries => adverse reaction CVA, RF, MI
- prostaglandin => increase gastric bicarb protective layer => side effect (GI bleed)
- prostaglandin => increase platelet aggregation => secondary use ASA (antiplatelet), side effect bleeding
Indication:
- Mild pain (analgesic): joint or bone injuries (sprains, strains), muscle pain, toothache, HA
- Fever (antipyretic)
- Inflammation (anti-inflammatory): OA, RA, gouty arthritis, Lupus, dysmenorrhea
Contraindication:
- Pregnancy (D)
- PUD
- RF
- Bleeding disorders
Caution with:
- AC
- Glucocorticoid
- ACE/ARB
- History of ischemic CVA
- MI
Side effects:
-Parenteral: much higher risk of RF
FDA Black box warning
-High risk for serious thrombotic events: sudden death, MI, UA, ischemic CVA, TIA, peripheral thromboses
Interactions:
-Alcohol
NSAIDs Nursing
Educate/monitor High risk for ACS & CVA
- Never take more than one type of NSAID, take the smallest dose, limit the length of NSAID use
- Call 911 with any new chest pain or neurological deficits
Educate/monitor RF: (see code phrases)
- Monitor for worsening fluid retention => HF symptoms, I/O imbalance
- Avoid with Hx. of RF, HTN, HF
Monitor for GI bleed/PUD
- Always take with food
- Avoid other gastric irritants (alcohol or taking multiple NSAIDs)
- Monitor for bleeding, caution with AC (see code phrases)
- High risk in elderly (PUD four times more common in older adults)
Montelukast
Leukotriene Modifiers
-Leukotriene is an inflammatory mediator
Indication:
-maintenance therapy (not for acute SOB)
Side effects, Adverse reactions:
- Depression
- Suicidal ideation
- Liver failure (Causes drug toxicity because “first-pass” doesn’t occur, Do liver function tests, Don’t take hepatotoxic drugs (acetaminophen, alcohol))
- Drug interactions
Medication Administration: PO
Nursing Interventions:
-consider age limits (for 1-year & up)
2nd Gen Antihistamines
Medication:
- Cetirizine
- Fexofenadine
- Loratadine
Medication Administration: PO (PRN)
Nursing Interventions (monitoring):
- Little to no sedative effect
- Little to no anticholinergic effect
Diphenhydramine, Meclizine
Category Class: 1st Gen Antihistamine
Mechanism of Action:
-inhibit vestibular stimulation in the inner ear
Indication:
- Nausea, motion sickness
- Secondary: insomnia
Contraindication:
- Pregnancy
- Lactation
- Newborn
- Children
- Older adults
- Anticholinergic effects: retention, glaucoma, HTN, BPH, tachycardia
Side effects, Adverse reactions:
- Crossing BBB: CNS depressant- drowsiness, dizziness, fatigue, disturbed coordination, FALL
- Anticholinergic effects (PNS)
- Hangover effect
Medication Administration: PO, IV, IM
Toxicity: excitation, hallucination, seizure
Assess
- Breathing (CNS depression –> respiratory depression –> shallow/diminished)
- VS (for anticholinergic effects)
- I/Os (for anticholinergic effects)
Warn against combination medications (decongestant A1 agonist)
Patient Education:
-CNS depression: avoid driving or operating dangerous machinery
Avoid other CNS depressants: ETOH, codeine
Aspirin
PO: takes the whole life of platelet to clear (7 days)
Category Class:
-Antiplatelet: small scheduled dose (MI, CVA prophylaxis)
MOA:
-prevents platelet aggregation
Indication:
-Prophylactic for patients at risk for thromboembolism
Contraindication:
- Pregnancy
- Hx. of bleeding disorder
- retinal/cerebral hemorrhage
- Thrombocytopenia
- PUD
- Aneurysm
- uncontrolled HTN
- NEVER to children <19 years (risk of Reye’s syndrome) => NEVER while breastfeeding
Adverse reactions:
-Hemorrhage: particularly GI bleed
Nursing Interventions (monitoring):
- Take with food to minimize GI upset/ GIB
- Reversal agent: platelet transfusion
- Stop taking for 7 days to clear from body after consulting with provider
- May be taken with clopidogrel (for further antiplatelet effect)
- Emergency medicine for acute MI, must chewReversal agent: platelet transfusion
for Hx. of GIB, PUD:
- Enteric-coated aspirin, don’t crush
- Buffered aspirin (mixed with calcium carbonate)
Interactions (with drugs/food/UV light):
- Avoid NSAIDs (increased risk of GI bleed)
- Avoid alcohol (increased risk of GI bleed)
Glucocorticoids
IV
-Methylprednisolone (Solu-Medrol)
PO
- Methylprednisolone (Medrol)
- Prednisone (Deltasone)
MOA:
-anti-inflammatory (similar to body’s cortisol, negative feedback)
Indication: IV -Acute exacerbation of inflammatory disorders (requires loading dose) PO -To wean from IV and to continue to wean -End-stage disease for maintenance Methylprednisolone & Dexamethasone -Nausea associated with chemotherapy "premedication" Inflammatory disorders
Contraindication:
-fungal/viral infections, live attenuated virus vaccine (intranasal influenza, small pox)
Side effects, Adverse reactions:
- Hyperglycemia (in diabetic patients)
- Leukocytosis (yet immunosuppressant)
- Immunosuppressant (anti-inflammatory mechanism- higher risk of infection)
- Water/Na retention (worsening of HF, edema, HTN) –> hypokalemia (dysrhythmia)
- Water/Na retention –> increased IOP (worsening of glaucoma)
- SubQ tissue loss with chronic use –> “paper skin” or “steroid skin”
- Adrenal suppression (never stop abruptly to avoid adrenal crisis) requires weaning
- Osteoporosis (take Vitamin D, Ca++, and exercise)
Medication Administration:
-IM, IV, PO, aerosol, topical, intra-articular injection
Nursing Interventions (monitoring): -Must always wean off
Methotrexate
MOA:
-slow down the progression of autoimmune diseases, peak effect in 3-6 weeks
Immunomodulator:
-High risk of infection, hepatotoxicity
Cytotoxic agent:
- Ulcerative stomatitis (sign of toxicity): inspect and assess mouth, gums, throat daily
- Bone marrow suppression: monitor CBC trend
Contraindication:
- Never during acute infection
- pregnancy/lactation (class X teratogenic)
- pediatrics
Patient Education:
- Take on empty stomach
- Avoid sunlight
Azathioprine, Cyclosporine, Tacrolimus
Category Class: immunosuppressant
MOA:
-slow down the progression of autoimmune diseases, peak effect in 3-6 weeks
Contraindication:
-Never during acute infection
Side effects:
- Renal failure, hepatotoxicity, Blood dyscrasia & bleeding
- Hirsutism (male pattern hair growth) reversible with discontinuing the medication
- Gingival hyperplasia: good dental hygiene and routine check-ups
“Ron Harry Hermione Beat Bad Guys”
Colchicine
MOA:
-anti-inflammatory only for gout
Contraindication:
-Pregnancy: C
Side effects:
- GI distress: take with food, avoid grapefruit juice
- suppressed bone marrow: Monitor CBC
- Rhabdomyolysis: Monitor for muscle pain and RF
-PO
Allopurinol
MOA:
-lowers serum uric acid biosynthesis
Contraindication:
-Pregnancy: C
Side effects:
-Hepatotoxicity, higher risk of nephrolithiasis: Monitor labs, I/O balance
-PO, IV
Antigout Nursing
Increase fluid (2-3 L/day) & monitor I/Os -to increase uric acid excretion => to avoid risk of nephrolithiasis
Avoid foods high in purine
- red meat, organ meat, scallops, aged cheese
- alcohol & caffeine can increases uric acid
For acute attacks
- NSAIDs
- Glucocorticoids
Acetaminophen
Category Class:
- Analgesic
- Antipyretic
MOA:
-Not anti-inflammatory: without the negative side effects of NSAIDs
-PO, PR, IV
Educate: max dose 4000mg/24 hrs. (to avoid hepatic failure) see code phrases
- For malnourished clients the limit is 3000mg/24 hrs
- ETOH use > 2drinks/day the limit is 2000mg/24 hrs
- Children age specific max dose
OD is managed by acetylcysteine
Acetaminophen (APAP)
Category Class:
- Analgesic
- Antipyretic
MOA:
-Not anti-inflammatory: without the negative side effects of NSAIDs
-PO, PR, IV
Educate: max dose 4000mg/24 hrs. (to avoid hepatic failure) see code phrases
- For malnourished clients the limit is 3000mg/24 hrs
- ETOH use > 2drinks/day the limit is 2000mg/24 hrs
- Children age specific max dose
OD is managed by acetylcysteine
Opioid Side Effects
respiratory suppression
- monitor respiration rate, depth, oxygenation
- caution with respiratory disorders
Loss of cough and gag reflexes
- monitor for silent aspiration
- hence used as antitussive
Suppress ANS control
- monitor VS for low HR & BP
- caution with cardiac disorders, dysrhythmias (heart block)
- monitor for orthostatic hypotension (FALL)
Suppress GI motility
- Monitor bowel sounds for hypoactive bowel sounds
- Monitor for constipation, ileus, bowel obstruction, anorexia
- always use prophylactic laxative
- increase fluid/fiber & activity
Stimulates CTZ in the brain and causes N/V
-Manage prophylactically
Suppress CNS –> sedation, hypnotic effect
- Monitor for drowsiness (risk of fall)
- Hence used for induction of anesthesia
- Assess home med list for any other drugs affecting CNS (stimulants, suppressants, alcohol, illicit drugs)
Relaxes the bladder muscles (detrusor muscles)
-Monitor for urinary retention
Relaxes the pupil
- Miosis (pinpoint pupils) even in dim light
- Poor vision in dim light, fall risk
Euphoria, dependence, tolerance, abuse disorder
- Check history for use disorder
- Cross-tolerance
- Taper-off to avoid withdrawal symptoms (anxiety, N/V, and pain, muscle pain, seizure, death)
- Assess for any chronic pain and how it is managed
Increase intracranial pressure
-CI after head trauma/injury or hemorrhagic CVA is suspected or inc ICP
Codeine Sulfate
Indication:
-PRN for cough, diarrhea, mild pain
Pro-drug: the drug metabolite is morphine
Route: PO, SubQ, IM, IV
Combination
- acetaminophen / codeine (300/30 mg) Rx.
- acetaminophen / codeine (300/60 mg) Rx.
Hydrocodone
Indication: PRN moderate pain
Route: Only PO
Combinations
- hydrocodone / acetaminophen
- hydrocodone / aspirin
- hydrocodone / ibuprofen
Oxycodone
Indication: PRN moderate pain (IV, PO)
Combinations:
- oxycodone / acetaminophen(5, 7.5, 10)
- oxycodone / ibuprofen
- oxycodone / aspirin
Tramadol
Route: PO (Sched IV)
Pro-drug: the drug metabolite is morphine
-Opioid-like (weaker but similar properties and effects)
tramadol ER for around the clock moderate pain mgmt.
Max dose: 300 mg/24 hrs
Morphine
Routes: PO/oral drop, PR, IV, IM, epidural, spinal (intrathecal/subarachnoid)
Not SQ
10x stronger than tramadol
Indication: PRN for severe pain
Controlled release
Hydromorphone
Routes: PO, IV, PR, IM, SQ
Indication: PRN for severe pain
6x stronger than morphine
Meperidine
Opioid-like
Routes:
-PO, SubQ, IM, IV
MOA:
- anticholinergic with secondary analgesic effects
- less respiratory side-effects
- patients allergic to opiates
short duration of action
-hence used in OR
Side effects:
- neurotoxicity (delirium, seizure)
- dysrhythmias
Contraindications:
-RF (higher risk of seizure and neurotoxicity)
Fentanyl
Routes: IV, IM (indication: anesthesia)
transdermal patch 12.0-100 mcg/h (indication: chronic pain
oral trans-mucosal lozenge(indication: acute pain in ED)
50-100 times more potent than morphine (is a synthetic opioid)
Short-acting for severe pain (onset immediate; duration 30-60 min)
Methadone
Route:
-PO, subQ, IM
Indication:
-heroine detoxification and maintenance programs
MOA
-Long acting opioid, reduces craving
Only through certified pharmacies
Opioid Nursing
Assess:
- What patient has done prior to current presentation for their pain
- Baseline VS and side-effects
Manage
- Chronic pain (scheduled + PRN for breakthrough pain)
- Acute pain
- Breakthrough pain
Properly administrate
- dilute, dilute, dilute, 4-5 min for IV push
- Know the reversal policy & naloxone
Educate:
-side-effects, risk of tolerance, dependence, use disorder
Monitor
- pediatrics/geriatrics closely (organ immaturity/dysfunction)
- obese patients
- Opioid retention in adipose tissue & prolonged effects
- misuse (by the patient)
- abuse (by the patient/family)
- diversion (by family, by nurse)
Consult
-pain management specialists
Naloxone
Category: opioid antagonist
Indication:
- treatment of opioid OD by competing for opioid receptors
- Reverse resp & CNS depression rapidly; regaining consciousness and breathing (Life-saving treatment)
- no effects in absence of opioids => used as a test to understand the cause of CNS depression
- Emergency medicine
Medication Administration:
-IV, intranasal spray, PO
Nursing Interventions:
-Monitor for acute withdrawal symptoms
-Abrupt onset of pain, anxiety, sweating, HA, nervousness
depression, suicidal ideation, abdominal cramps/pain, N/V, anorexia
-Monitor for dysrhythmia
-naloxone half life is shorter than opioids: monitor for recurrence of resp depression, may need multiple doses
Naltrexone
Category Class: opioid antagonist
MOA:
-Suppresses craving and pleasurable effects of alcohol
Indication:
- treatment of opioid OD by competing for opioid receptors
- Reverse resp & CNS depression rapidly; regaining consciousness and breathing (Life-saving treatment)
- no effects in absence of opioids => used as a test to understand the cause of CNS depression
- Emergency medicine
Medication Administration:
- daily PO
- Monthly IM depot injection
- IV, intranasal spray, PO
Nursing Interventions:
-Monitor for acute withdrawal symptoms
-Abrupt onset of pain, anxiety, sweating, HA, nervousness
depression, suicidal ideation, abdominal cramps/pain, N/V, anorexia
-Monitor for dysrhythmia
-naloxone half life is shorter than opioids: monitor for recurrence of resp depression, may need multiple doses
Examination/Surgery
Anticholinergic => mydriatics, cycloplegics (paralyze the ciliary muscle, accommodation)
- atropine
- cyclopentolate (generic only)
- homatropine (generic only)
- tropicamide
Side effects:
- Xerophthalmia (dry eye)
- Photophobia (mydriasis)
- Blurred vision (cycloplegia)
Nursing:
- Contraindication: glaucoma
- ensure using protective sunglasses to avoid damage to the eye while pupils are dilated
- Risk of fall associated (photophobia and cycloplegia)
Topical Anesthetics
For examination and procedures
- proparacaine
- tetracaine
Short onset of action (1 min)
short duration of action (15 min)
Causes loss of blink reflex => dried and damaged eye surface (must keep eye closed)
Nursing:
- Prevent corneal dryness (caused by loss of blinking): Cover closed eye with a eye patch
- Given in medical settings under medical supervision
Anti-Inflammation (NSAIDs)
- ketorolac tromethamine 1992
- diclofenac sodium
- Bromfenac 2005
Indication:
- reducing postoperative inflammation after cataract surgery
- seasonal allergic conjunctivitis (pain, burning, itching, photophobia)
Side effects:
- May delay healing process post-op
- May cause corneal damage (erosion, ulcer)
Anti-Inflammation (Glucocorticoids)
- prednisone
- dexamethasone
Contraindicated: viral infections, live attenuated virus vaccine (intranasal influenza, small pox)
Routes: PO, IM, IV, topical, aerosol, intra-articular injections
Side effects: glucocorticoid ones
Carbamide Peroxide (OTC)
Category Class: Cerumenolytics
Patient Education:
- Tilt the head side ways
- Place 5-10 drops in the ear
- Do not enter the tip of applicator in the ear canal
- Keep the drops in the ear for several minutes (by keeping head tilted)
- Flush the ear gently, NEVER suction
- Use tid up to 4 days
Glaucoma
Alpha2 agonists
- brimonidine
- MOA: decrease production of aqueous humor, increase outflow
- burning, stinging, blurred vision, HA, reddened sclera, systemic effects (vasodilation)
Prostaglandin analogs
- latanoprost
- MOA: vasodilation, increase outflow
- Increased pigmentation: color of iris and eyelids/lashes to brown
- Redness of conjunctiva(vasodilation), temporary itching/stinging (do not rub the eyes), blurry
- hypertrichosis (extra hair)
The Ear Nursing
- Check for TM intactness before administering drops (ototoxicity)
- Straighten the ear canal (may be very painful) use an ear wick
- Have patient remain in side-lying position for 5 minutes
- may place a small cotton in ear for 15 min; avoid packing
- For Abx: monitor for super-infections
Somatropin
- GH deficiency
- IM, SQ
Indication:
-dwarfism (before epiphyseal closure)
Contraindication:
- Other types of dwarfism unrelated to GH
- Obesity
- Respiratory disease (sleep apnea)
Side effects:
- DM (dec insulin secretion)
- Hypothyroidism
Octreotide
- GH excess
- Treatment: surgery/radiation pituitary
- IV, PO, SQ
Indication:
- Gigantism/acromegaly
- Severe diarrhea, esophageal varices & bleed
Side effects:
- Pancreatitis
- hypothyroidism
Nursing Interventions:
-Monitor kidney & liver
Levothyroxine Sodium
MOA:
-synthetic thyroid hormone
Indication:
- PO: hypothyroidism
- IV: myxedema coma (severe hypothyroidism)
Contraindication:
-MI
Side effects:
- sign/symptoms of hyperthyroidism (OD)
- signs/symptoms of hypothyroidism (under-dosed)
- Hyperglycemia
- Tachypnea
- Highly protein-bound (toxicity with hypoproteinemia or when taken with other protein-bound drugs i.e. oral AC)
Adverse reactions:
- Tachydysrhythmias
- chest pain, HTN, seizure
Nursing Interventions:
- Only on empty stomach (one hour before BF)
- Check levels frequently (TSH and T4, T3)
Patient Education:
- Requires lifelong replacement
- do not discontinue, change brand, or change dose without checking with endocrinologist
- Slow absorption & onset of action, long half-life (one week)
- full therapeutic effect in 6-8 weeks
Methimazole, PTU
MOA: inhibits TH synthesis
- full therapeutic effect in 3-12 weeks
- Does not destroy existing TH
Indication:
- Hyperthyroidism (Graves’ disease)
- Thyrotoxicosis (thyroid storm)
- Adjunct to irradiation
Contraindication:
- Pregnancy
- lactation
Side effects:
- sign/symptoms of hypothyroidism (OD)
- Signs/symptoms of hyperthyroidism (under-dosed)
- GI distress (take with meal)
Patient Education:
- Take same time daily
- Do not discontinue abruptly (risk of thyrotoxicosis)
- Avoid foods high in iodine (seafood)
- Many drug interactions (oral AC, insulin, digoxin, lithium, phenytoin)
Corticotropin
Secondary adrenal insufficiency (pituitary insufficiency => low ACTH)
-Contraindication: primary adrenal insufficiency (Addison’s disease)
Diagnosing secondary vs. primary adrenal insufficiency
-ACTH stimulation test: checking cortisol level pre & q30 min post corticotropin
Acute severe exacerbation of inflammatory disorders
-Lupus, multiple sclerosis (MS), systemic dermatomyositis, systemic sarcoidosis, psoriatic arthritis, RA, etc.…
Side effects:
- Fluid/Na retention (edema)
- RF
- Inc BG (monitor DM patients BG closely)
- Monitor trend of BP for HTN
Medication Administration:
- Must be given parenterally (IV/IM/SubQ)
- Repository or depot injection (slow absorption)
Nursing Interventions:
- Monitor cortisol level
- Taper dose, avoid abrupt discontinuation
Addison’s Disease: Glucocorticoids
Medications:
- Methylprednisolone: IV, PO
- Dexamethasone: PO, IM, IV
- Prednisone: PO
- Hydrocortisone: PO, IV, joint injection, topical
Primary adrenocortical insufficiency
- Addison’s disease
- adrenal crisis
Many inflammatory, autoimmune, & allergic diseases
-RA, MS, MG, UC, glomerulonephritis, shock, hepatitis, asthma/COPD, drug reactions, contact dermatitis, anaphylaxis
Contraindication:
- fungal/viral infections
- live attenuated virus vaccine (intranasal influenza, small pox)
Side Effects: Glucocorticoid ones
Desmopressin
MOA:
-↓ urine output, ↑osmolality of urine, little vasoconstrictive effect
Long duration of action (20 hours)
Routes: nasal spray, PO, IV, subQ
Indication:
- ADH Deficiency (Diabetic Insipidus)
- DI –> large amount of dilute urine, Na retention
Side effects:
- fluid overload => worsening HF
- Vasoconstriction
Nursing Interventions:
- Monitor: I/O, daily weight, CMP (electrolyte changes), AMS (water intoxication)
- Monitor for angina & MI, dysrhythmia, HTN
Vasopressin
-emergency drug (for severe hypotension as in shock) -NOT indicated for DI
MOA: peripheral vasoconstriction
Short duration of action (30-60 min)
Only given IV (vesicant)
Tolvaptan
MOA:
-aquaresis (excretion of water without electrolyte loss)
Indication: SIADH: syndrome of inappropriate antidiuretic hormone
- water retention
- natriuresis => hyponatremia
Side effects:
- hypovolemia
- ↑K
- ↑BG
PO (2009)
Calcitriol
MOA: goes to kidneys to become activated vitamin D
- Increased absorption of Ca++ in GI tract (When you have enough vitamin D in blood, Ca++ can be absorbed)
- Increased Ca++ absorption (increases activity of osteoclasts) –> increased Ca++ release from bone
Indication: Hypocalcemia
- Renal hormone replacement in ESRD on hemodialysis (PO/IV)***
- Severe vitamin D deficiency (PO)
- Hypoparathyroidism (PO)
- Psoriasis (topical, MOA unknown)
Side effects, Adverse reactions (Complications to monitor for):
-Dizziness, vertigo, falls, metallic taste
Calcitonin-Salmon
MOA:
- calcitonin receptor agonist (mimics the effect of thyroid hormone, calcitonin)
- deposit Ca into the bones => hence, it is indicated for osteoporosis
- Increase renal excretion
Side effects:
- numbness or tingly feeling around the mouth
- tachycardia, muscle spasms, hyperactive deep tendon reflexes (DTR), seizure
- nasal spray causes nasal dryness (alternate nostrils and use NS nasal spray)
IM, SQ, nasal spray
Indication: hypercalcemia
Causes of hypercalcemia
- Hyperparathyroidism: malignancies of parathyroid
- Drug-induced by: thiazide, Vit A/D, milk-alkali syndrome
- Prolonged immobility
Types of Insulin
Rapid acting
- Lispro
- Aspart
- Onset <30 min
- Peak 30-90 min
- Duration 305 hours
Short acting
- Regular
- Only IV insulin
- Onset 30 min
- Peak 2-5 hours
- Duration 4-12 hours
Intermediate acting
- Isophane NPH
- Only cloudy insulin
- Onset 1-2 hrs
- Peak 4-12 hrs
- Duration <24 hrs
Long acting
- Glargine: No peak
- Detemir: Peak 6-8hr
- Onset 1 hr
- Duration 24 hrs
Combination
- 70/30 (NPH/regular)
- 50/50 (NPH/regular)
- 75/25 (lispro protamine/lispro)
Insulin: MOA and indication
MOA:
- Promote cellular uptake of glucose => low BG
- Convert glucose into glycogen => low BG
- Promote cellular uptake of potassium => low K+
Indication:
all type I
type II
- after oral agents not able to control BG
- Acute stress: acute disease/surgeries/trauma (for diabetic patients who normally do not need insulin)
- Gestational
- Acute exacerbation of DM
- Hyperkalemia
Insulin Administration
- Syringe and multi-dose vial
- Insulin pen
- Insulin pump
SQ
- Always- slow absorption, there is less blood circulation in the SQ than IM
- Administer SQ in one general area (for consistent rate of absorption)
IV
- Only regular insulin
- When the BG is severely high
Rapid/short
- AC according to a sliding scale
- PRN for hyperglycemia (consult provider)
NPH: bid
Detemir: once daily at HS or bid
Glargine: once daily at HS
Rotate the site of injection to avoid lipodystrophy
- Lipoatrophy
- Lipohypertrophy
Insulin Nursing Interventions
Educate to wear a medical alert bracelet
Meal planning for the next 24 hours before administering insulin
- Avoid hypoglycemia at the time of “onset” and “peak”
- Monitor for hyperglycemia at the end of “duration of action”
- What to do with insulin dose if expecting NPO in the next 24 hours
Labs: serum glucose:
- point of care (capillaries blood sample)not appropriate with severe edema
- serum BG by laboratory (venous sample)
Insulin Patient Education
Storage:
insulin becomes ineffective after expiration
- Opened vials can be kept at room temp for up to 29 days or 3 months in refrigerator
- Unopened vials can be kept in refrigerator until the expiration date
Never place in freezer
Avoid exposure to direct sunlight or heat
Premixed vials always in refrigerator
Oral Antidiabetic Agents
MOA:
- ↑ cell sensitivity to endogenous insulin
- ↑ insulin production
- ↑ incretin (secreted by small intestine) to ↑ insulin
- ↓ breakdown of glycogen (hepatic glucose production)
- ↓ breakdown of starches in GI
Contraindication:
- Type-1
- many are pregnancy category C (use insulin instead during pregnancy)
Caution
- requires next 24 hrs meal planning
- hepatic & renal impairment (use insulin instead)
Side effects:
- Oral antidiabetics ↑ cardiac function & myocardial O2 demand
- Monitor for angina, dysrhythmias
NI: Avoid ETOH
- High carb content –> hyperglycemia
- Liver failure –> hypoglycemia effect
- Low PO intake –> malnutrition/hypoglycemia
- Interaction with oral agents (disulfiram-like reaction)
NI: Goal
- Keep fasting BG below 150 (normal <100)
- Prevent hypoglycemia (EMERGENCY)
Patient Education:
-Keep a log of BG with factors affecting (diet, infection, medication, activity)
Glimepiride, glipizide, glyburide
Oral Antidiabetic Agent
SE:
- hypoglycemia
- aplastic anemia
- weight gain
- seizure
- disulfiram-like reaction (avoid alcohol)
CI: -RF liver failure pregnancy -lactation -surgery & severe infection**
Metformin
Oral Antidiabetic Agent
Stop taking 48 hours prior & after IV contrast to avoid RF
Side effect:
- GI upset
- diarrhea: BID with meals to decrease
- nausea
- anorexia: contact provider if continues
- weight loss: contact provider if continues
- Vitamin B12 & folic acid (B9) deficiency (poor absorption) provide supplements PRN
Contraindication:
- severe infection
- acute disorders (shock, hypoxia)
- chronic alcohol abuse disorder
Acarbose
Oral Antidiabetic Agent
MOA: Blocks pancreatic amylase (prevents sucrose break down)
- sucrose (table sugar): dextrose (glucose) + fructose: SAFETY Education: manage hypoglycemia with dextrose paste not table sugar (sucrose)
- Take with the 1st bite of a meal tid
Side effect:
-Poor iron absorption => anemia (monitor H&H)
Contraindication:
- inflammatory bowel disease (IBS, UC)
- bowel ulceration/obstruction
Hypoglycemia
Causes:
- Too much insulin or oral agent
- Too little food, vomiting, diarrhea
- physical activity without proper carb loading
Definition
-BG < 70 mg/dL
Signs/Symptoms
Early:
-anxiety, diaphoresis, cold/clammy skin, shakiness, -palpitations (tachycardia)
Late:
-AMS, slurred speech, poor coordination, drowsiness, difficulty arousing from sleep, seizure/coma, death within minutes
beta-blockers reduce HR & anxiety hence making it difficult for the patient to report palpitation
Hypoglycemia Treatment
If patient is fully awake and can safely swallow:
- apple juice (dissolved sugar in water), sugar candy
- recheck BG in 15 min, if <75 retreat
- follow with some protein (peanut butter sandwich)
If patient is lethargic/drowsy (needing verbal or tactile stimulation to open eyes)
- should NOT take anything by mouth (high risk of dysphagia & aspiration)
- 1 mg glucagon IM => stimulate liver to release glucose; onset of action: 10 min
- 25-50 ml of 50% dextrose in water (D50); assure patent -IV site; onset of action: 1 min
ART
Medication:
- Enfuvirtide: SQ
- Maraviroc: PO
- Zidovudine: PO, IV
- Delavirdine: PO
- Raltegravir: PO
- Ritonavir: PO
Indication:
- HIV-infected individuals
- HIV-infected pregnant patients
- History of an AIDS-defining illness
- Inflammatory, infectious, cancer
- Serodiscordant couples (mixed serostatus)
Adverse reactions:
-Hepatotoxicity
-Nephrotoxicity
-Osteopenia => early onset osteoporosis and fractures
-Dyslipidemia: early onset coronary artery disease diseases (CAD, angina, MI)
-Fat redistribution syndrome (lipodystrophy)
(lipoatrophy on face, arms, legs, and buttocks)
(lipohypertrophy on abdomen, breasts, and buffalo hump)
(body image issues)
-Insulin resistance => Diabetes Melitus
HIV Maintenance Drugs
Medication:
- Tacrolimus: IV, PO
- Cyclosporine: IV, oral solution
- Azathioprine: PO (no IV form in the US)
MOA: Highly protein bound
- Many drug-drug interactions
- Toxicity with malnutrition
Contraindication:
- Pregnancy
- Breast feeding
Side effects:
- Hirsutism (male pattern hair growth) reversible with discontinuation
- Gingival hyperplasia: requires good dental hygiene and routine check-ups
Adverse reactions:
- Photosensitivity
- RF, hepatotoxicity, dysrhythmia, HTN
- Blood dyscrasia: thrombocytopenia, anemia, leukocytopenia
- lymphoma and other malignancies
Nursing Interventions: Monitor for rejection (malaise, fever, pain, organ dysfunction)
- Patient and family should know these sign/symptoms
- Provide contact information for the transplant team, contact with any sign of rejection
- Very strict adherence to drug regimen
Epoetin Alfa
MOA: Erythropoietic growth factors => ↑ RBC production
Indication:
- Low RBC secondary to CKD
- Anemia after chemotherapy and HIV drug (zidovudine)
- Hasting of bone marrow function after a bone marrow transplant
Contraindication:
- Pregnancy
- uncontrolled HTN
Side effects:
- HTN (HA) monitor BP
- increased H&H (monitor CBC & contact provider if Hgb is > 11 g/dL)
- Low iron and B12, & K (monitor and supplement as needed)
Adverse reactions:
-seizure, thromboembolic event (MI, CVA, DVT)
Medication Administration: IV/SQ
Filgrastim
Medication:
- Filgrastim (IV, SQ)
- Pegfilgrastim (SQ)
MOA: leukopoietic growth factor: inc neutrophil production
Indication:
- Neutropenia from antineoplastic drugs, HIV, neonatal neutropenia (To prevent infection)
- To increase WBC level prior to harvesting (autologous transplant)
Contraindication: Pregnancy C
Side effects:
- Bone/joint/muscle pain (managed with analgesics)
- Leukocytosis absolute neutrophil > 10,000 (monitor CBC)
Adverse reactions:
-Splenomegaly/rupture (long-term use) report any abd/back/shoulder pain
Oprelvekin
MOA: thrombopoietic growth factor: inc platelet production
Indication: chemotherapy-induced thrombocytopenia
Contraindication: pregnancy
Adverse reactions:
- Fluid retention & HF
- Tachydysrhythmia (A-fib/flutter)
- MI
- Conjunctival injection (red-eye)
- Papilledema
- Medication Administration: SQ
Flu Vaccine General
General
- CDC recommendation for the serotypes included in the vaccine changes yearly based on the strains of virus in vaccine
- Seasonal: fall to spring
It takes 2 weeks for protection to develop: avoid sick contacts, wash hands frequently
- precautions required during the first two weeks
- no protection during this time period
- immune system is busy making antibody against multiple variants of influenza
- higher susceptibility to other infections
Side effects (expected): Inflammatory/immune responses
- local inflammatory response at the injection site (local soreness, redness)
- Systemic inflammatory responses (fever, cough, malaise, body aches, vomiting, diarrhea)
IIV: inactivated influenza vaccine
Indication:
-everyone older than 6 months & pregnant
Route: IM/subQ
Contraindication
- age < 6 months
- severe allergy to egg
- Guillain-Barré Syndrome
LAIV: live attenuated influenza vaccine
Indication:
-2-49 years healthy & nonpregnant
Route: nasal spray
Contraindications:
- pregnancy
- with antiviral
- with aspirin
- egg allergy
- Guillain-Barré Syndrome
- chronic diseases, asthma
- Immunosuppressed
- working with at risk population
- acute phase of diseases (stuffy nose)
- other vaccines in the last 4 weeks
Pneumococcal polysaccharide vaccine (PPSV23)
IM/subQ
Indication:
- 2 years to 65 years if (immunocompromised, chronic diseases, smokers, living in long-term care facilities)
- 65 years of age (one dose; if received one before 65 give a booster after 65)
Contraindication: pregnancy, children < 2 years
Side effects:
-local and systemic inflammatory reactions: injection site soreness, fever, drowsiness, anorexia, malaise
Streptococcus Pneumoniae > 90 known serotypes hence=>Previous infection does not protect
Pneumococcal conjugate vaccine (PCV13)
IM/subQ
Indication:
- 6 months to 65 years if (immunocompromised, chronic diseases, smokers, living in long-term care facilities)
- 65 years of age (one dose; if received one before 65 give a booster after 65)
Contraindication: children < 6 months
Side effects:
-local and systemic inflammatory reactions: injection site soreness, fever, drowsiness, anorexia, malaise
Streptococcus Pneumoniae > 90 known serotypes hence=>Previous infection does not protect
Vaccines Informed Consent
Provide information including expected side effects, risks, benefits
Review vaccine information statement (VIS) approved by CDC
Educate the importance and safety of vaccines
Educate to keep immunization records
For children/infants
- consent is obtained from legal guardian
- assent obtained from the child after obtaining consent from legal guardian
Identify barriers (empathy and understanding for concerns)
- Beliefs such as complete eradication of vaccine-preventable diseases
- Misunderstanding of true contraindications
- Concerns regarding vaccine safety and efficacy
- Fear of multiple injections
- Cost
Vaccines Nursing
Monitor for S/S of adverse reactions
- Be prepared for emergency anaphylactic reaction (ABC)
- epinephrine
- diphenhydramine
- glucocorticoids
- NSAID
Reporting adverse effects (reactions)
-national DHHS (Vaccine Adverse Evenet Reporting System)
Reporting vaccine-preventable diseases
-VDH VDH Disease Surveillance
Vaccine Safe Administration
separate live (attenuated) such as MMR from other vaccines by 4 weeks
Avoid vaccination after
- Immunosuppressants (see immunosuppressive drugs)
- blood transfusions
- intravenous immunoglobulin (IVIg)
Do not mix vaccines
-use separate site and syringe for each vaccine
Keep refrigerated until ready to administer (do not freeze)
Safe IM Administration
Infants & children: vastus lateralis or ventrogluteal muscle
Older children, adolescents, adults: deltoid
To reduce pain:
- deep injection in the largest muscle, slow push, involve parents
- distraction (cough)
- topical anesthesia (lidocaine ointment)
- cool compress and gentle movement of the limb after
- Involve caregivers, provide praise
Never administer injections while the child is asleep
Hormonal Agents
Indications: (CA or non-cancerous diseases)
- prostate CA, BPH
- breast CA
- Endometriosis
- uterine fibroids
- polycystic ovarian disease
- precocious puberty
- IBS
Side-effects:
- hot flashes, ↓ libido, & gynecomastia (educate transient and worse at the beginning of treatment)
- osteoporosis (Ca & vitamin D, weight-bearing exercise)
- dysrhythmia & pulmonary edema (see code phrases)
Contraindication:
-Pregnancy (X)
