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Pharmacology > Topic 3: Drugs for inflammation, fever & pain (Analgesic) & Topic 4: Drugs for infection > Flashcards

Topic 3: Drugs for inflammation, fever & pain (Analgesic) & Topic 4: Drugs for infection Flashcards

1
Q

NSAIDs: FDA-Approved Indications

A

1) Acute gout
2) Acute gouty arhtritis
3) Ankylosing spondylitis
4) Bursitis
5) Fever
6) Juvenile rheumatioid arthritis
7) Mild-moderate pain
8) Osteoarthritis
9) Primary dysmenorrhea
10) Rheumatoid arthritis
11) Tendinitis
12) Various ophthalmic uses

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2
Q

Contraindications for NSAIDs

A
  • known drug allergy
  • conditions that place pt @ risk for bleeding including; Vit.K deficiency and peptic ulcer disease
  • Pregnancy C category use first two trimesters ONLY
  • not for nursing mothers
  • Pt’s undergoing elective surgery stop taking a week prior
  • children w/flu like symptoms (Reye’s syndrome)
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3
Q

Adverse effects of NSAIDs

A
  • effect on GI tract
  • Range from heartburn-GI bleeding
  • acute renal failure
  • increased risk for MI & stroke
  • Heart failure
  • tinnitus, hearing loss
  • actue reversible hepatotoxicity
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4
Q

Toxicity and management of NSAIDs

A
  • tinnitus, hearing loss
  • children:hyperventilation & CNS effects: dizziness, drowsiness, behavioral changes
  • metabolic acidosis & respiratory alkalosis
  • hypoglycemia
  • Tx includes removing salicylate from GI tract; correcting fluid, electrolyte, acid-base distr. salicylate elimination (hemodialysis)
  • charcoal
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5
Q

NSAIDs interactions

A
  • Alcohol
  • Anticoagulants
  • Aspirin and other salicylates w/other NSAIDs
  • Diuretics/ACE inhibitors
  • Lithium
  • Corticosteroids
  • NSAID induced hyperkalemia or hyponatremia can occur
  • Herbals: feverfew, garlic, ginger, ginko
  • Bisphophonates
  • Cyclosporine
  • Protein-bound drugs
  • Uricosurics
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6
Q

NSAID nursing process

A

Assess for
-drug allergies, contraindications, cautions, drug interactions
-document duration, onset, location, type of inflammation; precipitating, exacerbating, relieving factors
-underlying signs of infection
-age
-use of ketorolac (drug ordered fro a short term)
Perform
-head-to-toe
-vital signs
-take medication history
Analyze
-lab test results; hematologic, renal, hepatic functioning (RBC, hemoglobin level, hematocrit, WBC, platelet, liver enzyme levels; ALP, AST, LDH)
-Inspect joints

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7
Q

NSAID pt education

A
  • Don’t crush/chew enteric-coated or sustained-release
  • take w/antacids/food to decrease GI upset
  • instruct to report to physician any moderate-severe GI upset, dyspepsia w/nausea, V, abdominal pain, blood in stool or V
  • avoid ulcerogenic substances (alcohol, prednisone, aspirin products, other NSAIDs)
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8
Q

When pt is taking NSAIDs monitor for?

A
  • bowel patterns, stool consistency, occurrence of GI symptoms &/or dizziness, doc. findings
  • lab tests (CBC, BUN levels, platelet counts, serum bilirubin, AST, ALT levels)
  • safe ambulation
  • occurrence of adverse effects and toxicity
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9
Q

Acetylsalicylic acid (Aspirin)

A
  • daily tab recommended as propylactic therapy
  • Pt’s w/systemic lupus erythematosus benefit
  • antiplatelet action
  • no black box warning
  • PO
  • assess odor
  • assess pt w/history of asthma, wheezing/other resp. problems
  • I.D. Pt’s diagnosed w/aspirin triad (asthma, nasal polyps, rhinitis)
  • if used as antigout, oral dose given w/food, milk, meals
  • monitor serum levels if given for antiarthritic
  • mainly lower dose, if higher monitor for clinical presentation/serum aspirin levels
  • be aware of toxicity
  • if used as antipyretic, pts temp will decrease w/in 1 hour
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10
Q

Ketorolac (Toradol) NSAID

A

Indications: Acute painful conditions that would otherwise require opioid level analgesia. Used for its powerful analgesic effects

  • PO, IV/IM
  • Short term use (up to 5 days)
  • not for minor/chronic pain
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11
Q

Indomethacin (Indocin) NSAID

A
  • Therapeutic actions for use in Tx of rheumatoid arthritis, osteoarthritis, acute bursitis or tendonitis, ankylosing spondylitis, and acute gouty arthritis
  • PO, Rectal, IV (for closure of patent ductus arteriosus)
  • premature labor
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12
Q

Ibuprophen (Advil/Motrin) NSAID

A
  • Safe adverse-effect profile
  • used for analgesic effects in management of rheumatoid arthritis, osteoarthritis, primary dysmenorrhea, gout, dental pain, musculoskeletal disorders, antipyretic actions
  • PO, OTC & prescriptions
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13
Q

Antipyretic: Acetaminophen (Tylenol) Mechanism of action

A
  • Blocks peripheral pain impulses by inhibiting prostaglandin synthesis
  • Decreases febril body temp. by acting on hypothalamus
  • lacks inflammatory effects
  • products not associated w/cardiovascular effects or platelet effects
  • doesn’t cause aspirin related GI tract irritation or bleeding, nor any aspirin-related acid-base changes
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14
Q

Antipyretic: Acetaminophen (Tylenol) Indications

A
  • Tx of mild-moderate pain/fever
  • Subs. for aspirin
  • drug of choice for children & adolescents w/flu syndromes. Also for pt’s who can’t tolerate aspirin
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15
Q

Antipyretic: Acetaminophen (Tylenol) Contraindications

A
  • known drug allergy
  • severe liver disease
  • genetic disease glucose-6-phosphate dehydrogenase (G6PD) deficiency
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16
Q

Antipyretic: Acetaminophen (Tylenol) Adverse effects

A
  • skin disorders, N/V
  • Blood disorders or dyscrasis (e.g. anemias), and nephrotoxicities, hepatotoxicity (excessive doses)
  • combination limited to 325mg
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17
Q

Antipyretic: Acetaminophen (Tylenol) Toxicity and management

A
  • hepatic necrosis

- hepatictoxicity. Acute can be reversed w/antidote for acetaminophen which is acetylcysteine. Long term permanent.

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18
Q

Antipyretic: Acetaminophen (Tylenol) Interactions

A
  • Alcohol
  • Other hepatotoxic drugs
  • Phenytoin, barbiturates, warfarin, isoniazid, rifampin, beta blockers, anticholinergic drugs
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19
Q

Analgesics Antipyretic implementation

A
  • pain management strategies include: type of pain & rating, quality, duration, precipitating factors, interventions
  • general principles of pain management: individualized care, mild pain=nonopioid drugs, moderate-severe pain=stepped approach w/opioids, administer analgesics as ordered before pain gets out of control, consider use of nonparm measures
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20
Q

non-opioid implementation (acetaminophen)

A
  • taken as prescribed & w/in recommended dosage range over 24hr period due to risk for liver damage and acute toxicity
  • if taking acetaminophen w/OTC drugs read labels to identify total amount of acetaminophen & other drug-drug interactions
  • suppository dosage of acetaminophen can be put on ice then run over by water
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21
Q

Antipyretic: Acetaminophen dosages

A
  • acetaminophen can be crushed
  • adults taking 3000 mg/day or greater increase risk for acute hepatotoxicity. Death after 15g
  • nasogastric or orogastric tube or IV
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22
Q

acetaminophen anedote

A

Liver damage from acetaminophen minimized by acetylcysteine (foul taste & odor) can mix with cola or flavored water to increase palatability

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23
Q

Acetaminophen patient education

A
  • If taking w/hydrocodone (Vicodin, Norco) or oxycodone (Percocet, Tylox) danger of overdose, increase risk of hepatotoxicity
  • read label to avoid overdose (OTC, prescribed)
  • s/s acetaminophen overdose:bleeding, loss of energy, fever, sore throat, easy bruising (hepatotoxicity)
  • combination products limed to 325mg acetaminophen, total daily doses 4000mg. Tylenol=3000mg/day
  • pt’s w/liver disease or alcohol consumption advised not to exceed 2000mg/day
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24
Q

Opioid analgesics can be characterized according to their mechanism of action

A

There are

1) Agonists
2) Agonist-antagonists
3) Antagonists (nonanalgesic)

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25
Q

Mechanism of action for analgesic opioid agonists

A
  • binds to opioid pain receptor in brain & causes analgesic response-reduction of pain sensation
  • diff. drugs in this class exert their effects by binding to different degrees of kappa and mu opioid receptors
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26
Q

Analgesic/opioid receptors mechanism of action

A

The mu, kappa, and delta receptors are most responsive to drug activity with the mu being the most popular

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27
Q

Mechanism of action for analgesic opioid agonist-antagonist also called a partial agonist or a mixed agonist

A

Bind to a pain receptor and causes a weaker pain response than does a full agonist

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28
Q

Mechanism of action for analgesic opioid antagonist

A

Binds to a pain receptor but does not reduce pain signals. It functions as a competitive antagonist because it competes with the and reverses the effects of agonist and agonist-antagonist drugs at the receptor site

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29
Q

Define equianalgesia

A

Refers to the ability to provide equivalent pain relief by calculating dosages of diff. drugs and/or routes of administration that provide comparable analgesia

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30
Q

Indications for opioids

A
  • Strong opioid (morphine, hydromorphone, oxycodone) control postop and other pain
  • morphine/hydromorphone=1st line analgesics in immediate postop setting due to their injectable forms
  • oxycodone=orally administered
  • oxycontin=sustained release, 12 hrs
  • opioids suppress medullary cough center
  • constipation=unwanted side effects of opioids due to decrease GI tract motility
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31
Q

Contraindications for opioids

A
  • known drug allergy and severe asthma
  • itching not allergic reaction, result of histamine
  • caution in cases of respiratory insufficiency especially when resuscitative equipment not available and in conditions involving INTRACRANIAL PRESSURE (severe head injury); morbid obesity &/or sleep apnea; myasthenia gravis; paralytic ileus (bowel paralysis); * pregnancy, especially w/long term use
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32
Q

Adverse effects for opioids

A

Cardiovascular: hypotension, flushing, bradycardia
CNS: Sedation, disorientation, euphoria, lightheadedness, dysphoria
GI: N/V, constipation, biliary tract spasm
Genitourinary: urinary retention
Integumentary: itching, rash, wheal formation
Respiratory: respiratory depression and possible aggravation of asthma

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33
Q

Drugs in nonsteroidal anti-inflammatory drugs (NSAIDS/NON-OPIOID)

A

1) Acetylsalicylic acid (Aspirin)
2) Ketorolac (Toradol)
3) Indomethacin (Indocin)
4) Ibuprofen (Advil/Motrin)

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34
Q

Drugs for antipyretic

A

1) Ibuprofen
2) Acetaminophen (Tylenol)
3) Aspirin (platelet inhibition)

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35
Q

Drugs for analgesic/opioids

A 
Opioids
1) Morphine
2) Oxycodone Hydrochloride (OxyContin/Percocet)
3) Meperidine (Demerol)
4) Hydromorphone (Dilaudid)
5) Nalbuphine (Nubain)
Opioid antagonist
1) Naloxone
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36
Q

Drugs for Penicillins

A

Penicillin G

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37
Q

Drugs for Cephalosporins

A

1) Ancef

2) Rocephin

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38
Q

Drugs for Macrolides

A

1) Erythromycin

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39
Q

Drugs for Aminoglycosides

A

1) Tobramycin

2) Gentamicin

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40
Q

Drugs for Flurorquinolones

A

1) Cipro

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41
Q

Drugs for Sulfonamides

A

1) Trimethoprim and Sulfamethoxazole (Bactrim)

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42
Q

Drugs for Antitubercular drugs

A

1) Isoniazid (INH)

2) Rifampin

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43
Q

Drugs for Antifungal

A

1) Nystatin (Mycostatin)
2) Fluconazole (Diflucan)
3) Amphotericin B

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44
Q

Drugs for Antiviral

A

1) Acyclovir (Zovirax)

2) Tamiflu

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45
Q

Drugs for Miscellaneous

A

1) Metronidazole (Flagyl)

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46
Q

Opioid Antagonist

A

Naloxone (Narcan): binds to receptor sites (mu, kappa, delta).

  • competitive antagonists
  • reverse opioid affects (resp. depression, itching)
  • short lived (1 hour)
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47
Q

Toxicity/management of opioids

A

-gradual dose reduction after chronic opioid use helps minimize risk of severity of withdrawal symptoms

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48
Q

Interaction of opioids

A

-alcohol
-antihistamines
-barbiturates
-benzodiazephiens
-phenothiazine
-other CNS depressants
Can all result in additive resp. depressant effectss
-combined use of opioids can result in respiratory depression, seizures, and hypotension

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49
Q

Lab test interactions of opioids

A

Can cause abnormal increase in

  • serum levels of amylase
  • alanine aminotransferase
  • alkaline phosphatase
  • bilirubin
  • lipase
  • creatinine kinase
  • lactate dehydrogenase
  • urinary 17-ketosteroid levels
  • an increase in urinary alkaloid and glucose concentrations
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50
Q

Analgesic nursing assessment

A

-perform thorough health history,

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51
Q

Penicillins are?

A

Bactericidal antibiotics, meaning they kill a wide variety of gram-positive and some gram-negative bacteria

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52
Q

Beta-lactamases

A

Bacteria that have acquired the capacity to produce enzymes capable of destroying penicillins

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53
Q

Penicillin (and Cephalosporins) mechanism of action and drug effects

A

Inhibition of bacterial cell wall synthesis

  • penicillin binding proteins: by binding to proteins the penicillin molecule interefers with normal cell wall synthesis
  • bacterial death results from lysis (rupture) of its cell walls
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54
Q

Indication for penicillin (and cephalosporins)

A

For prevention and Tx of infections caused by susceptible bacteria

  • most common bacteria destroyed by penicillins are: gram-positive such as streptococcus, enterocuccus, staphlococcus
  • extended-spectrum penicillins can destory gram-+/- and anaerobic. These are used to treat many health-care associated infections
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55
Q

Contraindications for penicillins

A
  • known drug allergy/type of reaction
  • important to know that some penicillins don’t end with “cillin” so don’t give it to a pt that is allergic to penicillin
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56
Q

Adverse effects of penicillins (and cephalosporins)

A
  • allergic reactions
  • urticaria, pruritus, angioedema
  • idiosyncratic (unpredictable) reactions: maculopapular eruptions, eosinophilia, Stevens-Johnson syndrome, exfoliative dermatitis
  • Anaphylactic reactions
  • those with history of throat swelling or hives from penicillin should not receive cephalosporins
  • most common involve GI system
  • IV formulations (some) contain large amounts of sodium and/or potassium. Doses must be adjusted for pt’s w/renal dysfunction
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57
Q

Interactions for penicillins

A
  • NSAIDs
  • oral contraceptives
  • warfarin
  • rifampin
  • probenecid
  • methotrexate
  • aminoglycosides (IV) and clavulanic acid
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58
Q

Nursing assessment for antibiotics: sulfonamides, penicillins, cephalosporins, macrolides, quinolones, aminoglycosides, tetracyclines

A
  • history/symptoms of hypersensitivity or allergic reactions
  • determine pt’s age, weight, baseline vital signs w/body temperature
  • lab tests such as liver function (AST, ALT levels), kidney function (BUN, creatinine levels), cardiac function (EKG), ultrasonography, culture and sensitivity tests, CBC, platelet clotting tests
  • obtain specimens for cultures BEFORE beginning antibiotic therapy
  • assess I&O
  • record baseline neurologic assessment findings
  • assess bowel sounds/patterns
  • check for contraindications, cautions, drug interactions
  • obtain list of pt’s medications (herbs, etc.)
  • cultural assessment (racial/ethnic)
  • assess learning preparedness, willingness, education level for pt education of safe administration
  • baseline findings for oral mucosa, respiratory tract, GI tract, genitourinary tract (risk for superinfection)
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59
Q

Superinfection due to antibiotics are evidenced by?

A

Fever, lethargy, mouth sores, perineal itching

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60
Q

Nursing interventions when giving antibiotics

A

1) give oral w/in time frame and fluids/foods
2) give as prescribed to maintain effective blood levels
3) dont omit or double doses
4) Dont give oral at same time w/antacids, calcium supplements, iron products, laxatives containing magnesium, or antilipemic drugs
5) herbal/dietary supplements can be used unless they interact
6) continually monitor for hypersensitivity reactions past the initial assessment phase because immediate reactions may occur w/in 1-72 hrs. Characterized by wheezing, SOB, swelling of face/hands, itching/rash
7) signs of hypersensitivity=stop dosage form IMMEDIATELY (if IV, stop infusion), contact prescriber, monitor pt

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61
Q

Nursing assessment for penicillins

A
  • determine drug allergies BEFORE therapy
  • assess history of asthma, sensitivity to multiple allergins, aspirin allergy, and sensitivity to cephalosporins. These are associated w/ higher risk for penicillin allergy
  • note results of C&S tests
  • assess neuro, abdominal, bowel assessment
  • pt’s w/electrolyte imbalances, cardiac disease, and/or renal disease assessment of serum sodium and potassium levels because some penicillins contain those concentrations
  • w/any dose important to assess for patient safety of immediate, accelerated, or delayed allergic reaction
  • remember, not all penicillins end in “CILLIN”
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62
Q

Implementation for penicillins

A

To prevent getting C. diff when giving penicillin have pt consume probiotics, supplements, or cultured dairy products (e.g kefir)
Points to remember
1) take oral w/6 oz of water (not juice)
2) penicillin V, amoxicillin, & amoxicillin/clavulanate given w/water & 1hr before or 2hrs after meals, take w/snack
3) Procaine & benzathine salt penicillin are thick so give them IM w/21-guage needle
4) Reconstitute IM imipenem/cilastin in sterile saline w/lidocaine into large muscle mass
5) IV penicillins use diluent & infuse over time. Monitor IV site for swelling, tenderness, heat, redness, leaking, and pain
6) check compatibilities of IV fluids and drugs prior to infusion
7) if pt has anaphylactic reaction give epinephrine & other emergency drugs. Supportive equipment (oxygen)

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63
Q

Natural penicillins: Penicillin G and penicillin V potassium

A

Penicillin G has 3 salt forms: benzathine, procaine, potassium. All given by injection (IV, IM).

  • benzathine and procaine salts are used as longer-acting IM injections. Never give them IV because their consistency is too thick
  • IM helpful for syphilis
  • penicillin G potassium for IV
  • penicillin V oral use only
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64
Q

adverse effect of doxycycline, a tetracycline antibiotic.

A

Photosensitivity is a common adverse effect. The client should avoid direct sun exposure and tanning bed use while taking this medication. Exposure to the sun can cause severe burns.

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65
Q

Tetracycline is contraindicated in children younger than 8 years of age because?

A

It can cause permanent discoloration of the adult teeth and tooth enamel, which are still forming in the child.

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66
Q

Clients who are allergic to penicillins have an increased risk of allergy to? 4%.

A

beta-lactam antibiotics. The incidence of cross-reactivity between cephalosporins and penicillins is reported to be between 1% and 4%.

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67
Q

When a patient is taking sulfonamide antibiotics what should they be encouraged to do?

A

Clients should be encouraged to drink plenty of fluids (2000 to 3000 mL/24 hours) to prevent drug-related crystalluria associated with sulfonamide antibiotics.

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68
Q

Azithromycin is a newer macrolide antibiotic. It has?

A

longer duration of action, as well as fewer and less severe GI adverse effects than erythromycin.

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69
Q

A health care–associated infection is?

A

An infection that is acquired during the course of receiving treatment for another condition in a health care facility. The infection is not present or incubating at the time of admission; also known as a nosocomial infection.

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70
Q

Prophylactic antibiotic therapy is used to?

A

prevent infections in individuals who are at high risk of development of an infection during or after a procedure. The antibiotics are given before the procedure for prophylactic treatment.

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71
Q

Not completing a full course of antibiotic therapy can allow bacteria that are not killed but have been exposed to the antibiotic to adapt their physiology to become resistant to that antibiotic. Administering antibiotics to treat viral infections is not effective and may expose small amounts of bacteria that may be present to the antibiotic and therefore risk the development of resistance.

A

.

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72
Q

Cephalosporins (semisynthetic antibiotics)

A
  • structurally & pharmacologically related to penicillins
  • bactericidal, interfere bacterial cell wall synthesis
  • bind to same penicillin binding proteins in bacteria
  • 5 generations; depending on generation they can be active against gram +/-, or anaerobic
  • not active against fungi, viruses or enterococci
  • 1st generation most gram + coverage, later generations most gram -
  • Anaerobic coverage found only with second-generation
  • 5th generation covers gram + (MRSA) and gram -
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73
Q

Adverse effects of Cephalosporins (semisynthetic antibiotics)

A
  • mild diarrhea, abdominal cramps, rash, pruritus, redness, edema
  • chemically similar to penicillins so a pt allergic to penicillin may also have allergic reaction to cephalosporins, called cross sensitivity
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74
Q

Pregnancy category for cephalosporins (antibiotic)

A

Pregnancy category B

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75
Q

Contraindications of cephalosporins (antibiotic)

A

Patients with known hypersensitivity to them and in patients with a history of life-threatening allergic reaction to penicillins

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76
Q

Cephalosporin: Cefazolin (Ancef)

A
  • Prototypical 1st generation
  • provides coverage against gram+ but limited coverage against gram-
  • available for parenteral use
  • used commonly for surgical prophylaxis and for susceptible staphylococcal infections
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77
Q

Cephalorsporin: Ceftriaxone (Rocephin)

A
  • long acting 3rd generation given ONLY once a day for Tx of infections
  • easily pass through blood-brain barrier so it is one of the few that are indicated for Tx of meningitis
  • given both IV and IM (only injection)
  • 93-96% bound to plasma protein
  • metabolized in the INTESTINE after biliary excretion
  • not given to hyperbilirubinemic neonates or to pt’s w/severe liver dysfunction
  • should NOT be administered w/calcium infusions
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78
Q

Macrolides

A
  • bacteriostatic except in high concentrations they can be bactericida
  • azithromycin and clarithromycin have longer durations of action than erythromycin which allows them to be given less often. Produce fewer and milder GI tract adverse effects than erythromycin
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79
Q

Macrolides: Erythromycin

A
  • bitter taste & quickly degraded by acidity of stomach, so several salt forms and many dosage formulations developed to circumvent these problems
  • therapeutic effect is its ability to irritate GI tract, which stimulates smooth muscle and GI motility. Benefit to pt’s w/decreased GI motility and helpful in facilitating passage of feeding tubes from stomach into small bowel
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80
Q

Macrolides mechanism of action

A
  • bacteriostatic, inhibit protein synthesis by binding reversibly to 50s ribosomal subunits of susceptible microorganisms
  • Tx for wide range of infections: upper/lower respiratory tract, skin, and soft tissue caused by some strains of Streptococcus & Haemophilus, syphilis, lyme disease, gonorrhea, chlamydia, mycoplasma, corynebacterium infections
  • effective against several bacterial species that often reproduce inside host cells instead of just in the bloodstream or interstitial spaces
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81
Q

Macrolides indications

A
  • Streptococcus pyogenes
  • mild-moderate upper/lower respiratory tract infections caused by Haemophilus influenzae
  • spirochetal infections such as syphilis, lyme disease
  • gonorrhea, chlamydia, mycoplasma infections
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82
Q

Contraindications of macrolides

A

Known drug allergy

-often used as alternative drugs for pt’s w/allergies to beta-lactam antibiotics

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83
Q

Adverse effects of macrolides

A
  • Erythromycin: GI-related, N/V
  • Azithromycin and clarithromycin: lower incidence of these GI tract complications
  • palpitations, chest pain QT prolongation
  • Headache, dizziness, vertigo
  • N, hepatotoxicity, heartburn, vomiting, diarrhea, flatulence, cholestatic jaundice, anorexia, abnormal taste
  • rash, urticaria, phlebitis @ IV site
  • hearing loss, tinnitus
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84
Q

Interactions with Macrolides

A

Possess two properties that can cause drug interactions: they are highly protein bound, they are metabolized in the liver

  • drugs metabolized in the liver, drug interactions arise from competition between the drugs for metabolic enzymes (cytochrome P-450) leads to pronounced drug interactions, result is delay in the metabolic clearance of one or more interacting drugs thus prolonged and toxic drug effect
  • reduce efficacy of oral contraceptives
  • clarithromycin & erythromycin not used w/moxifloxacin, pimozide, thioridazine, or other drugs that prolong QT interval, because malignant dysrhythmias can occur
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85
Q

What happens when macrolides are given with drugs that compete for hepatic metabolism such as carbamazepine, cyclosporine, theophylline, and warfarin?

A

The results are enhanced effects and possible toxicity of the latter drugs, and pt’s must be monitored

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86
Q

Macrolide: erythromycin

A
  • available in several diff. salt and dosage forms for oral use that were developed to circumvent some of the drawbacks it have chemically
  • injectable form available for IV use
  • also available in topical forms for dermatologic use & in ophthalmic dosage forms
  • absorption of oral form enhanced if taken on empty stomach, taken w/meal or snack
  • associated w/many drug interactions because it is a strong inhibitor of cytochrome P450 enzymes
87
Q

Antibiotic: Tetracycline

A
  • Bacteriostatic, inhibit bacterial protein synthesis by binding to 30S bacterial ribosome
  • 3 naturally occurring tetracycline: demeclocycline, oxytetracycline, tetracycline. 2 semisynthetic: doxycycline, minocycline
  • tigecycline (Tygacil) indicated for skin and soft-tissue infections, intraabdominal infections, pneumonia. Effective against many resistant bacteria
  • ability to bind to (chelate) divalent (Ca++, Mg++) and trivalent (Al++++) metallic ions to form insoluble complexes. The COADMINISTRATION with MILK, ANTACIDS, or IRON salts causes REDUCTION in oral absorption
  • strong affinity for calcium precludes use in pediatric pt’s younger than 8, can result in TOOTH DISCOLORATION
  • avoid if PREGNANT and NURSING MOTHERS. They pass in breast milk can be route of exposure leading to tooth discoloration in nursing children
88
Q

Tetracyclines differ from one another in the following ways

A
  • Oral absorption: all except tigecycline are adequately absorbed
  • Body tissue penetration: doxycycline and minocycline possess best penetration potential
  • Half life and resulting dosage schedule:
89
Q

Tetracycline mechanism of action

A
  • Inhibit protein synthesis in susceptible bacteria
  • inhibit growth of and kill wide variety of Rickettsia, chlamydia, mycoplasma, gram -/+
  • Tx of spirochetal infections (syphilis, lyme disease, pelvic inflammation)
  • Demeclocycline inhibits action of antidiuretic hormone, useful in Tx of SIADH
90
Q

Indications for tetracycline

A
  • Chlamydia
  • Mycoplasma
  • Rickettsia
  • Other bacteria: acne, cholera, lyme disease etc.
  • Protozoa
91
Q

Contraindications for tetracycline

A
  • Known drug allergy

- Must be avoided in pregnant and nursing women and children younger than 8 years old

92
Q

Adverse effects of tetracyclines (antibiotic)

A
  • discoloration of teeth
  • tooth enamel hypoplasia in both fetuses and children, possibly retard fetal skeletal development if taken during pregnancy
  • photosensitivity
  • alteration of intestinal and vaginal flora: diarrhea, vaginal candidiasis, reversible bulging fontanelles in neonates; thrombocytopenia, coagulation, hemolytic anemia, exacerbation of systemic lupus
  • GI upset, enterocolitis, maculopapular rash
93
Q

Interactions of tetracycline

A
  • When taken w/antacids, antidiarrheal drugs, dairy products, calcium, enteral feeding, iron preparations, the oral absorption is reduced
  • can potentiate effects of oral anticoagulants, more monitoring of anticoagulant effect and possible dosage adjustment
  • antagonize effects of bactericidal antibiotics and oral contraceptives
  • can cause increased blood urea nitrogen levels
94
Q

Sulfonamides (antibiotic) mechanism of action

A
  • inhibit bacterial growth (bacteriostatic) by preventing bacterial synthesis of folic acid
  • compete w/PABA for bacterial enzyme tetrahydopteroic acid synthetase
  • also considered antimetabolites
95
Q

Indications for sulfonamides (antibiotic)

A
  • Against gram +/-
  • achieve high concentrations in kidneys, where eliminated so Tx of UTI’s
  • common susceptible organisms: Enterobacter, Escherichia coli, Klebsiella, Proteus mirabilis, Proteus vulgaris, S. aureus
  • results of C&S testing helps optimize drug selection
  • urinary analgesic (phenazopyridine (Pyridium) is given w/it to help w/pain associated with UTI
  • sulfamethoxazole/trimethoprim used for respiratory tract infections. Also prophylaxis and Tx of opportunistic infections in pt’s w/HIV. Drug of choice for infection caused by bacterium Stenotrophomonas maltophilia
  • Staphylococcus
96
Q

Aminoglycosides (antibiotics)

A

Natural and semisynthetic antibiotics that are bactericidal drugs
-potent antibiotics (virulent infections)
-several routes NOT ORAL
-

97
Q

Aminoglycosides (antibiotics) Nursing process

A
  • Serum levels monitored in pt’s blood
  • dosages adjusted to maintain optimal levels that maximize drug efficacy/minimize toxicity (therapeutic drug monitoring)
  • nephrotoxicity/ototoxicity associations
  • dosage adjusted to pt’s level of renal function based on estimates of creatinine clearance
  • in order to be effective the serum level needs to be @least 8x higher than minimum inhibitory concentration (MIC)
  • work through concentration-dependent killing
  • ONCE daily dosing
  • trough (lowest) levels routinely measured to ensure adequate renal clearance of drug and avoid toxicity (drawn 8-12 hours after administration)
  • lower dosages Tx UTI’s
98
Q

Minimum inhibitory concentration (MIC)

A

MIC for any antibiotic is a measure of the lowest concentration of drug needed to kill a certain standard amount of bacteria. This value determined in vitro (in lab) for each drug

99
Q

Concentration dependent killing

A

Achieving a drug plasma concentration that is a certain level above the MIC, even for a brief period, results in most effective bacterial kill

100
Q

Trough levels of aminoglycosides (antibiotics) that are above 2 mcg/mL are associated with?

A

Greater risk for both ototoxicity and nephrotoxicity

101
Q

In Aminoglycosides what does a rising serum creatinine level suggest?

A

Reduced creatinine clearance by the kidneys and is indicative of declining renal function
-measured @least every 3 days

102
Q

When are both peak and trough levels measured in aminoglycosides?

A

When given 3x a day

103
Q

Aminoglycosides mechanism of action

A

-Bind to ribosomes (30s) & prevent protein synthesis in bacteria
-mostly combinations w/other antibiotics, combined effect greater (synergistic effect)
-

104
Q

What happens when aminoglycosides and beta-lactam antibiotics are combined?

A

Beta-lactam given first so they can break down cell walls to allow aminoglycosides to gain access to ribosomes

105
Q

Postantibiotic effect of aminoglycosides

A

Period of continued bacterial growth suppression that occurs AFTER short term antibiotic exposure.
-enhanced with higher peak drug concentrations and concurrent use of beta-lactam antibiotics

106
Q

Indications for Aminoglycosides

A
  • use for serious gram- infections (Pseudomonas, Escherichia coli, Proteus, Klebsiella, Serratia, acinetobacter
  • specific conditions involving gram+ cocci (Enterococcus, S.aureus, bacterial endocarditis) NEVER used alone to Tx gram + infections
  • Prophylaxis in procedures of GI or GU tract
  • given in combination w/ empicillin or vancomycin for penicillin allergic pt’s
  • Administer w/caution in premature and full-term neonates due to renal immaturity
  • in pediatric pt’s: pneumonia, meningitis, UTI can occur
  • inactive against fungi, viruses, most anaerobic bacteria
107
Q

Contraindictions for Aminoglycosides (antibiotic)

A
  • known drug allergy
  • Pregnancy category= C-D
  • can cross placenta and cause fetal harm
  • used for pregnant women ONLY in event of life-threatening infections.
  • don’t give to lactating women
108
Q

Adverse effects of aminoglycosides (antibiotic

A
  • nephrotoxicity (kidneys) occurs in 5-25% & manifested by urinary casts, proteinuria, increased blood urea nitrogen (BUN) & serum creatinine levels. Reversible but monitor renal function
  • ototoxicity (ears) hearing/balance function. 3-14%, not reversible, permanent. 8th cranial nerve. Dizziness, tinnitus, sense of fullness in ears, hearing loss
  • headaches, paresthesia, vertigo, skin rash, fever, over growth of nonsusceptible organisms, neuromuscular paralysis. Greatest risk in pt’s w/preexisting renal impairment, pt’s already receiving other renally toxic drugs, & pt’s receiving high-dose/prolonged aminoglycoside therapy
109
Q

Interactions with aminoglycosides

A
  • nephrotoxicity increased w/concurrent use of other nephrotoxic drugs (vancomycin, cyclosporine, amphotericin B)
  • concurrent use w/ loop diuretics increases risk for ototoxicity
  • can potentiate warfarin toxicity
  • concurrent use w/neuromuscular blocking drugs
110
Q

Aminoglycosides: Tobramycin

A

Used in Tx for recurrent pulmonary infections in pt’s with cystic fibrosis by both injectable and inhaled dosing
-available in topical and opthalmic dosage forms

111
Q

Aminoglycosides: Gentamicin

A
  • IV/IM dosage same for both routes
  • indicated for Tx of infection w/several susceptible gram+/- bacteria
  • available in several dosage forms (injections, topical ointments, opthalmic drops/ointments)
112
Q

Fluoroquinolones (Quinolones)

A

Potent bactericidal broad-spectrum antibiotics

-excellent oral absorption comparable to IV injections

113
Q

Fluoroquinolones (Quinolones) Mechanism of action

A

Destroy bacteria by altering their deoxyribonucleic acid (DNA) by interfering w/bacterial enzymes DNA gyrase and topoisomerase IV

  • do not inhibit production of human DNA
  • kill mostly gram- and some gram+
  • some diffuse into & concentrate themselves in human neutrophils
  • some bacterial resistance
114
Q

Fluoroquinolones (Quinolones) Indications

A
  • active against gram- and select gram+
  • most secreted by kidneys as unchanged drug
  • Tx of complicated UTI infections
  • Respiratory, skin, GI, and bone and joint infections
  • combination w/aminoglycosides Tx P. aeruginosa infections
  • In prepubescent children NOT recommended, they can affect cartilage development
  • children w/cystic fibrosis can use them
115
Q

Contraindictions of Fluoroquinolones (Quinolones)

A

Known drug allergy

116
Q

Adverse effects of Fluoroquinolones (Quinolones)

A
  • Bacterial overgrowth associated w/long term use
  • Cardiac effect: prolongation of QT interval, dysrhythmias (those taking class Ia & class III antidysrhythmic drugs),
  • Black box warning: tendinitis/tendon rupture seen in older adult, renal failure, concurrent glucocorticoid therapy pt’s
  • CNS stimulation (seizures)
  • peripheral neuropathy
  • liver injury
117
Q

Interactions of Fluoroquinolones (Quinolones)

A
  • Concurrent use of oral quinolones w/antacids, calcium, magnesium, iron, zinc preparations, or sucralfate=reduction in oral absorption of quinolone. So take interacting drugs 1 hour before or after quinolones
  • Dairy products
  • Enteral tube feedings
  • Probenecid=reduced renal excretion
  • Nitrofurantoin
  • oral anticoagulants use w/caution
118
Q

Ciprofloxacin (Cipro)

A
  • broad coverage
  • oral, injectable, ophthalmic, otic
  • excellent bioavailability, can work orally as well as many IV antibiotics
  • capable of killing wide range of gram-
  • effective against difficult to kill gram-
  • kill some anaerobic bacteria as well as atypical organisms such as Chlamydia, Mycoplasma, Mycobacterium
  • Drug of choice for anthrax
119
Q

Miscellaneous antimicrobial drug: Metronidazole

A

-Class nitroimidazole
-against anaerobic used to Tx intraabdominal/gynecologic infections (Peptostreptococcus, Eubacterium, Bacteroides, Clostridium)
-Tx of protozoal infections (amebiasis, trichomoniasis)
-interferes with microbial DNA synthesis
-used orally to Tx antibiotic-associated colitis
Contraindicated: known drug allergy
-oral/injectable forms
-pregnancy B category but DON’T use during first trimester
ADVERSE EFFECTS:
-Dizziness, headache, GI discomfort, nasal congestion, reversible neutropenia and thrombocytopenia
DRUG INTERACTIONS
-acute alcohol intolerance, avoid for 24 hrs before therapy then 36 hrs after
-Increase toxicity of lithium, benzodiazepines, cyclosporine, calcium channel blockers, various antidepressants, warfarin

120
Q

Nursing assessment for potent antibiotics: Aminoglycosides, Quinolones, Miscellaneous antibiotics (metronidazole)

A
  • Reserved for Tx of potent infections & given parenteral routes
  • critical assessment for history of/current symptoms indicative of hypersensitivity or allergic reactions
  • nursing physical exam
  • document age, weight, baseline vital signs
  • diagnostic/lab values (AST, ALT, ECG, ultrasonography, and/or cardiac enzymes
  • C&S
  • WBC count
  • Hemoglobin level
  • Hematocrit
  • RBC count
  • clotting values
  • sensory/motor intactness
  • baseline abdominal/GI assessments
  • note contraindications, cautions, drug interactions
  • obtain medication lists
  • cultural assessment
  • assess for SUPERINFECTION
  • assess immune system status
121
Q

Aminoglycosides assessment

A

Assess for

  • hypersensitivity/preexisting health conditions or altered neurologic and renal function
  • obtain medication list due to cautions, contraindications, & drug interactions
  • known for ototoxicity & nephrotoxicity so perform baseline hearing tests & assessment of vestibular function
  • nephrotoxicity=increased risk w/use of other nephrotoxic drugs
  • perform renal function studies (BUN level, urinalysis, serum & urine creatinine levels), document
  • if renal baseline functioning is decreased prescriber will need to adjust dosage amounts due to risk of nephrotoxicity
  • neuromuscular assessment
  • neonates & older adults at higher risk for nephrotoxicity, neurotoxicity, and ototoxicity & require careful assessment before and during drug therapy
  • assess hydration status
122
Q

Nursing assessment for quinolones

A
  • careful assessment of preexisting CNS conditions may be exacerbated by concurrent use
  • assess existing neuropathies, quinolones may precipitate peripheral neuropathy
  • assess cardiac history
  • assess baseline liver function
  • drug interactions: antacids, iron, zinc, ucralfate as they affect absorption of the quinolone
  • oral anticoagulants interact w/and alter antibacterial activity
123
Q

Nursing assessment for metronidazole

A
  • allergy & other nitroimidazole derivatives
  • contraindications, cautions, drug interactions & document findings
  • review C&S BEFORE therapy (sometimes medication administration may be started prior to results then medication can be changed)
  • baseline assessments for neurologic system, GI system, GU system
  • acquire alcohol intake
124
Q

Implementation with aminoglycosides

A
  • given as ordered w/hydration (fluid intake up to 3000 mL/day)
  • because of nephrotoxicity/ototoxicity determine/monitor pt’s renal function during therapy
  • dosing adjusted based on creatinine clearance calculated from pt’s serum creatinine level
  • monitor renal function to prevent toxicity
  • monitor BUN levels, glomerular filtration rate (GFR) during therapy
  • alteration in auditory, vestibular, or renal function may indicate need for dosage adjustment/withdrawal
  • consumption of yogurt/buttermilk and/or probiotics may help prevent antibiotic-induced superinfections
  • ophthalmic dosage forms: redness, burning, itching of eyes adverse reaction
  • check instramuscular sites for induration, DON’T reuse site
  • monitor IV sites for heat, swelling, redness, pain, phlebitis & initiate measures per protocol
125
Q

Patient education with aminoglycosides

A

-Instruct pt to report any changes in hearing, tinnitus, or a full feeling in ears, N/V w/motion, ataxia, nystagmus, & dizziness may indicate issues w/vestibular nerve

126
Q

Special considerations for gentamicin

A

1) IM: give deeply/slowly into muscle mass to minimize discomfort
2) IV: check for incompatibilities w/drugs, give only clear or slightly yellow solutions diluted w/NS or D5W

127
Q

Implementation for quinolones

A
  • give as prescribed/full course
  • DON’T take w/antacids, iron, zinc, multivitamins, sucralfate due to decreased absorption of antibiotic
  • if pt needs to take calcium/magnesium instruct them to take 1 hr before or after quinolone
  • Force fluids
128
Q

Implementation for metronidazole

A
  • given w/food or meals to help decrease GI upsed
  • Do not chew extended-release forms
  • avoid alcohol
  • Intravaginal give at bedtime w/applicator
  • Topical creams (not near eyes), ointments, lotions apply thinly, wear gloves
  • store IV form at room temp.
129
Q

Patient teaching for aminoglycosides

A
  • Educate about drug, purpose, adverse effects including hearing loss which may occur after completion of therapy
  • advise pt to report any change in hearing to prescriber
  • Increase in fluids up to 3000mL/day to maximize absorption of oral doses, minimize some adverse effects, ensure adequate hydration
  • Report persistent headache, N, vertigo. Educate about s/s of superinfection (diarrhea); vaginal discharge; stomatitis, loose and foul smelling stools; cough
130
Q

Patient teaching for Quinolones

A

Educate about

  • incidence of PHOTOSENSITIVITY (use sunscreen, sunglasses)
  • advise to report headache, dizziness, diarrhea, restlessness, V, oral candidiasis, flushing of face, inflammation of tendons
  • drug interactions w/calcium, magnesium, probenecid, nitrofurantoin, oral anticoagulants, antacids, iron, zinc, sucralfate
  • instruct to take Ca+/Mg+ 1hr before/after therapy
  • Probenecid may reduce excretion of antibiotic & cause toxicity
  • Since quinolones may alter intestinal flora, thus vit. K synthesis, oral anticoagulants use w/caution
  • instruct to take ciprofloxacin/levofloxacin EXACTLY how ordered
131
Q

Patient teaching for Metronidazole

A
  • avoid alcohol or alcohol products due to risk for disulfiram-like reaction (severe V)
  • purpose of drug such as its use as either antibacterial or an antifungal medication, because this knowledge is crucial to achieving therapeutic effects and preventing adverse effects
132
Q

A group of natural and semisynthetic antibiotics that are classified as bactericidal drugs, are very potent, and are capable of potentially serious toxicities (e.g nephrotoxicity, ototoxicity)

A

Aminoglycosides

133
Q

Very potent, bactericidal, broad spectrum antibiotics and include norfloxacin, ciprofloxacin, levofloxacin, and moxifloxacin

A

Quinolones

134
Q

Antimicrobial drug of the class nitroimidazole, had good activity against anaerobic organism, and is widely used for intraabdominal and gynecologic infections; it is also used to treat protozoal infections (amebiasis, trichomoniasis)

A

Metronidazole

135
Q

Fungal infections are evidenced by?

A

Fever, lethargy, perineal itching, and other anatomically related symptoms

136
Q

Gentamicin has a high potential for nephrotoxicity. Nephrotoxicity typically occurs in 5% to 25% of clients. Thus, the client’s renal function test results for?

A

BUN and creatinine must be monitored closely throughout therapy.

137
Q

Dangerous cardiac dysrhythmias are more likely to occur when quinolones are taken by clients receiving class Ia and class III antidysrhythmic drugs such as?

A

disopyramide and amiodarone. For this reason, such drug combinations should be avoided.

138
Q

When infused too rapidly, clients receiving vancomycin may develop hypotension accompanied by?

A

flushing or itching of the head, face, neck, and upper trunk area. This phenomenon is called red man syndrome.

139
Q

Trough serum drug levels should be drawn at least?

A

8 to 12 hours after the medication is infused.

140
Q

A disulfiram-like (Antabuse) reaction may occur with concurrent ingestion of metronidazole and?

A

Alcohol, leading to facial flushing, tachycardia, palpitations, nausea, and vomiting.

141
Q

In gram-positive cocci, gentamicin is usually given in combination with?

A

a penicillin antibiotic.

142
Q

Concomitant use of lithium and ______ may result in lithium toxicity. Thus, a client who reports taking lithium should?

A

metronidazole

-alert the nurse to notify the health care provider because of the potential significant interaction.

143
Q

Quinolones are not used in?

A

prepubescent children because of the risk of cartilage development issues. Quinolones may also cause a cardiac effect that involves prolongation of the QT interval on the electrocardiogram. The use of these medications can result in tendonitis or ruptured tendons in adults.

144
Q

Sulfamethoxazole/trimethoprim often used in Tx of?

A

UTI’s

145
Q

Contraindications for sulfonamides

A
  • known drug allergy (chemically related drugs such as sulfonylureas, thiazide, and loop diuretics, and carbonic anhydrase inhibitors generally safe in pt who has allergy)
  • cyclooxygenase-2 inhibitor celecoxib (Celebrex) should NOT be used w/known allergy
  • pregnant women at term and in infants younger than 2 months
146
Q

Adverse effects of sulfonamide drugs

A
  • allergic reactions (sulfa allergy or sulfur allergy)
  • delayed cutaneous reactions; begin w/fever followed by a rash (morbilliform eruptions, erythema multiforme, or toxic epidermal necrolysis
  • Photosensitivity reactions (common w/tetracycline class)
  • mucocutaneous, GI, hepatic, renal, hematologic
  • immune mediated & involve production of reactive drug metabolites in body
147
Q

Interactions of sulfonamides

A
  • may potentiate hypoglycemic effects of sulfonylureas in diabetes Tx, toxic effects of phenytoin, and the anticoagulant effects of warfarin, which can lead to hemorrhage
  • may increase cyclosporine-induced nephrotoxicity
  • may reduce efficacy of oral contraceptives
148
Q

Sulfamethoxazole/trimethoprim (co-trimoxazole)

A

A fixed combination drug product containing 5:1 ratio of sulfamethoxazole to trimethoprim
-oral and injectable dosage forms

149
Q

Antitubercular drugs

A
  • Tx infections caused by Mycobacterium
  • two categories: primary or first line drugs and secondary or second-line drugs
  • do drug susceptibility tests, then pt started on four-drug regimen
  • pt adherence to regimen monitored closely due to nonadherence and adverse effects
150
Q

Antitubercular drug: Isonizid

A

Primary antitubercular drug

-either sole drug in prophylaxis of TB or in combination w/other antitubercular drugs

151
Q

Antitubercular mechanism of action

A

Inhibit protein synthesis, cell wall synthesis, various other mechanisms

  • reduction of cough, therefore, reduction of the infectiousness. Normally occurs w/in 2 weeks of drug therapy
  • successful Tx means taking mult. antibiotic drugs for at least 6 months or longer
152
Q

Indications for antitubercular drugs

A

Tx of both pulmonary and extrapulmonary TB

  • combination of isoniazid and ethambutol used to treat pregnant women w/out teratogenic complications. Can also used Rifampin
  • effective in management of Tx failures and relapses
  • infection w/Mycobacterium, M tuberculosis
  • prophylaxis Tx of TB
153
Q

Contraindications for Antitubercular drugs

A
  • severe drug allergy
  • major renal or liver dysfunction
  • chronic alcohol use
154
Q

Adverse effects of antitubercular drugs

A
  • Isoniazid causes pyridoxine deficiency and liver toxicity so supplements of pyridoxine are given
  • QT prolongation
155
Q

Interactions of antitubercular drugs

A

Isoniazid can cause false positive readings on urine glucose tests and in increase in the serum levels of the liver function enzymes alanine aminotransferase and aspartate aminotransferase

156
Q

Isoniazid (INH)

A
  • Most used
  • single drug for prophylaxis or combination w/other antitubercular drugs
  • bactericidal drug that kills mycobacteria by disrupting cell wall synthesis and essential cellular functions
  • metabolized in liver through process called acetylation
  • slow acetylators are people that have a genetic deficiency of the liver enzymes
  • mostly used in oral form, injection available
  • oral formulation containing isoniazid and rifampin
  • contraindicated in those w/previous isoniazid-associated hepatic injury or any acute liver disease
  • causes pyridoxine deficiency so take w/supplements
157
Q

Rifampin

A
  • synthetic macrocyclic antibiotics
  • activity against mycobacterium, meningococcus, haemophilus type b, M. leprae
  • bactericidal, inhibits protein synthesis
  • used alone or in combination
  • oral/parenteral formulations
  • contraindicated for those with allergy to rifamycin
  • potent enzyme inducer
  • Urine, saliva, tears, sweat to be red-orange-brown colored
158
Q

Assessment for antitubercular drugs

A
  • obtain history, medication profile, nursing history
  • head-to-toe
  • note specific history of diagnosis or symptoms of TB
  • results of last purified protien derivative (PPD) or tuberculin skin test & reaction at intradermal site
  • review recent chest x-ray/results
  • liver function studies (bilirubin lever, liver enzyme levels), kidney function (BUN, creatinine clearance)
  • major liver &/or renal dysfunction contraindications
  • note baseline neurologic functioning prior to therapy
  • assess hearing status
  • gross eye examination (visual disturbance and optic neuritis w/isoniazid, levofloxacin, ofloxacin, Blindness w/ethambutol
  • age (toxicity increased in older adults, or 13 years and younger)
  • CBC prior to giving isoniazid, streptomycin, and rifampin (hematologic disorders)
  • analysis of sputum specimens
159
Q

Patient education with antitubercular drugs

A

-strict adherance to drug regimen
-use audiovisuals and take-home info
-mult. drugs often used to improve cure rates
-pt needs to state understanding of all instructions
-taken EXACTLY as ordered & at same time (critical to maintain steady blood levels)
-finish ENTIRE prescription
-may take w/food to minimize GI upset
-

160
Q

Nursing implementation for antitubercular drugs

A
  • Monitor for s/s of liver dysfunction (fatigue, jaundice, N/V, dark urine, anorexia) contact prescriber immediately
  • Monitor kidney function (BUN, creatinine) notify altered levels
  • Vision changes report ASAP
  • Monitor uric acid levels/advise pt report symptoms of gout
  • notify s/s of peripheral neuropathy
  • obtain sputum sample early
  • follow up visits
  • monitor IV site every HOUR
  • Cultural considerations (patient teaching w/all family members)
161
Q

Evaluation of antitubercular drugs

A

Monitor pt’s for adverse reactions:
-hearing loss (ototoxicity); nephrotoxicity; seizure; altered vision; blindness; GI upset; fatigue; N/V; fever; jaundice; numbness; tingling, or burning of extremities; abdominal pain, easy bruising

162
Q

Patient-centered teaching for antitubercular drugs

A
  • take medications as ordered
  • stress follow up appts.
  • avoid antacids, phenytoin, carbamazepine, beta blockers, benzodiazepines, oral anticoagulants, oral antidiabetic drugs, oral contraceptives, theophylline
  • those taking isoniazid watch for adverse effects
  • pyridoxine (vit b6) prevents isoniazid-precipitated peripheral neuropathies and numbness/tingling
  • those taking rifampin report adverse effects of fever, N/V, anorexia, jaundice, bleeding, may indicate hepatitis or hematologic disorders
  • wear sunscreen PHOTOSENSITIVITY
  • women taking rifampin and contraceptives switch birth control
  • wash hands/cover mouth
  • proper disposal of secretions
  • proper rest, nutrition, general health
  • medical alert tag w/allergies
  • contact prescriber w/increase in fatigue, cough and/or sputum
  • rifampin may have red-orange-brown discoloration of skin, sweat, tears, urine, feces, sputum, saliva, and tongue. Reverses s/discontinuation
  • those taking bedaquline (Sirturo), take w/food, drug interactions, alcohol
163
Q

______ is needed to combat the peripheral neuropathy associated with isoniazid

A

Vitamin B6

164
Q

Counsel women taking oral contraceptives therapy who are prescribed rifampin, why?

A

The ineffectiveness of oral contraception

165
Q

Antifungal drugs

A

Tx fungal infections, systemic mycotic infections & some cutaneous or subcutaneous mycoses Tx w/oral or parenteral drugs
-topical used w/out prescriptions

166
Q

Mechanism of action for antifungal drug: Fluconazole (Diflucan)

A
  • fungistacic or fungicidal, dependent on concentration
  • rapid growing fungi & inhibit fungal cell cytochrome P-450 enzyme which produces ergosterol
  • when ergosterol is inhibited, results in defect (leaky cell membrane) so fungal cells die
167
Q

Mechanism of action for antifungal drug polyenes: Nystatin (Diflucan) & Amphotericin B

A

Bind to sterols in cell membrane of fungi, once bound to ergosterol, channel forms in fungal cell membrane that allows potassium and magnesium ions to leak out of fungal cell. Loss of ions causes fungal cellular metabolism to be altered & leads to death of cell

168
Q

Indications for antifungals

A

-Specific to drug

169
Q

Indications for antifungals: Amphotericin B & Nystatin

A
  • Amphotericin B effective against wide range. Sometimes given w/flucytosine in Tx of Candida. Also Tx for aspergillosis, blastomycosis, candidiasis, coccidioidomycosis, cryptococcosis, fungal endocarditis, histoplasmosis
  • Nystatin similar, use limited due to toxic effects. Parenteral form. Tx of oropharygeal candidiasis (thrush)
170
Q

Indications for antifungals: Fluconazole

A

Tx of esophageal, oropharyngeal, peritoneal, UTI, vaginal, systemic candida infections & cryptococcal meningitis

171
Q

Contraindications for antifungals

A
  • Drug allergy
  • liver failure
  • kidney failure
  • porphyria
172
Q

Adverse effects for antifungals

A
  • drug interactions
  • hepatotoxicity
  • Amphotericin B associated w/multitude adverse effects, prescribers often order premedication (antimetics, antihistamines, antipyretic, corticosteroids) to prevent/minimize infusion-related reactions
173
Q

Interactions with antifungals

A

-underlying source of problem is many antifungal drugs & other drugs, are metabolized by cytochrome P-450 enzyme system. Result of coadministration of two drugs that are broken down by this system is that they compete for limited amount of enzymes, one of the drugs ends up accumulating it

174
Q

Antifungal drug: Amphotericin B

A
  • Tx of severe systemic mycoses
  • main drawback is it causes many adverse effects
  • almost all pt’s given IV experience fever, chills, hypotension, tachycardia, malaise, muscle and joint pain, anorexia, N/V, headache. Pretreament w/antipyretics, antihistamines, antimetics, and corticosteroids decrease severity of infusion-related reaction
  • lipid formulations higher cost
  • contraindicated in pt’s w/known hypersensitivity & severe bone marrow suppression or renal impairment
  • injectable, oral, topical
  • 1mg test dose given over 20-30 min
  • local irrigant (bladder irrigation) for Tx of candidal cystitis and has been used intrapleurally & intraperitoneally for Tx of fungal infections in those body cavities
175
Q

Antifungal drug: Fluconazole (Diflucan)

A
  • better adverse effect profile than amphotericin B, excellent coverage against many fungi
  • oral excellent bioavailability (almost completely absorbed into circulation)
  • oral & injectable
  • single dose effective for the Tx of vaginal candidiasis infections
176
Q

Antifungal drug: Nystatin

A

Polyene often applied topically for Tx of candidal diaper rash, taken orally as prophylaxis against candidal infections during periods of neutropenia in pt’s receiving immunosuppressive therapy, used for Tx of oral and vaginal candidiasis
-parenteral, several oral and topical formulations

177
Q

Nursing process for antifungal drugs

A
  • Before therapy assess/document vital signs, weight, hemoglobin levels, hematocrit, RBC, CBC w/differential, liver & renal function test results, C&S
  • before amphotericin B identify contraindications, cautions, drug interactions. Baseline renal function, hepatic function test due to adverse effects of nephrotoxicity and hepatotoxicity
  • avoid concurrent admin. of nephrotoxic drugs
178
Q

Implementation for antifungal drugs

A
  • IV: use in-line filter/monitor for extravasation
  • IV amphotericin B: DON’T administer cloudy/precipitates
  • monitor vitals every 15min
  • severe reaction discontinue infusion/closely monitor, contact prescriber
  • monitor IV site for: phlebitis
  • monitor I&O, report decreasing urinary output <240mL/8hrs
  • monitor lab values during therapy
  • document weight frequently
  • weight gain of 2 or more lbs in 24 hrs or 5 or more lbs in a week indication of medication-induced renal damage
179
Q

Patient centered care/education for antifungals

A
  • female pt’s use of antifungal for vaginal infection abstain from sex until Tx completed
  • long term Tx of amphotericin B possible adverse effects: tinnitus, blurred vision, burning/itching @IV site, headache, rash, fever, chills, hypokalemia, GI upset, anemias. Notify prescriber of bleeding, bruising, and/or soft tissue swelling
  • aspirin, acetaminophen, and/or ibuprofen, antihistamines, antiemetics, and antipasmotics prescribed for management of adverse effects
  • good hand washing techniques
  • proper dosing for nystatin. Oral solutions shaken before measuring dose, avoid mouthwash
  • fluconazole alternative method of contraceptive. Report jaundice, N/V, clay-colored stools, dark urine
180
Q

What is candidiasis?

A

An opportunistic fungal infection caused by C. albicans, occurs in pt’s taking broad-spectrum antibiotics, antineoplastics, or immunosuppressants, as well as in immunocompromised persons.

  • When it occurs in the mouth (oral candidiasis or thrush) common in newborns or immunocompromised
  • vaginal is yeast seen in diabetes mellitus, women taking oral contraceptives, pregnant women, post antibiotic therapy
181
Q

Antifungals are administered?

A

Systemically or topically

182
Q

Before administration of antifungals what should the nurse do?

A

Thoroughly assess for allergies as well as interactions w/other drugs the patient may be taking, including prescription, OTC, and herbals

183
Q

Amphotericin B must be?

A

Properly diluted according to manufacturer guidelines and administered using an IV infusion pump. Tissue extravasation of fluconazole at the IV infusion site leads to tissue necrosis; therefore, check the site hourly and document the assessment

184
Q

What is the MOST common drug used to treat oral candidiasis?

A

Nystatin (Mycostatin)

antifungal drug that is used for a variety of candidal infections. It is applied topically as a cream, ointment, or powder. It is also available as a troche and an oral liquid or tablet.

185
Q

What is the MOST important action for the nurse to complete before administration of intravenous (IV) amphotericin B?

A

Check for premedication prescriptions.

Almost all clients given IV amphotericin B experience fever, chills, hypotension, tachycardia, malaise, muscle and joint pain, anorexia, nausea and vomiting, and headache. Pretreatment with an antipyretic, antihistamine, and antiemetic can minimize or prevent these adverse reactions.

186
Q

Which antifungal drug can be given intravenously to treat severe yeast infections as well as a one-time oral dose to treat vaginal yeast infections?

A

Fluconazole is an antifungal drug that does not cause the major adverse effects of amphotericin when given intravenously. It is also very effective against vaginal yeast infections, and a single dose is often sufficient to treat vaginal infections.

187
Q

The nurse needs to know that major adverse effects are MOST common by which drug?

A

Amphotericin B (Amphocin)

The major adverse effects caused by antifungal drugs are encountered most commonly in conjunction with amphotericin B treatment. Drug interactions and hepatotoxicity are the primary concerns in clients receiving other antifungal drugs, but the IV administration of amphotericin B is associated with a multitude of adverse effects.

188
Q 
The nurse has provided education to a client about fungal skin infections. Further client teaching is necessary when the client includes which condition in the discussion of fungal skin infections?
  Thrush
  Impetigo
  Athlete’s foot
  Vaginal yeast infection
A

Impetigo
Impetigo is a bacterial skin infection and would not be classified as a fungal skin infection. If the client included this in the discussion, further teaching is needed.

189
Q 
What are important for the nurse to monitor in a client receiving an antifungal medication? (Select all that apply.)
  Creatinine
  Daily weights
  Mental status
  Intake and output
  Blood urea nitrogen
A 
Creatinine
Daily weights
Intake and output
Blood urea nitrogen
Nursing interventions appropriate to clients receiving antifungal drugs vary depending on the particular drug. However, it is important for the nurse to monitor all clients for indications of possible medication-induced renal damage so that prompt interventions can occur to prevent further dysfunction. Monitoring intake and output amounts, daily weights, and renal function tests will help prevent such damage.
190
Q

Most common contraindications for antifungal drugs

A

Drug allergy, liver failure, kidney failure, and porphyria (for griseofulvin) are the most common contraindications for antifungal drugs.

191
Q

During an infusion of amphotericin B, the nurse knows that which administration techniqe may be used to minimize infusion-related adverse effects?

A

Infusing the medication over a longer period of time

192
Q

When teaching a patient who is taking nystatin lozenges for oral candidiasis, which instruction by the nurse is correct?

A

Dissolve the lozenge slowly and completely in your mouth

193
Q

Antiviral drugs

A

Kill or suppress viruses by either destroying virions or inhibiting their ability to replicate

194
Q

Antivirals (NON-HIV) Mechanism of action (Tx of influenza, HSV, VZV, CMV, hepatitis)

A

Block activity of polymerase enzyme that normally stimulates synthesis of new viral genomes.
-result=impaired viral replication which allows elimination of virus by immune system

195
Q

Antiviral (NON-HIV) Indications

A

Tx of Herpes simplex virus (HSV), Varicella-Zoster Virus (VZV), Cytomegalovirus (CMV), hepatitis B and C infections

196
Q

Antiviral (NON-HIV) Contraindications

A
  • known severe drug allergy
  • Amantadine contraindicated in lactating women, children younger than 12 months, pt’s w/eczematous rash
  • Famciclovir contraindicated in allergy to drug or similar drug (penciclovir)
  • Ribavirin has teratogenic potential
  • aerosol form not for pregnant women
197
Q

Antiviral (NON-HIV) adverse effects

A
  • Specific to drug

- Selective killing difficult, as a result many healthy human cells, may be killed which results in serious toxicity

198
Q

Antiviral (NON-HIV) Interactions

A
  • arise mostly from systemic routes

- topically administered routes has a decrease in incidence

199
Q

Antiviral (NON-HIV) Acyclovir (Zovirax)

A

Synthetic nucleoside analogue used to suppress replication of HSV-1, 2, & VZV

  • Drug of choice for Tx of initial/recurrent episodes
  • oral, topical, injectable
200
Q

Antiviral (NON-HIV) Oseltamivir (Tamiflu)

A

Neuraminidase inhibitors

  • Active against influenza A & B
  • Indicated for Tx of uncomplicated acute illness caused by influenza infection in adults
  • Shown to reduce duration of influenza by several days
  • Adverse effects: N/V
  • Oral use ONLY
  • Indicated for prophylaxis and Tx of influenza
  • Tx w/this drug needs to begin w/in 2 days of symptom onset
201
Q

Antiretroviral drugs mechanism of action

A

-Reverse transcriptase inhibitors block enzymes

202
Q

Antiretroviral drugs Indications

A

Active HIV infection

-few Tx hepatitis B

203
Q

Contraindications for Antiretroviral drugs

A

-known severe drug allergy

204
Q

Antiviral drugs nursing assessment (NON-HIV)

A
  • head-toe-physical before administration
  • obtain medical/medication history
  • Document allergies
  • Assess nutritional status, baseline vital signs, contraindications, cautions, drug interactions
  • Obtain list of prescription, OTC, herbals, dietary supplements
  • before therapy assess: energy levels, weight loss, vital signs, lesion characteristics
  • age
  • before giving acyclovir assess vital signs, medication history, pain levels w/zoster lesions
  • Oseltamivir useful against influenza virus A&B, must be given as ordered w/in 2 days of onset of flu symptoms; assess presenting symptoms & date of onset
205
Q

Assessment of HIV antivirals or antiretrovirals

A
  • Closely assess allergies, cautions, contraindications, drug interactions
  • main contraindication includes severe drug allergy and other toxicities
  • protease inhibitors requires assessment of medical history, vital signs, baseline weight, allergies, medication history, results of baseline lab tests (CBC, renal & liver function). Also ordered during different phases of Tx
  • protease inhibitor adverse effect is lipid abnormalities w/redistribution of fat stores so assess emotional status and support systems
  • Bone demineralization adverse effect with long term use so assessment of calcium and vitamin D levels is crucial to pt safety before, during, after therapy
  • Assess hydration
206
Q

Assessment of Antiviral drugs

A

-Assessment of knowledge & need for long term
-education level, reading level, the way they learn best, familiarity w/community resources
-mental status
-emotional state
-value systems, social patterns, hobbies, support, spiritual beliefs
-financial status
-

207
Q

Antiviral Implementation (NON-HIV)

A
  • Appropriate technique when applying ointments, aerosol powders, IV, oral forms
  • wash hands, gloves before/after administration
  • use of drugs may lead to superimposed/superinfection
  • take oral w/meals (minimize GI upset)
  • store capsules @room temp. do not crush/break
  • acyclovir double check order
  • topical apply using finger cot/gloves
  • avoid eye contact
  • IV acyclovir stable for 12hrs room temp. will precipitate when refrigerated. Dilute as recommended (5% dectrose in water/NS) infuse w/caution
  • infuse longer to avoid renal damage
  • hydration during and after for prevention of crystalluria
  • monitor IV site
  • document/report redness, heat, swelling, pain, red streaks indication of phlebitis
  • document lesion characteristics
  • isolate those w/chickenpox/herpes zoster, give analgesics
208
Q

Patient teaching for antivirals

A
  • use caution while driving or activities requiring alterness (dizziness)
  • take full course
  • immunocompromised avoid crowds/those infected
  • safe sex (HIV) condom use. Genital herpes=abstinence
  • female pt’s w/genital herpes undergo papanicolaou spear test every 6 months
  • report: decreased urinary output, seizures, syncope, nervousness, lightheadedness, jaundice, wheezing, abnormal sensations in hands/feet, anorexia, N/V, diarrhea, weakness, changes in taste, acid regurgitation, abdominal/flank or back pain
  • provide demonstrations for administration
  • force fluids 3000mL/24hrs
  • suppress NOT cure virus
  • early Tx needed for full results
  • report difficulty breathing, drastic changes in BP, bleeding, new symptoms; worsening of infection, fever/chills, other unusual problems
  • follow up appts.
  • prevent skin reaction due to photosensitivity
209
Q

Recommendations for occupational HIV exposure may include the use of which drugs?

A

Emtricitabine and tenofovir

210
Q

When the nurse is teaching a patient who is taking acyclovir for genital herpes, which statement by the nurse is accurate?

A

“This drug will help the lesions dry and crust over.”

211
Q

Viruses can enter the body through at least four routes:

A

(1) inhalation through the respiratory tract
(2) ingestion via the GI tract
(3) transplacentally via mother to infant
(4) inoculation via skin or mucous membranes.
The inoculation route can take several forms, including sexual contact, blood transfusions, sharing of syringes or needles, organ transplantation, and animal bites (including human, animal, insect, spider, and others). Viruses cannot enter the body through an allergic reaction caused by medication.

212
Q

Which types of antiviral drugs are used to treat HIV infection? (Select all that apply.)
Fusion inhibitors
Protease inhibitors
Neuraminidase inhibitors
Reverse transcriptase inhibitors
Nonnucleoside reverse transcriptase inhibitors

A

Fusion inhibitors
Protease inhibitors
Reverse transcriptase inhibitors
Nonnucleoside reverse transcriptase inhibitors

Neuraminidase inhibitors are used in the treatment of the influenza virus.

213
Q

Before administering an antiviral drug, perform a?

A

1) head-to-toe physical assessment
2) take a medical and medication history
3) Document any known allergies before use of these and any other medications
4) assess the client’s nutritional status and baseline vital signs because of the profound effects of viral illnesses on physiologic status, especially if the client is immunocompromised
5) Assess and document any contraindications, cautions, and drug interactions associated with all of the antiviral drugs

  • Monitoring for adverse effects would occur AFTER the medication has been administered.

Pharmacology (28 decks)

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