Topic 5: Drugs that affect the immune and hematological systems Flashcards
Antimetabolites
Antagonists analogue
- antineoplastic antimetabolites are cell-specific analgouges. Inhibit cellular growth by interfering w/synthesis/actions of the compounds critical to cellular reproduction: vitamin folic acid, purines, pyrimidines (DNA, RNA)
- Two mechanisms: falsely substituting for purines, pyrimidines, folic acid, or inhibit critical enzymes involved in synthesis/function of those compounds
- S phase of cell cycle
Folic acid antagonism
Methotraxate is an analogue of folic acid
- Inhibits action of dihydrofolate reductase (enzyme that converts folic acid to its active form folate needed for synthesis of DNA)
- DNA not produced and cell dies
Pyrimidine antagonism
Floxuridine and fluorouracil are synthetic analogues of uracil, and cytarabine is a synthetic analogue of cytosine
- Capecitabine is a prodrug of fluorouracil and is converted to that drug in the liver and other body tissues. Can be given orally
- Incorporating themselves into the metabolic pathway for synthesis of DNA & RNA and thereby interrupting synthesis of both of these nucleic acids
Antimetabolites Indicatons
Tx of variety of solid tumors and some hematologic cancers
- used in combination chemo regimens to enhance overall cytotoxic effect
- Methotrexate also for Tx of severe cases of psoriasis (skin) rheumatoid arthritis
- oral/topical can be used for low-dose maintenance/palliative (noncurative) cancer therapy
Antimetabolites adverse effects
- Hair loss
- N/V
- Diarrhea
- myelosuppression
- Major toxicity includes: neurologic, cardiovascular, pulmonary, hepatobiliary, GI, genitourinary, dermatologic, ocular, otic, metabolic toxicity
- most common: fever, malaise
- metabolic toxicity: tumor lysis syndrome
- severe but reversible for of dermatologic toxicity (palmar-plantar dysesthesia or paresthesia)
Antimetabolites interactions
Administration of one antimetabolite drug with another that causes similar toxicities may result in additive toxicities
Methotrexate (Folate antagonist)
- Useful for Tx of solid tumors (breast cancer, head and neck, and lung cancers & for management of acute lymphocytic leukemia and non-Hodgkin’s lymphomas
- immunosuppressive activity, it inhibits lymphocyte multiplication, so it’s useful in Tx of rheumatoid arthritis
- its combined immunosuppressant and antiinflammatory properties make it useful for Tx of psoriasis
- high dose associated w/severe bone marrow suppression always given in conjunction w/the “rescue” drug leucovorin (antedote)
- injectable, oral (tablet) forms
- preservative free injectable required for intrathecal (into subarachoid space) administration, in Tx of cancers
Loucovorine
Rescue drug for methotrexate.
- Antidote for folic acid antagonists
- body produces active folic acid via metabolic steps utilizing enzyme dihydrofolate reductase. Because methotrexate inhibits this enzyme, healthy cells die due to lack of folic acid. By giving Loucovorine (which is rapidly converting to the active form of folic acid), it provides the body w/active folic acid, which prevents death of normal cells
Pyrimidine antagonists Fluorouracil (5-FU) (Efudex, Adrucil)
- parenteral formulations
- Variety Tx regimens, including palliative Tx of cancers of the colon, rectum, stomach, breasts, and pancreas
- also used in adjuvant setting in Tx of breast and colorectal cancer
Nursing process: Assessment for Antineoplastic drugs
- physical assessment
- bowel/bladder patterns
- neurologic status
- heart sounds
- heart rhythm
- breath sounds
- lung function
- exam skin/mucosa (turgor, hydration, color, temp.)
- s/s fear/anxiety, insomina, irritability, shakiness, restlesness, palpitations
- past/present abilities for ADL
- pain assessment
- pattern of pain
- note oral, pharyngeal, esophageal, abdominal pain; painful swallowing; epigastric/gastric pain; achiness in joints or lower extremities; numbess, tingling, burning sensation, sharp pain in extremities
- lab tests (electrolytes, minerals, vitamins, uric acid, RBC, WBC, platelets/clotting & bleeding time, renal function (BUN, creatinine, serum uric acid, urine creatinine clearance) hepatic function (AST, ALT, LDH, bilirubin), cardiac enzymes
- assess for tumor markers
Nursing assessment for altered nutritional status and impaired oral mucosa
- s/s of altered nutrition w/focus on weight loss, abnormal serum protein-albumin and blood urea nitrogen (BUN) levels, weakness, fatigue, lethargy, poor skin turgor, pale conjunctiva
- oral mucosa for S/S stomatitis, difficulty swallowing, taste changes, viscous saliva, dryness, cracking, and/or fissures w/or w/out bleeding of the mucosa
Nursing assessment for effects on the GI mucosa
- bowel sounds
- presence of diarrhea, urgency, abdominal cramping
- presence of blood in stool/consistency, color, odor, amount
- N/V (acute, delayed, anticipatory; if V occurs, determine color, amount, consistency, frequency, odor, blood
Nursing assessment for alopecia
- pt’s views, concerns, emotions about hair loss
- need to prepare for hair loss
Nursing assessment for bone marrow suppression
- S/S of anemia or decrease in RBCs, hemoglobin level, & hematocrit (pallor, oral mucus membranes, conjunctiva; fatique, lethargy, loss of interest, SOB, inability to concentrate)
- S/S leukopenia (Decrease WBCs, and/or absolute neutorphil count) fever, chills; tachycardia, abnormal breath sounds; productive cough w/purulent, green/rust colored sputum; change in urine color; lethargy, fatigue, acute confusion
- S/S thrombocytopenia (decrease in thrombocytes <100,000) and platelet clotting factors; unusual bleeding (petechiae; purpura; ecchymosis; gingival (gum) bleeding, excessive bleeding from punture sites, joint pain, blood in stool, urine, V; loss of function of extremities; decrease in BP/elevated pulse
For possible sterility, teratogenesis, and damage to ovaries with amenorrhea: in adult male patients, asses?
Female?
Male: baseline reproductive history w/attention to sexual functioning, fathering of children, past/current reproductive or sexual problems
Female: in addition to those already mentioned, inquire about fertility, menstrual/childbearing history, age of onset of menses and menopause
(Antineoplastic) With cell cycle-specific drugs what should the nurse assess for?
Document allergies, cautions, contraindications, drug interactions
- most antimetabolite drugs do not produce severe emesis (vomiting)
- Pentostatin & some pyrimidine analogues have emetic potential, so perform baseline GI functioning
- folate antagonists not likely to cause emesis, but are associated w/GI abnormalities (ulcers, stomatitis). Since given parenterally (IV) assess peripheral access areas or central venous sites to prevent risk for damage to surrounding tissue, joints, and tendons. Assess every hour for redness, swelling, heat, or pain PRN
Antineoplastic drug: Topoisomerase I Inhibitor Mechanism of action
Semisynthetic analogues of the compound camptothecin (these drugs referred to as Camptothecins)
- Inhibit DNA function in S-Phase by binding to topoisomerase I complex (complex normally allows DNA strands to be temporaily cleaved and then reattached in a critical step called religation)
- binding retards the religation process and results in DNA strand break
Antineoplastic drug: Topoisomerase I Inhibitor Indications
- Tx of ovarian and colorectal cancer
- Irinotecan approved for Tx of metastatic colorectal cancer, small-cell lung cancer, and cervical cancer
Antineoplastic drug: Topoisomerase I Inhibitor Adverse effects (Irinotecan [Camptosar])
- Hematologic effects
- severe diarrhea (cholinergic diarrhea). Treated w/atropine
- delayed diarrhea may occur 2-10 days after infusion of irinotecan
- diarrhea can be severe & life-threatening must be treated aggressively with loperamide
- N/V (supportive care including IV rehydration and antimetic drug therapy)
Antineoplastic drug: Topoisomerase I Inhibitor Interactions with Irinotecan (Camptosar)
- Laxatives and diuretics NOT given due to risk of worsening dehydration
- severe cardiovascular toxicity, thrombosis, pulmonary embolism, stroke, acute fatal MI when Irinotecan is given w/fluorouracil and leucovorin
- only injectable form
Antineoplastic drug: Topoisomerase I Inhibitor nursing assessment
- hematologic adverse effects
- baseline WBC
- continual assessment of GI tract due to potential irinotecan-related cholinergic diarrhea
Before chemo assess patients for the presence of
1) genetic markers of oral cancer
2) genetic determinants of testosterone or estrogen metabolism
3) genetically linked enzyme system abnormalities
Premedication with antimetics give?
30-60 minutes BEFORE administration of the antineoplastic to help reduce N/V, prevent dehydration& malnutrition, and promote comfort
Antineoplastic patient teaching
- OTC medications to avoid: aspirin, ibuprophen, combination of these)
- measures to prevent infection
- frequent skin care
- measures to minimize oral mucosal breakdown
- daily regiment to increase urinary health (cranberry)
- discuss options for alopecia (hair loss)
- methotrexate: report N/V, fever, sore throat, muscle aches, and pains, unusual bleeding. Avoid alcohol, salicylates, NSAIDs, exposure to sunlight or ultraviolet light. Alternative contraceptive measures for 3 months or longer
Nadir refers to the?
average number of days it takes for a chemotherapeutic drug to have its peak effect on the bone marrow, which would coincide with the client’s lowest white blood count and highest risk for infection or bleeding.
The nurse would anticipate administering which medication to clients receiving high-dose methotrexate (Trexall)?
Leucovorin (Wellcovorin)
Leucovorin is given to block the systemic toxic effect of high-dose methotrexate. It is a form of folic acid that does not require dihydrofolate reductase to produce folic acid. Therefore, it is used to prevent or treat toxicity induced by methotrexate, a folic acid antagonist.
Nausea and vomiting are frequent adverse effects associated with antineoplastic therapy. What should the nurse advise clients experiencing these unpleasant adverse effects?
Try to maintain hydration and nutrition, which are very important during treatment.
It is very important for clients undergoing chemotherapy to maintain adequate nutrition and hydration. Several antiemetic drugs are used to prevent these adverse effects.
Combinations of antineoplastic drugs are frequently used for which purpose? (Select all that apply.)
Prevent drug resistance
Provide a synergistic action
Decrease the severity of adverse effects
Administering a combination of antineoplastic drugs allows for smaller doses of each, which can minimize the severity of adverse effects and help prevent drug resistance. Additionally, there is a synergistic action between some of the medications.
The nurse is assessing a patient who has experienced severe neutropenia after chemotherapy and will monitor for which possible signs of infection?
Fever, sore throat, chills
The nurse is assessing a patient who had developed anemia after two rounds of chemotherapy. What are indications of anemia?
Hypoxia, fatigue
Antineoplastic Cell cycle non-specific (CCNS) Cytotoxic antibiotics
Natural substances produced by the mold Streptomyces as well as semisynthetic substances
-Bone marrow suppression common toxicity, also heart failure, acute left ventricular failure (doxorubicin)
Antineoplastic Cell cycle non-specific (CCNS) Cytotoxic antibiotics mechanism of action
Interact w/DNA through intercalation (drug molecule inserted between the two strands of a DNA molecule, blocks DNA synthesis)
- inhibit enzyme topoisomerase II, leads to DNA strand breaks
- many generate free radicals which leads to DNA strand breaks and programmed cell death
Antineoplastic Cell cycle non-specific (CCNS) Cytotoxic antibiotics Indications
Tx solid tumors & some hematologic malignancies
Antineoplastic Cell cycle non-specific (CCNS) Cytotoxic antibiotics Adverse effects
- Hair loss
- N/V
- Myelosuppression
Antineoplastic Cell cycle non-specific (CCNS) Cytotoxic antibiotics Toxicity/management
- Severe cases of cardiomyopathy are associated w/doxorubicin
- routine monitoring of cardiac ejection fraction, cumulative dose limitations, use of cytoprotective drugs can decrease the incidence of toxicity
Antineoplastic Cell cycle non-specific (CCNS) Cytotoxic antibiotics Interactions
- Increased toxicity when in combination w/other chemo drugs/radiation therapy
- bleomycin & doxorubicin cause serum digoxin levels to increase. Observe for signs of digoxin toxicity
Antineoplastic Cell cycle non-specific (CCNS) Cytotoxic antibiotics Doxorubicin (Adriamycin)
- used in combinations
- contraindicated in those with hypersensitivity, severe myelosuppression, those @risk for severe cardiotoxicity
- ONLY injectable form
- liposomal drug delivery system (Doxil). Drug encapsulated in a lipid bilayer called a liposome. Caused reduced systemic toxicity and increased duration of action
Miscellaneous antineoplastics: Hydroxyurea (Hydrea)
- Antimetabolite interferes w/synthesis of DNA by inhibiting incorporation of thymidine into DNA
- Works mainly in S and G1 phase of cell cycle
- Tx of squamous cell carcinoma in concert w/radiation to take advantage of its radiosensitizing activity. Also leukemia
- Oral form only
- Adverse effects: edema, drowsiness, headache, rash, hyperuricemia, N/V, dysuria, myelosuppression, elevated liver enzyme levels, muscular weakness, peripheral neuropathy, nephrotoxicity, dyspnea, pulmonary fibrosis
- Interacts with anti-HIV drugs
- concurrent use w/fluorouracil increases risk for neurotoxic symptoms
- can reduce clearance of cytarabine, so dosage reduction of cytarabine is recommended when in combination
Miscellaneous antineoplastics: Octreotide (Sandostatin)
Management of a cancer-related conditon called carcinoid crisis and Tx of the diarrhea caused by vasoactive intestinal peptide-secreting tumors (VIPomas)
One of major adverse effects of cytotoxic antibiotics is
Pulmonary fibrosis
In patients with documented cardiac disease or a history of thoracic irradiation, administer dactinomycin, daunorubicin, and doxorubicin with?
Extreme caution due to cardiovascular toxicity. CT scans and ultrasound studies may be needed before and during Tx to assess cardiac ejection fraction because of risk for cardiotoxicity, which is often associated with cumulative doses
With the use of miscellaneous drug hydroxyurea (misc. antineoplastic) the nurse will assess
-Liver, renal, neurologic, pulmonary function, baseline blood cell counts
Patients receiving cytotoxic antibiotics require more?
Frequent monitoring of pulmonary function
- baseline chest x-rays obtained for comparison w/subsequent x-rays if pneumonitis occurs
- monitor results of liver, renal function tests throughout therapy w/doxorubicin
- heart sounds, daily weights, BP, pulse rate, monitoring for s/s of cardiovascular toxicities important w/doxorubicin
- an increase in 2 lbs or more in 24 hrs or 5lbs in a week notify prescriber could indicate fluid retention or heart failure.
Misc. antineoplastic: Hydroxyurea used sparingly. Given orally. Monitor for?
- Platelet/leukocyte counts before, during, after Tx due to bone marrow suppression
- platelet counts below 100,000 platelet/mm or leukocyte count falls below 2000 cells/mm, temporarily halt therapy until counts rise to normal
- hyperuricemia may precipitate gout-related symptoms
- allopurinol prescribed to control levels of uric acid
- sipuleucel-T associated with infusion-related reactions
In case of allergic reaction with antineoplastic drugs what can you give them?
Epinephrine, antihistamines, antiinflammatory
Patient centered care for antineoplastic drugs
- Avoid aspirin, ibuprofen, products containing them to prevent excessive bleeding
- be open about alopecia risk
- encourage fluid increase (3000mL/day)
- if constipation occurs tell them ways to manage: increasing fluids, balanced diet,
- diarrhea: avoid spicy foods, gas-producing foods, caffeine; high-fiber foods; alcohol; very hot/cold foods, & beverages. Preventive medication (synthetic opioids) or absorbents-protectants
- importance of daily weights
- proper technique for monitoring BP/PR. Use journal
- cytotoxic importance of adhering to daily heart healthy regimen of conserving energy, planned activities, seeking/asking for assistance w/care PRN
- importance of reporting hypotension, bradycardia, chest pain dyspnea
Clients receiving doxorubicin need to be monitored for?
cardiac toxicity. There is a lifetime limited dose that clients are allowed to receive to minimize the occurrence of cardiomyopathy.
The nurse should question a prescription of hydroxyurea (Hydrea) for a client with which laboratory test result?
Platelet count of 8000/mm3
Hydroxyurea causes bone marrow suppression, which is evidenced by a decrease in red blood cells, WBCs, and platelets. A platelet count of 8000/mm3 compared with a normal platelet count range of 150,000 to 400,000/mm3 is significantly lower than normal.
What are the possible severe adverse effects specific to the cytotoxic antibiotics?
Pneumonitis Liver toxicity Nephrotoxicity Cardiovascular toxicity As with all of the antineoplastic drugs, cytotoxic antibiotics have the undesirable effects of hair loss, nausea and vomiting, and myelosuppression. Severe adverse effects specific to the cytotoxic antibiotics include pulmonary fibrosis, pneumonitis, liver toxicity, heart failure, cardiovascular toxicity, tissue damage in the event of extravasation, kidney toxicity, and lung toxicity. This class of drugs is not known for neurotoxicity.
When providing education to a client undergoing antineoplastic drug therapy, the nurse instructs the client to immediately notify the health care provider for which signs and symptoms?
Blood in urine
Bleeding gums
Swollen tongue
New and persistent cough
The client must contact the health care provider immediately if any of the listed signs or symptoms occur:
· Fever or chills with a temperature higher than 100.5° F (38.1° C)
· New sores or white patches in the mouth or throat
· Swollen tongue with or without cracks and bleeding
· Bleeding gums
· Dry, burning, “scratchy,” or “swollen” throat
· A cough that is new and persistent
· Changes in bladder function or patterns
· Blood in the urine
· Changes in gastrointestinal or bowel patterns, including “heartburn” or nausea, vomiting, constipation, or diarrhea lasting longer than 2 or 3 days
· Blood in the stools
Hematopoietic drugs
Promote synthesis of various types of major blood components by promoting the growth, differentiation, & function of their corresponding precursor cells in the bone marrow
Hematopoietic drugs Mechanism of action
- Not toxic to cancer cells, they have beneficial effects in Tx of cancer
- They decrease duration of chemo-induced anemia, neutropenia, & thrombocytopenia and enable higher doses of chemo to be given ; decrease bone marrow recovery time after bone marrow transplant or irradication; & stimulate other cells in immune system to destroy/inhibit growth of cancer cells as well as virus-fungus-infected cells
- produced by recombinant DNA technology
- they bind to receptors on surfaces of specialized progenitor cells in bone marrow
Hematopoietic drugs Indication
Colony stimulating factors stimulate neutrophils to grow and mature and directly oppose the detrimental bone marrow actions of chemo.
Hematopoietic drugs Contraindications
- drug allergy
- use of filgrastim, sargramostim, and pegfilgrastim contraindicating in presence of more than 10% myeloid blasts (immature tumor cells in bone marrow) because they colony-stimulating factors may stimulate malignant growth of these myeloid tumor cells
Hematopoietic drugs adverse efffects
Mild
-common are fever, muscle aches, bone pain, flushing
Hematopoietic drugs interactions
- Filgrastima nd sargramostim significant drug interactions when given with myelosuppressive (bone marrow suppressant) antineoplastic drugs. They are administered to enhance production of bone marrow cells, so if myelosuppressive antineoplastics are given the drugs antagonize each other
- they are not given w/in 24 hrs of administration of myelosuppressive
- they are given soon after this time to help prevent the WBC nadir from dropping
- use with caution; don’t give with other meds that potentiate their myeloproliferative (bone marrow stimulating) effects (lithium, corticosteroids)
Hematopoietic drugs: Filgrastim (Neupogen)
- synthetic analogue of humane granulocyte colony-stimulating factor (also called G-CSF)
- Promotes proliferation, differentiation, activation of cells that make granulocytes
- prevents/treats febril neutropenia in pt’s receiving myelosuppressive for nonmyeloid (non bone marrow)
- given BEFORE infection, NOT w/in 24 hrs AFTER myelosuppressive chemo
- pegfilgrastim (Neulasta)=long acting, reduces # of injections required
Nursing assessment for hematopoetic drugs
- Assess medication order/indications
- lab values (WBC w/sargramostin & filgrastim)
- monitor baseline blood counts
- measure drug response
- prior to administration assess: vital signs, skin turgor/intactness, bowel sounds/patterns, breath sounds
- assess IV/subcutaneous sites PRN
- from lab values assess chemo-induced absolute neutrophil nadir (low point). Important because dose timing is critical in helping to boost blood cell counts
- with filgrastim assess for existing joint/bone pain for possible adverse effect of mild-severe bone pain
Implementation for hematopoietic drugs
- administer as ordered
- rotate subcutaneous/IV sites
- administer Filgrastim BEFORE pt receives myelosuppressive chemo develops infection, NOT w/in 24 hrs before/after myelosuppressive chemo. Once their absolute neutrophil count (ANC) reaches 10,000 cells/mm discontinue
- give Filgrastim and use D5W to dilute
Patient teaching for hematopoietic drugs
- avoid hazardous tasks, fatigue common
- report signs of infection: sore throat, diarrhea, vomiting, and/or fever of 100.5F (38.1 C) or higher. Report excessive fatigue, loss of appetite, edema, bleeding
- pregnancy discouraged
- bone pain and flulike symptoms can occur, use of non-opioids or opioid analgesics, some relief w/ acetaminophen and ibuprofen
- FDA black box warning
- adverse effects usually disappear w/in 72 to 96 hrs after therapy
Nursing management associated with administration of biologic response-modifying drugs (hematopoietic)
Focuses on use of careful aseptic technique and other measures to prevent infections: proper nutrition, oral hygiene, monitoring of blood counts; management of adverse effects including joint/bone pain and flu-like symptoms
-do NOT administer filgrastim and sargramostim w/in 24 hrs of a myelosuppressive antineoplastic and follow timeframe
Hematopoietic factors: Erythropoietin (Epogen)
Epoetin alfa (Epogen, Procrit) Biosynthetic form of the natural hormone erythropoietin, which normally secreted by kidneys in response to a decrease in RBCs. Promotes the synthesis of erythrocytes (RBCs) by stimulating RBC progenitor cells in bone marrow
-Tx of anemia associated w/end-stage renal disease, chemo-induced anemia, anemia associated w/zidovudine
-causes progenitor cells in bone marrow to manufacture large # of immature RBCs to speed up maturation
-ineffective w/out adequate iron stores/bone marrow function
-those receiving also need oral/IV iron
-Injection (IV or subcutaneously)
-sub route=slower
CONTRAINDICATIONS
-Drug allergy
-uncontrolled HPT
-hemoglobin levels above 10g/dL for cancer pt’s & 11g/dL renal pt’s
-head/neck cancers, those @risk for thrombosis
ADVERSE EFFECTS
-HPT
-fever, headache, pruritus, rash, N/V, arthralgia, injection site reactions
FDA REQUIRES
-those receiving for chemo-induced anemia must be registered in a risk mitigation program called ESA Apprise Oncology
Biological Response-Modifying and Antirheumatic Drugs: Interferons
Proteins that have 3 basic properties: antiviral, antitumor, immunomodulating
- 3 groups of drugs: alfa, beta, gamma interferons; each with own antigenic and biologic activity. Most used in Tx of certain viral infections and certain types of cancer
- in body they are activated by T cells & other cells in response to viral infection.
Biological Response-Modifying and Antirheumatic Drugs: Interferons Mechanism of action
- protect human cells from virus attack by enabling human cells to produce enzymes that stop viral replication & prevent viruses from penetration of healthy cells
- prevent cancer from dividing/replicating & increase activity of other cells in immune system (macrophages, neutrophils, NK cells)
- effect on cancer cells caused by combination of direct inhibition of DNA and protein synthesis w/in cancer cells (antitumor effects) & mult. immunomodulatory effects on host’s immune system
- increase cytotoxic activity of NK/phagocytic ability of macrophages
- increase expression of cancer cell antigens on cell surface, enabling immune system to recognize cancer cells easily (destruction)
Interferons have three different effects on the immune system
1) Restore function, if impaired
2) augment (amplify) immune’s ability to function as body’s defense
3) inhibit immune system from working. May be useful when immune system dysfunctional (autoimmune disease) case in MS
- Interferon beta 1a and 1b indicated for Tx of MS; inhibiting dysfunctional immune system prevents further damage
Biological Response-Modifying and Antirheumatic Drugs: Interferons indications
(Antiviral, antineoplastic, immunomodulatory)
Tx of viral infections, various cancers, some autoimmune disorders
Biological Response-Modifying and Antirheumatic Drugs: Interferons Contraindications
- known drug allergy
- may include autoimmune disorders, hepatitis or liver failure, concurrent use of immunosuppressant drugs, severe liver disease
Biological Response-Modifying and Antirheumatic Drugs: Interferons adverse effects
-AE=Adverse effect
Flu-like symptoms: fever, chills, headache, malaise, myalgia, and fatigue
- dose-limiting AE=fatigue
- high dose=exhausted, confined to bed
- alfa-2b black box warning related to potential to cause or aggravate autoimmune disorders and neuropsychiatric symptoms
Biological Response-Modifying and Antirheumatic Drugs: Interferons Interactions
- seen w/both interferon alfa-2a and 2b when used w/drugs metabolized in liver via cytochrome P-450 enzyme. Combination results in decreased metabolism and increased accumulation of these drugs, leads to drug toxicity
- interferon w/antiviral enhances activity of both, lead to toxicity
- additive toxic effects to bone marrow from interferon gamma w/myelosuppression
Before administering interferons assess the patient for?
History of drug allergies as well as autoimmune disorders, hepatitis, liver failure, or AIDS
Contraindications for interferons include
Concurrent use of immunosuppressant drugs, liver dysfunction, severe liver disease, & AIDS-related Kaposi’s sarcoma
It is important to note that interferon alfa-2b has a black box warning associated with possible?
Aggravation and/or precipitation of autoimmune disorders and neuropsychiatric symptoms
- determine baseline WBC & platelet couts PRIOR to initiation of therapy
- monitor serum lab values (blood urea nitrogen, creatinine levels, ALP, AST levels) BEFORE & DURING Tx
- document baseline neurologic functioning, bowel status, heart sounds, PR, BP
Administer interferons parenterally by either subcutaneous, IV, or IM route, be sure to?
Rotate sites/use accurate technique
Interferons: With concern of infection, monitor patients?
Vital signs with attention to temperature
- also monitor for occurrence of chills and headache indicative of a fever
- and ECG, before and during Tx so monitor results & report chest pain, hypotension, hypertension, or dyspnea
- Acetaminophen can be prescribed for help with fever and headache
- encourage fluid increase
Patient teaching: Interferons may cause increased?
Fatigue & flulike symptoms. Fatigue may be severe enough to keep them in bed. Let them know this may occur
- interactions occur w/any drug metabolized by the P450 enzyme system.
- educate about various interacting drugs
Monoclonal antibodies
Tx of cancer, rheumatoid arthritis & other inflammatory diseases, MS, organ transplantation
- in cancer Tx advantage over antineoplastics because they can specifically target cancer cells and have minimal effect on healthy cells. This reduces many AE
- mab abbreviation for monoclonal antibody
Monoclonal antibodies mechanism of action
Diverse
Monoclonal antibodies contraindications
- drug allergy (can be controlled w/supportive medications)
- known active infectious processes due to their immunosuppressive qualities
Monoclonal antibodies AE
- acute symptoms: allergy, flulike symptoms
- administer medication/control symptoms
Monoclonal antibodies interactions
- few, no major food interactions
- administration of adalimumab with the anti-rheumatoid arthritis drug anakinra (an interleukin) may increase risk for serious infections secondary to neutropenia
Monoclonal antibodies Adalimumab (Humira) mechanism of action
- works through specificity for human tumor necrosis factor (TNF)
- TNF naturally occurring cytokine involved in normal inflammatory and immune responses
- patients with RA, elevated levels of TNF are found in synovial fluid in the spaced of affected joints. In addition to preventing TNF molecules from binding to the TNF cell surface receptors, adalimumab modulates inflammatory biologic responses induced/regulated by TNF
Monoclonal antibodies Adalimumab (Humira) Indications
- Tx of severe cases of Rheumatoid arthritis (RA) that failed to respond to other medications (methotrexate)
- indicated for Crohn’s disease, ulcerative colitis, plaque psoriasis, psoriatic arthritis, and B cell chronic lymphocytic leukemia
- use alone or concurrently with medications
Monoclonal antibodies Adalimumab (Humira) contraindications
- pt’s w/active infectious process due to their immunosuppressive qualities (localized or systemic, acute or chronic)
- known drug allergy contraindication, depending on urgency of the clinical situation, a given monoclonal antibody may by the viable treatment option for a seriously ill patient
Monoclonal antibodies Adalimumab (Humira) AE
- localized inflammatory reaction at injection site
- upper respiratory tract and urinary tract infections
- risk for various malignancies=highest reported incident effects
- allergy or flulike symptoms such as fever, dyspnea, and chills
- risk for acquiring an infection is a serious adverse effect of all the biological response-modifying agents, because they alter the normal immune response.
Assessment for monoclonal antibodies Adalimumab (Humira)
- assess and document history of allergic reactions
- mild-severe reactions
- vitals and any signs of infection
- make sure they don’t have active infections or HIV
- presence of any conditions
- medications that represent cautions, contraindications, or indications
Nursing diagnosis for biologic response-modifying drugs
-imbalanced nutrition/ impaired skin integrity related to adverse effects of biologic response-modifying drugs
Patient teaching for biologic response-modifying drugs
- instructor patient record excessive fatigue, loss of appetite, edema, or bleeding
- report any signs of infection: sore throat, diarrhea, vomiting, fever of 100.5 F or higher
- pregnancy discouraged, use other contraceptives choices for up to 2 years after completion of therapy
- adverse effects will disappear w/72-96 hours after therapy discontinued
Disease-Modifying Antirheumatic Arthritis Drugs (DMARDs)
- modify disease of rheumatoid arthritis
- exhibit antiinflammatory, antiarthritic, & immunomodulating effects and work by inhibiting the movement of various cells into an inflamed, damaged area, such as a joint.
Disease-Modifying Antirheumatic Arthritis Drugs (DMARDs) Mechanism of action
Vary
-indicated for Tx of rheumatoid arthritis, some have other uses
Disease-Modifying Antirheumatic Arthritis Drugs (DMARDs) Contraindications
- not to be used in patients with active bacterial infections, herpes zoster, active/latent tuberculosis, or acute or chronic hepatitis B or C
- not be used combination w/other DMARD’s or immunosuppressants
Disease-Modifying Antirheumatic Arthritis Drugs (DMARDs) Adverse effects
- diarrhea
- upper respiratory tract infection
- headache
- hypertension
- lipid abnormalities
- anemia
- insomnia
Disease-Modifying Antirheumatic Arthritis Drugs (DMARDs): Abatacept (Orencia) Mechanism of action
Selective costimulation modulator;inhibits T-cell activation
Disease-Modifying Antirheumatic Arthritis Drugs (DMARDs): Abatacept (Orencia) Indication
Tx of rheumatoid arthritis
- dosed according to body weight and is given at 4-week intervals
- administered IV & filter MUST be used
- half life=8-25 days
Disease-Modifying Antirheumatic Arthritis Drugs (DMARDs): Abatacept (Orencia) contraindication
- known hypersensitivity to it or any of its components
- Use caution in pt’s w/history of recurrent infections/COPD
- Bring pt’s up to date with all current immunizations BEFORE starting Abatacept therapy
- not given w/Anakinra or TNF blocking drugs because of risk for serious infections, or with herb Echinacea due to immunostimulant properties
Disease-Modifying Antirheumatic Arthritis Drugs (DMARDs): Abatacept (Orencia) Adverse effects
- headache
- upper respiratory tract infections
- hypertension
- may increase risk for infections associated w/live vaccines
- may decrease response to dead/live vaccines
Assessment of Disease-modifying antirheumatic arthritis drugs (DMARDs)
- assessment of any past or present medical conditions as well as a thorough assessment of allergies
- list all drugs pt taking
- assess contraindications
- assess specific type of DMARD
- bone marrow suppression AE so assess/monitor baseline blood cell and platelet counts BEFORE, DURING, and AFTER therapy
Nursing diagnosis for DMARDs
-risk for infection related to adverse effect of bone marrow suppression related to DMARD’s and Immunomodulating drugs
Planning for DMARDs
-pt remains healthy and free from injury to self with minimizing risk for infection (proper diet, fluid intake, staying away from crowds) and reports an elevation of temperature of 100.5 to prescriber for immediate treatment
Patient teaching for DMARDs
- pt will experience improved joint function and decreased joint pain
- encourage patient to report bleeding, excess fatigue, fever, or respiratory symptoms
The recommended therapy with nonbiologic DMARDs usually begins with?
Methotrexate or leflunomide for most patients. Biologic DMARDs are generally reserved for those pt’s whose disease does not respond to methotrexate or leflunomide.
-biological DMARDs include etanercept, infliximab, adalimumab, abatacept, and rituximab
Oprelvekin stimulates the production of?
Epoetin stimulates the production of?
Interleukins (aldesleukin) and interferons activate the?
Oprelvekin stimulates the production of platelets
Epoetin stimulates the production of red blood cells (RBCs) in the bone marrow
Interleukins (aldesleukin) and interferons activate the immune system but do not increase production of white blood cells (WBCs).
Filgrastim increases the production of WBCs in the bone marrow, triggering the common adverse effect of?
bone pain
Filgrastim (Neupogen) is usually discontinued when a client’s ANC rises above?
10,000 cells/mm3. However, some health care providers will stop it when the ANC is between 1000 and 2000 cells/mm3.
Monoclonal antibody drugs are usually contraindicated in patients with?
known active infectious processes because of their immunosuppressive qualities. Use of alemtuzumab is also contraindicated in clients with active systemic infections and immunodeficiency conditions, including AIDS.
What are the functional cells of the humoral immune system that mature into immunoglobulins?
B cells
The functional cells of the humoral immune system are the B lymphocytes. When an antigen binds to receptors located on the B cells, a biochemical signal is sent to the B lymphocytes. These B cells then mature or differentiate into plasma cells, which in turn produce antibodies.
What is the mechanism of action of biologic response–modifying drugs?
Direct toxic effect on tumor cells, causing them to rupture Enhancement or restoration of the host’s immune system defenses against a tumor
Adverse modification of a tumor’s biology, making it harder for the tumor cells to survive and reproduce
In terms of their activity against cancer cells, biologic response–modifying drugs work by one of three mechanisms: (1) enhancement or restoration of the host’s immune system defenses against the tumor; (2) direct toxic effect on the tumor cells, which causes them to lyse, or rupture; or (3) adverse modification of the tumor’s biology, which makes it harder for the tumor cells to survive and reproduce. This class does not interrupt any genetic level of cell replication.
Interferons have?
Antivira and antitumor properties and strengthen the immune system
When planning care for a patient who is receiving interferon therapy, the nurse must keep in mind that the major dose-limiting factor is?
Fatique
The nurse is administering methotrexate as part of Tx for a patient w/rheumatoid arthritis and will monitor for which sign of bone marrow suppression?
Increased bleeding tendencies
Erythropoietic drugs (epoetin alfa and darbepoetin alfa),
three colony-stimulating factors (filgrastim, pegfilgrastim,
and sargramostim), and one platelet-promoting drug
(oprelvekin) promote the synthesis of?
various types of major blood components by promoting the growth, differentiation, and function of their corresponding precursor cells in the bone marrow
All hematopoietic drugs decrease the duration of?
chemotherapy-induced anemia, neutropenia, and thrombocytopenia and allow higher dosages of chemotherapy to be given; decrease bone marrow recovery time after bone marrow transplantation or irradiation; and stimulate other cells in the immune system to destroy or inhibit the growth of cancer cells, as well as virus- or fungus-infected cells
Neutrophils are the most important granulocytes for fighting infection. Colony-stimulating factors stimulate?
Neutrophils to grow and mature and thus directly oppose the detrimental bone marrow actions of chemotherapy
Colony-stimulating factors also enhance the functioning of mature cells of the immune system, such as macrophages and granulocytes. This increases the?
ability of the body’s immune system to kill cancer cells, as well as virus- and fungus-infected cells
What is a serious concern with monoclonals?
Infection
Immunosuppressant drugs mechanisms of action
Selectively suppress T-lymphocyte cell lines, which prevents involvement in immune response & results in pharmacologically immunocompromised state similar to that in a cancer patient or in a patient with acquired immunodeficiency syndrome (AIDS)
Immunosuppressant drugs indications
- Suppression of immune-mediated disorders and malignancies and improvement of short-term and long-term allograft survival.
- used for many immune-related disorders, including rheumatoid arthritis, systemic lupus erythematosus, Crohn’s disease, multiple sclerosis (MS), myasthenia gravis, psoriasis, and others.
Immunosuppressant drugs contraindications
depending on the patient’s condition may include
- renal or hepatic failure
- hypertension
- concurrent radiation therapy
- Pregnancy not contraindication, but these drugs should be given ONLY in clinically urgent situations
Immunosuppressant drugs Adverse effects
serious adverse effects are limited to the particular
drug.
-Cyclosporine and tacrolimus can cause NEPHROTOXICITY
-corticosteroids, cyclosporine, and tacrolimus can cause
posttransplant DIABETES MELLITUS
-AVOID live vaccines
By virtue of their actions, immunosuppressants place
patients at increased risk of?
opportunistic infections. Immunosuppressant drugs may also increase the risk of certain types of cancers, especially skin cancers
Immunosuppressant drugs interactions
-have narrow therapeutic windows, drug interactions can be significant.
• Drugs that cause increased levels of immunosuppressant drugs can cause toxicity, whereas drugs that reduce immunosuppressant drug levels may lead to organ rejection
-GRAPEFRUIT can inhibit metabolizing enzymes and thus increase activity of cyclosporine, tacrolimus, and sirolimus.
-Grapefruit juice may increase the bioavailability of
cyclosporine by 20% to 200% and should be AVOIDED
- Foods high in potassium (bananas and tomatoes)
increase cyclosporine NEPHROTOXICITY
-Meals that have high fat content can increase sirolimus levels
- herbal preparations. The enzyme-inducing
properties of St. John’s wort reduce therapeutic levels of cyclosporine and cause organ rejection
-immunostimulant properties of cat’s claw and
echinacea undesirable in transplant recipients,
because effects that are opposite those of the
immunosuppressants
Immunosuppressent: With azathioprine, assess?
white blood cell and platelet counts, noting any signs and symptoms of infection as well as any bleeding tendencies due to the potential for drug-related leukopenia and thrombocytopenia
With cyclosporine therapy:
• Specifically assess the?
functional level of all organs as well as assess for any underlying cardiovascular, central nervous system, hepatic, and/or renal disease because of potential drug-related toxicities involving these systems and the physiologic impact of the organ transplant process on multiple systems.
• Perform a baseline oral assessment because of the possible adverse effect of drug-induced gingival hyperplasia.
• Assess and document baseline blood pressures because as many as 50% of patients taking this drug have moderate hypertension
Oral immunosuppressants need to be taken with?
food to minimize GI upset
- Oral forms of the drugs are used whenever possible to decrease the risk for infection associated with parenteral injections and subsequent injury to the first line of defense (the skin)
- use of premedication protocols involving various antihistamines and/or anti-inflammatory drugs common.
It is very important with the use of any of the immunosuppressants to be sure that?
supportive treatment equipment and related drugs are available in case of an anaphylactic or allergic reaction
Immunosuppressants: Cyclosporine is now available in several oral formulations, but these are not to be used interchangeably. Do not?
refrigerate these oral solutions. Oral solutions may be mixed in a glass container with chocolate milk, milk, or orange juice and served at room temperature. Once the solution is mixed, make sure the patient drinks it immediately. Avoid Styrofoam containers or cups because the drug has been found to adhere to the inside wall of such containers
Administered intravenously, cyclosporine is usually diluted with?
normal saline or 5% dextrose in water and infused
using an intravenous (IV) infusion pump. Always infuse over the recommended time period. Monitor the patient very closely during the infusion, especially during the first 30 minutes, for any allergic reactions, as manifested by facial flushing, urticaria, wheezing, dyspnea, and rash
Patient education with immunosuppressants
-always have a one-week supply of medications
available so that there is never a risk of running out
-Oral antifungals given w/immunosuppressants to treat oral candidiasis that occurs as a result of immunosuppression and fungal overgrowth
-Inspect oral cavity as often as necessary (at least once
every shift) for white patches on tongue, mucous
membranes, and/or oral pharynx may indicate oral
candidiasis
-Monitor results of lab studies (hemoglobin level, hematocrit, and white blood cell, platelet counts) If the values drop below normal ranges, notify prescriber
Immunosuppressant: Cyclosporine (Sandimmune)
Mechanism of action
Inhibits activation of T cells by blocking production and release of the cytokine mediator IL-2
Immunosuppressant: Cyclosporine (Sandimmune) Indication
prevention of organ rejection (kidney, liver, heart transplants)
-also used for Tx of other immunologic disorders such as various forms of arthritis, psoriasis, and irritable bowel disease
Immunosuppressant: Cyclosporine (Sandimmune) contraindications
- If patient already using Neoral, Gengraf or generic cyclosporine-modified cannot use cyclosporine
- If an error occurs prescriber has to be notified
- black box warnings including renal impairment which includes structural kidney damage, increased risk for serious and fatal infections, liver injury, seizures, encephalopathy, and skin cancer
- Pregnancy not contraindication but only given in urgent situations
Immunosuppressant: Cyclosporine (Sandimmune) Adverse effects
- moderate high BP
- neurotoxicity including tremors, hepatotoxicity with cholestasis and hyperbilirubinemia, post-transplant diabetes mellitus, gingival hyperplasia, and hirsutism
- narrow (low) therapeutic index and so this reason lab monitoring of drug levels may be used to avoid toxicity
Assessment for immunosuppressants
- assess functional levels of organ systems, lab values for liver and renal= including alkaline phosphatase, AST, ALT, bilirubin, BUN, and creatinine, common drugs interactions assess for those to prevent interactions, asses vitals BP
- assess cardiovascular or CNS diseases because of drug-related toxicities involving these systems as well as the physiologic impact of organ transplant process, perform oral assessment to watch gingivitis
Patient teaching with immunosuppressants
- need for lifelong immunosuppressants
- avoid situations exposing them for a risk of infection such as crowds, malls, and movie theaters
- report fevers, chills, increases fatigue, sore throat, bleeding gums and candidiasis symptoms, tremors, increase in BP
- females use other form of contraceptives during treatment for up to 12 weeks after therapy ends
- needs to be taken at the same time on day every day no skipping or doubling up of doses
- Don’t take with grapefruit
- black box warning= limit UV exposure
Immunosuppressant: cyclosporin drug interactions
clarithromycin, fluconazole, amiodarone, estrogens, verapamil, allopurinol, protease inhibitors, HMG CoA reductase inhibitors= they inhibit metabolism of cyclosporine results in increased levels of cyclosporine and toxicity
- Phenytoin, phenobarbital, carbamazepine, rifampin, St John’s wort= they induce metabolism of drug results in decreased levels/reduced effect
- NSAIDs inhibit synthesis of renal prostaglandin which results in increased nephrotoxic effects of drug and renal failure
- Grapefruit juice increases absorption of drug results in toxicity. Grapefruit juice also may increase the bioavailability of drug by 20% to 200% and should be avoided
- Foods high in potassium, such as bananas and tomatoes can increase drugs nephrotoxicity
Immunosuppressant: Azathioprine (Imuran) Mechanism of action
blocks metabolism of purines inhibiting the synthesis of T cell, DNA, RNA, and proteins and thereby blocking immune response
Immunosuppressant: Azathioprine (Imuran) Indications
- prophylaxis of organ rejection concurrently with other immunosuppressant drugs such as cyclosporine and corticosteroids
- Prevention of organ rejection in kidney transplantation and Tx of rheumatoid arthritis
- associated with hepatosplenic T-cell lymphoma (rare WBC cancer that is fatal)
Immunosuppressant: Azathioprine (Imuran) contraindications
- allergic to drug
- renal or hepatic failure
- hypertension
- concurrent radiation therapy
- Pregnancy not contraindication but this drug would only be given in urgent situations
Immunosuppressant: Azathioprine (Imuran) interactions
- Allopurinol decreases metabolism results in bone marrow suppression
- ACE inhibitors, tacrolimus, ribavirin, sulfamethozazole/trimethoprim, roflumilast increase its effects also results in bone marrow suppression
- Mercaptopurine, live vaccines, leflunomide, natalizumab increased effects of drugs listed results in increased toxicity of the drugs
- Warfarin and inactivated vaccines decreased effects of drugs listed results in possible clots with warfarin, decreased response to inactivated vaccines
Immunosuppressant: Azathioprine (Imuran) Adverse effects
- leukopenia, thrombocytopenia, hepatotoxicity
- carries black box warning regarding bone marrow suppression and the development of lymphoma and other malignancies
Assessment for Immunosuppressant: Azathioprine (Imuran)
- signs of infection (increased temperature, productive cough with sputum that is not clear in color, and complaints of urinary frequency, urgency, and burning)
- WCB and platelet count
- noticing S/S of infection and bleeding tendencies due to potential drug related leukopenia and thrombocytopenia -If the leukocytes or platelets are low the prescriber needs to know
- liver functions, dark urine, jaundice, increased AST, ALT, and bilirubin tests
Patient teaching for Immunosuppressant: Azathioprine (Imuran)
- advise pt take drug exactly as prescribed, contact prescriber if dose missed
- Avoid exposure to crowds or with those with infections
- Treatment with transplant patients is life-long to avoid transplant rejection
- Educate about reporting to prescriber fever, rash, severe diarrhea, sore throat, chills, and any unusual bleeding or bruising
- Encourage pt to inspect mouth for any white patches due to oral candidiasis because they will need Tx
Common adverse effects of azathioprine include?
leukopenia, thrombocytopenia, and hepatotoxicity
Clients should avoid consuming what with cyclosporine?
avoid consuming grapefruit or grapefruit juice because they will increase the blood concentrations of cyclosporine. Sunscreen should be used to avoid photosensitivity, and the medication should be taken with food or chocolate milk to prevent gastrointestinal upset
Before administration of an immunosuppressant drug, the nurse should perform which actions? (Select all that apply.)
Check liver enzyme tests.
Assess level of consciousness.
Assess blood pressure and heart rate.
Check blood urea nitrogen and creatinine levels.
Serious adverse effects to immunosuppressant drugs include neurotoxicity, nephrotoxicity, hepatotoxicity, and hypertension
Iron
Stored in Liver, spleen, and bone marrow. Deficiency of this mineral is the principle nutritional deficiency resulting in anemia
- dietary sources of iron include: meats, certain vegies, grains
- when pt can’t tolerate oral iron give IV
- 4 iron products available: iron dextran (INFeD), iron sucrose (Venofer, ferric gluconate (Ferrlecit, Nulecit), and ferumoxytol (Feraheme)
Ferrous Sulfate (Feosol) mechanism of action
iron is an oxygen carrier in both hemoglobin and myoglobin and is critical for tissue respiration. Also maintenance of normal hemoglobin and hematocrit levels and improved energy level. Administration of iron corrects iron deficiency symptoms such as anemia, dysphagia, dystrophy of the nails and skin, and fissuring of the angles of the skins and also maintains the bodily functions
Ferrous Sulfate (Feosol) indication
- prevention/Tx of iron deficiency anemia
- After identifying cause Tx can aimed at attempting to correct cause rather than alleviating symptoms
- Iron supplements used in erythropoietin therapy because it’s essential for product of RBCs
- normally children and women (especially pregnant women) most likely develop iron deficiency
- Women due to menstrual blood losses and men are less likely to develop deficiency
Ferrous Sulfate (Feosol) contraindications
- ulcerative colitis and regional enteritis
- excessive body iron stores
- peptic ulcer disease
- cirrhosis, gastritis, and esophagitis
- known drug allergies, hemochromatosis (iron overload), hemolytic anemia, and any other anemias not associated with iron deficiency
Adverse effects of Ferrous Sulfate (Feosol)
nausea, vomiting, diarrhea, constipation, stomach cramps/pain, black tarry stools, temporarily discolored tooth enamel and eyes, pain at injection
Ferrous Sulfate (Feosol) toxicity
results from combination of the corrosive effects on the GI mucosa and metabolic/hemodynamic effects cause by toxicity
- Tx includes: suctioning and maintenance of airway, correction of acidosis, and control of chock and dehydration with IV fluids or blood, oxygen, and vasopressors
- Serum iron concentration more than 300 places pt @ risk for intoxication, coma, shock, seizures, chelation therapy with deferoxamine initiated
- FDA approved deferiprone used for overload
Ferrous Sulfate (Feosol) interactions
- absorption of iron enhanced when given w/ascorbic acid and decreased when given w/antacids and calcium
- Iron preparations decrease absorption of certain antibiotics, including tetracyclines and quinolones
Nursing assessment for Ferrous Sulfate (Feosol)
- past/present medical history, include prescriptions, OTC, herbal that patient is taking and allergies
- assess and document S/S of anemia such as fatigue, changes in nails and skin, and cracking of the angles and lips
- Assess of allergies, indications, contraindications before administering iron supplements
- Assess the bone marrow and how the body stores its iron. Possible blood tests before, after and during
Nursing implementation for Ferrous Sulfate (Feosol)
- erythropoiesis-stimulating drugs; do not administer with other product or shake vial
- Monitor BP, give vitamin b12
- Instruct pt to dilute oral liquid dosage forms and sip through plastic straw to avoid discoloration of tooth enamel
- Other oral forms of iron need given w/plenty of fluids (NOT with antacids or milk, not with meals-risk for absorption of drug), but might want to take with food due to GI symptoms
- If antacids and milk used schedule @ least 2 hours before or after dosage of iron
- Have patient remain upright after administration for 30 mins, warn patients that poop will be black tarry feces
Patient teaching for Ferrous Sulfate (Feosol)
Encourage pt’s to take iron supplements cautiously to avoid toxicity
- recommend taking with 4-6 ounces of water or other fluid to minimize GI upset and increase absorption. -Instruct to sit upright up to 30 mins after taking an oral iron product to prevent esophageal irritation or corrosion. -Remind black tarry stools
- Encourage to each meats (mollusks, pork, chicken, turkey, beef, liver), certain vegetables (dark leafy greens such as spinach/Swiss chard), and grains (whole grains, fortified, cereals, bran)
Iron Dextran Mechanism of action
Iron is oxygen carrier in both hemoglobin and myoglobin and is critical for tissue respiration
- maintenance of normal hemoglobin and hematocrit levels and improved energy level
- Administration of iron corrects iron deficiency symptoms such as anemia, dysphagia, dystrophy of the nails and skin, and fissuring of the angles of the skins and also maintains the bodily functions
Iron Dextran indication
intended for IV or IM use for Tx of iron deficiency. Iron deficiency when oral iron therapy is unsatisfactory. ‘As well as Ferrous Sulfate’
Iron Dextran contraindications
ulcerative colitis and regional enteritis, conditions of excessive body iron stores, peptic ulcer disease, cirrhosis, gastritis, and esophagitis. Also contraindicated with known drug allergies, hemochromatosis (iron overload), hemolytic anemia, and any other anemias not associated with iron deficiency
Iron Dextran adverse effects
- anaphylactic reactions
- orthostatic hypotension and fatal anaphylaxis because of this a test dose of 25mg is administered before full dose. -Due to this reaction other products are being used first (ferric gluconate and iron sucrose). As well as nausea, vomiting, diarrhea, constipation, stomach cramps/pain, black tarry stools, temporarily discolored tooth enamel and eyes, pain at injection
Assessment for iron dextran
- assess past/present medical history, include prescriptions, OTC, herbal that patient is taking and allergies
- assess and document S/S of anemia such as fatigue, changes in nails and skin, and cracking of the angles and lips
- Assess allergies, indications, contraindications before administering iron supplements
- Assess the bone marrow and how the body stores its iron
- Possible blood tests before, during and after
Iron dextran Implementation
test dose is given and if not adverse effects the rest will be give 1 hour later
- IM must in large muscle mass using Z-track method
- IV must be flushed with 10mL of normal saline
- premedication of Benadryl, acetaminophen, or IV hydrocortisone may be prescribed to decrease
Iron dextran patient teaching
- take iron supplements cautiously to avoid toxicity
- recommend taking with 4-6 ounces of water or other fluid to help minimize GI upset and increase absorption. -Instruct to sit upright up to 30 mins after taking an oral iron product to prevent esophageal irritation or corrosion. -Remind of black tarry stools
- Encourage to each meats (mollusks, pork, chicken, turkey, beef, liver), certain vegetables (dark leafy greens such as spinach/Swiss chard), and grains (whole grains, fortified, cereals, bran)
When administering ferrous sulfate (iron) to a client, the nurse plans to give this medication with which fluid to increase absorption of the iron?
Orange juice
The absorption of iron can be enhanced when it is given with ascorbic acid (vitamin C), which is present in orange juice
Iron dextran should be administered?
deep in a large muscle mass using the Z-track method and a 23-gauge, 1½-inch needle to prevent skin irritation and potential necrosis
Constipation and change in the color of stool to darker or green are the most common complaints with?
iron supplementation and are expected adverse effects
Epoetin alfa (Epogen) is the biosynthetic form of erythropoietin and is a hormone produced by the kidneys in response to a decrease in erythrocytes. The client in?
renal failure has impaired kidney function and therefore may have this medication prescribed to treat anemia that is associated with end-stage renal disease that results from the lack of natural production of this hormone
Many individuals find that they need to take oral iron products with meals or food because of the commonly encountered adverse effect of gastrointestinal upset even though altered absorption occurs. If?
antacids or milk products are used, schedule them at least 1 to 2 hours before or after the oral dosage of iron or avoid taking with dairy products
Epoetin alfa has an increased risk of thrombolic events. If the client has a change in the level of consciousness, this might be a sign of?
a stroke or myocardial infarction. Clients taking this medication need assessment and monitoring for this possibility
Dermatologic Drugs: General Antibiotic Drugs: Silver Sulfadiazine (Silvadene) Mechanism of action
Tx or prevent skin infections on burns
General Antibiotic Drugs: Silver Sulfadiazine (Silvadene) Indication
bacteria responsible most commonly Streptococcus pyogenes and staphylococcus aureus
- Tx in burns with infections at burn site
- synthetic antimicrobial drug produced when silver nitrate reacts with the chemical sulfadiazine
- appears to act on the cell membrane and cell wall of susceptible bacteria and is used as an adjunct in the prevention and treatment of infection in second and third degree burns and less frequently in cellulitis or eczematous extremities
General Antibiotic Drugs: Silver Sulfadiazine (Silvadene) contraindications
not used in patients who are allergic to sulfonamide drugs
General Antibiotic Drugs: Silver Sulfadiazine (Silvadene) Adverse effects
similar to topical drugs and include pain, burning, and itching
General Antibiotic Drugs: Silver Sulfadiazine (Silvadene) routes
available only as 1% cream and is applied topically to cleanse and debrided burned areas once or twice daily using a sterile gloved hand. The topical cream can’t be too potent or else it will cause damage. The blood supply on the burned areas is reduced so the cream has to be less potent to be effective
General Antibiotic Drugs: Silver Sulfadiazine (Silvadene) nursing assessment
assess allergies, contraindications, cautions, and drug interactions. Assess results of any culture and sensitivity testing that may be ordered before giving the antibacterial to ensure appropriate drug sensitivity
General Antibiotic Drugs: Silver Sulfadiazine (Silvadene) implementation
cleanse affected area of any debris, drainage, or residual medication. Wear gloves, wash hands before and after administration, provide comprehensive education providing wound care and for home health care, document site for drainage, color, amount, swelling, temperature, odor, color, and pain. Follow manufacturer’s guidelines
General Antibiotic Drugs: Silver Sulfadiazine (Silvadene) patient teaching
teaching patient that burns can become infected, make sure there is improved conditions of skin and healing or lesions/wounds (decrease in size as well)
Anti-Acne Drugs: Tretinoin (Retinoic Acid, Retin-A Micro)
Mechanism of action:
- Appears to act as irritant to the skin, in particular the follicular epithelium. Stimulates turnover of epidermal cells, results in skin peeling. While this is occurring, free fatty acid levels of the skin are reduced, and horny cells of the outer epidermis cannot adhere to one another. Without fatty acids and horny cells, acne and its comedo or “pimple”, cannot exist
- Retin-A acne product contains tretinoin formulated inside a synthetic polymer called a “microsponge system.” This system is made of round microscopic particles of synthetic polymer. These microspheres act as reservoirs for tretinoin, allowing the skin to absorb small amount of the drug over time
Anti-Acne Drugs: Tretinoin (Retinoic Acid, Retin-A Micro) Indications
Common bacterial causes include Staphylococcus species and Propionibacterium acnes. Used to treat acne and improve the dermatologic changes (fine wrinkling, mottled hyperpigmentation, roughness) associated with sun damage
Anti-Acne Drugs: Tretinoin (Retinoic Acid, Retin-A Micro) contraindications
waxing procedures are contraindicated in patients using tretinoin
Anti-Acne Drugs: Tretinoin (Retinoic Acid, Retin-A Micro) Adverse effects
local inflammatory reactions, which are reversible when therapy is discontinued. Common adverse effects are excessively red and edematous blisters, crusted skin, and temporary alternations in skin pigmentation. Severe sunburn can occur with this drug, and patient must use appropriate sunscreens
Anti-Acne Drugs: Tretinoin (Retinoic Acid, Retin-A Micro) Routes
topically administered shown to enhance the repair of skin. It increases the formation of fibroblasts and collagen used to rebuild skin. Because of potential irritation and peeling apply once every 2 to 3 days
Anti-Acne Drugs: Tretinoin (Retinoic Acid, Retin-A Micro) Assessment
assess allergies, contraindications, cautions, and drug interactions, always consider the concentration of the medication, length of exposure to skin, condition of the skin, size of the affected area, and hydration of the skin. All these have a significant influence on the action of the medication. Inspect skin or affected area thoroughly with an adequate light source, assess overall health and hygiene, ask if there is a history of immunosuppression
Anti-Acne Drugs: Tretinoin (Retinoic Acid, Retin-A Micro) Patient teaching
apply sunscreen when going out in the sunlight due to sensitive skin from skin peeling and turning over. Maintain general hygiene, cleanliness, hydration, and proper nutrition. Apply dressings as direction, encourage patient to notify prescriber with unusual changes that occur
a topical antiinfective drug used to treat and prevent infection in second- and third-degree burns
Silver sulfadiazine
Isotretinoin and tretinoin are effective topical treatments for acne vulgaris. Isotretinoin inhibits? and tretinoin stimulates?
Isotretinoin inhibits sebaceous gland activity
tretinoin stimulates the turnover of epidermal cells, resulting in skin peeling
