NCM 206 - Pharmacology

• first antibiotic used clinically

• primarily bactericidal; drug of choice for infections

• oral dose - 1/2 of dose is absorbed

• parenteral dose - more effective

• Ex. Procaine (Wycillin) - extends action, less painful IM

• Ex. Aqueous - short duration, IM very painful

• preferred orally, 2/3 absorbed in GIT

• less potent

• effective against mild-moderate infection in URT

• effective against ANTHRAX

• effective against both gram (+) and gram (-)

• not penicillinase resistant

• Ex. ampicillin (ampicin) - causes maculopapular rash

• Ex. amoxicillin (amoxin)

• Ex. bacampicillin (penglobe)

• effective against gram (+)

• Ex. cloxacillin (postaphlin-a) - ORAL

• Ex. dicloxacillin (dynapen) - ORAL

• Ex. methicillin (staphcillin) - PARENTERAL, causes interstitial nephritis

• Ex. nafcillin (vigopen) - PARENTERAL, causes neutropenia (dec. WBC)

• effective against gram (-)

• not penicillinase-resistant

• less toxic than aminoglycosides

• Ex. piperacillin, ticarcillin disodium

• protects penicillin from enzyme

• combine penicillinase-sensitive penicillin with beta-lactamase inhibitor

• Ex. [ORAL] amoxicillin + clavulanic acid = Augmentin, Amoxyclav

• Ex. [PARENTERAL] ampicillin + sulbactam = Unasyn

• Ex. [P] piperacillin + tazobactam = Tazocin

MOA: interfere with ability of bacteria to build cell walls by making bacteria swell then burst from osmotic pressure

Duration: 6 - 8 hrs

• absorbed rapidly in GIT (sensitive to gastric acid levels)

CI:

• allergies (to penicillin, cephalosporins, etc.)

• renal disease - require lower dose due to dec. excretion

• pregnant + lactating - diarrhea & superinfections in infant (penicillin carried thru breastmilk)

AE:

• organs involved in GIT

  • N/V, Diarrhea

  • Mouth - glossitis, stomatitis, sore mouth, furry tongue

• hypersensitivity rxn - rash, fever, wheezing, anaphylactic shock, death

• Pain & inflammation at injection site

DI:

• aspirin - inc. effect

• probenecid - reduces uric acid = dec. swelling

• tetracycline, erythromycin - dec. effect, antagonistic

• oral contraceptive pills (OCP) - dec. effect

• taken with food, acidic, juice - dec. effect

NI:

• Monitor for superinfections

• Evaluate renal [elev. BUN & creatinine] & liver [elev. AST, ALT] functions

• Diarrhea r/t superinfections {mgt: take yogurt; more fluids}

• Inform physician before taking other meds

• Cultures - prior to 1st dose, if medication effective

• Alcohol is OUT! / Ask about allergies

• Take full course of meds

• Evaluate cultures, WBC, C&S

• mgt. small frequent feedings (prevent diarrhea)

• mgt. ice chips, sugarless candy (furry mouth)

• mgt. administer slowly, remove IV line, warm compress (injection site)

• antibiotics related to penicillin

• discovered in seawater (1948)

• effective against gram (+) and (-)

• Beta-lactamase resistant

• bactericidal or bacteriostatic depending on

  • susceptibility of organism being treated

  • dose

  • tissue concentration of drug

  • rate of bacterial multiplication

• A: PO well absorbed

• D: PB 75-85%

• M: HL - t1/2 = 1.5-2.5hr

• E: unchanged in urine 60-80%

• 6 hrs interval

• “fa”, “pha” drugs

• effective against gram (+) and (-); BROAD SPECTRUM

• can be destroyed by B-lactamase

• RI, skin, GU, bone, myocardial infections

• Ex. Ce__fa__droxil, ce__fa__zolin, ce__pha__lexin

• Often used as surgical prophylaxis

• Bacteria susceptible: PEcK

• “fo”, “fu” drugs

• effective against gram (-), diminished activity against gram (+)

• not affected by B-lactamase

• Ex. Ce__fu__roxime, ce__fo__tetan, ce__fo__nicid, ce__fo__xitin

• Bacteria susceptible: PEcK & HEN

• “ft” drugs

• effective against gram (-), diminished activity against gram (+) [less activity than 2nd gen]

• B-lactamase resistant

• Ex. Ce__ft__riaxone, ce__ft__azidime, ce__f__ixime, ce__f__dinir"

• Bacteria susceptible: HENPEcK, Serratia marcescens

• “fe” drugs

• greater action against gram (-), minimal action against gram (+)

• Resistant to most B-lactamase

• Ex. Ce__fe__pime (Maxipime), Ce__f__pirome

• Bacteria susceptible: PEcK, staph & strep, pseudomonas aeruginosa

• broad spectrum

• Ex. Ceftaroline, ceftobiprole

• Bacteria susceptible: Methicillin-resistant staphylococcus auerus, Vancomycin-resistant enterococci

• mgt: use gloves for contact precaution and avoid transmission

Proteus mirabilis

Escherichia coli

Klebsiella pneumoniae [strepto & staph]

Haemophilus influenzae

Enterobacter aerogenes

Neisseria gonorrhea / meningitis

• lack an outer membrane

• surrounded by layers of peptidoglycan

• has an outer membrane containing lipopolysaccharide

• surrounded by a thin peptidoglycan cell wall

• ORAL - GI: Flatulence, NAVDA, bloody stool

  • best to be taken on an empty stomach

  • if with gastric irritation, take with food or milk to inc. absorption

• CNS symptoms - fever, rash, pruritus, headache, vertigo [HYPERSENSITIVITY RXN]

• IV, IM - prolonged / high doses = phlebitis or thrombophlebitis

  • mgt: use small gauge needle, look for large veins, alternate infusion sites, administer slowly

• NEPHROTOXICITY - Renal Failure

• Superinfections - alter the normal flora

• Anaphylaxis - allergic reaction

• Cefmetazole (1stGen) / Cefoperazone moxalactam (3rdGen) + alcohol = DISULFIRAM-LIKE REACTION: flushing, dizziness, headache, N/V, muscular cramps, chest pain, palpitations, dyspnea

  • may lead to extreme CV collapse, convulsion, death

  • Aminoglycosides / vancomycin = INCREASED NEPHROTOXICITY

• anticoagulant / thrombolytics / NSAIDS = increased risk of bleeding

  • mgt: monitor blood loss

• “pril” drugs

• AKA ACE inhibitors

• MOA: blocks conversion of angiotensin I to angiotensin II

• Uses: hypertension, MI (myocardial infarction)

• SE: cough, hypotension, HA, dysgeusia, insomnia, N/V, diarrhea

• AE: reflex tachycardia, angina, cardiac arrhythmia, CHF, ulcer, liver & renal problems, photosensitivity, hyperkalemia, neutropenia, angioedema

• DI:

  • probenecid = dec. elimination

  • potassium supplement & diuretics = potent vasoconstrictor

  • NSAIDS = dec. hypotensive effect

  • antacid = dec. absorption

  • tetracycline = dec. absorption of tetracycline

• CI: renal disease, severe Na depletion, CHF, pregnant or lactating

• encourage implement lifestyle changes

• administer on an empty stomach for better absorption

• alert if the patient is for surgery/dialysis/situations which may drop fluid volume

• Parenteral form only if oral form is not available

• Adjust dose if with renal failure

• Do not give if BP is below 90/70, monito BP esp. for 2 hrs after the first dose [check for hypotension]

• Avoid ambulation [dizziness]

• Report cough or angioedema

• Report dysgeusia if more than 1 month

• “sartan” drugs

• MOA: selectively bind the angiotensin II receptors in the blood vessels and adrenal cortex [relaxation of blood vessels]

• Uses: when ACE inhibitors are not tolerated

• SE: HA, diarrhea, dyspepsia, cramps

• AE: angioedema, hyperkalemia

• CI: Kidney dysfunction, CHF, pregnancy

• ensure female patient is not pregnant

• take without food

• “dipine” drugs

• MOA: prevents movement of calcium ions in the myocardium and vascular smooth muscles [prevents contraction of blood vessels]

• Uses: angina, hypertension, atrial fibrillation (abnormal heart rhythm)

• SE: HA, dizziness, hypotension, syncope, reflex tachycardia, constipation, AV block, bradycardia, peripheral edema

• monitor ECG, CR, BP

• Have “E” cart available with IV administration

• Position to decrease peripheral edema [if edema is in lower extremity, elevate legs]

• Protect drug from light and moisture

• Increase OFI and fiber in diet

• Avoid overexertion when anginal pain is relieved

• may give paracetamol if with HA

• take with meals or milk

• do not chew or crush = sustained release

• MOA: relaxes smooth muscles of blood vessels, promotes inc. blood flow

• ex. hydralazine (apresoline), minoxidil (loniten), diazoxide (hyperstat), nitroprusside (nitropress)

• Uses: severe hypertension, emergencies

SE/AE:

• hydralazine

  • tachycardia (beta blockers), palpitations, edema (diuretics), HA, dizziness, GI bleed, lupus like (autoimmune disease), neurologic symptoms

• Minoxidil

  • similar effects, excess hair growth, precipates angina

• Nitroprusside & diazoxide

  • hyperglycemia

• CI: allergy, pregnancy, lactation, cerebral insufficiency

• DI: + other antihypertensive drugs = additive effect

• __d__irectly acts on vascular smooth muscle

• __i__ncrease renal and cerebral flow

• __l__upus-like reaction (fever, facial rash, muscle-joint pain, splenomegaly)

• __a__ssess peripheral edema

• __t__ake with food [inc. absorp.]

• __o__ther side effects (HA, dizziness, anorexia, inc. cardiac, dec. BP)

• __r__eview BP (orthostatic hypotension), Blood Glucose

• “olol” drugs

• MOA: block beta 1 (cardiac) and/or beta 2 (lungs) adrenergic receptor sites, dec. effect of SNS

• Uses: hypertension, dysrhythmias, angina pectoris

• AE: rebound hypertension

• CI: asthma, heart block, COPD, diabetes mellitus, electrolyte imbalance [ABCDE]

• DI:

  • +antacids = delayed drug absorption

  • +lidocaine = inc. plasma level of lidocaine

  • +insulin/OHA = hypo/hyperglycemia

  • +cardiac glycosides = additive bradycardia

  • +calcium channel blockers = inc. pharmacologic and toxic effects of both

  • +cimetidine = dec. metabolism of beta blockers

  • +theophylline = impaired bronchodilation effect

• lifestyle modification; compliance (rebound hypertension)

• monitor blood sugar with diabetic pt.

• monitor triglycerides and cholesterol level

• monitor BP & pulse before and after

• withhold if pulse is <60 or SBP <90

• monitor any change in the rhythm or signs of CHF

• MOA: blocks alpha 1 adrenergic receptors, results in vasodilation of arteries and veins

• use in benign prostatic hyperplasia

• dec. VLDL (very low density lipoprotein) and LDL = dec. fat deposits

• does not affect glucose metabolism & resp. function

• causes Na & H2O retention with edema; given with diuretics

• Warnings: renal disease, elderly more sensitive

• Potent Alpha Blockers (very strong effect on blood vessels) hypertensive crisis (180 systolic BP) & severe hypertension from catecholamine secreting tumors of the adrenal medulla (pheochromocytoma- non-cancerous tumor that grows on adrenal gland)

• Ex. tolazoline - to lower inflammation of prostate gland

• Ex. prazosin (minipress) - CHF

• SE: orthostatic hypertension, first dose syncope, nausea, drowsiness, nasal congestion, weakness, loss of libido

• DI:

  • +other antihypertensive, alcohol, nitrates = inc. hypotensive effect

  • prazosin + anti inflammatory drugs = peripheral edema

  • prazosin + nitroglycerin = syncope

• monitor BP frequently

• protect from falling/injury

• assess BP and HR before each dose

• if dose is during the day, client must remain recumbent for 3-4 hrs

• assist with ambulation if pt. is dizzy

• implement safety precautions

• report if edema is present

• sugarless gum, sips of tepid H2O to relive dry mouth

• MOA: decrease sympathetic response from brainstem to the peripheral vessels, dec. peripheral vascular resistance & BP

• dec. epinephrine, norepinephrine, renin release

• SE/AE: drowsiness, HA, dry mouth, dizziness, bradycardia, hypotension, constipation, occasional edema or weight gain

• DI: paradoxical hypertension - difficult to control, life threatening with propranolol

  • +methyldopa (aldomet) = chronic pregnancy induced hypertension (PIH)

  • +clonidine (catapres) = sublingual

  • +diuretics = causes Na & water retention

• monitor baseline VS (q30 mins until stable during initial therapy) & weight (refer: wt. gain > 4 lbs/week)

• abrupt D/C = hypertensive crisis (restlessness, tachycardia, tremors, HA, inc. BP), compliance

• taper dose gradually over more than one week

• recommend the last dose to be taken at bedtime

• sugarless gum, sips of tepid water to relieve dry mouth

• AKA Peripherally Acting Sympatholytics

• MOA: block norepinephrine release from the sympathetic nerve endings that results in decrease BP

• SE: orthostatic hypotension, Na & water retention, vivid dreams, nightmares, suicidal intention (reserpine)

• Ex. reserpine (serpasil), guanethidine monosulfate (ismelin)

• take with meals

• no alcohol

• MOA: blocks both alpha 1 and beta 1 receptor sites, dec. BP, moderately dec. PR

• SE: orthostatic hypotension, GI disturbances, nervousness, dry mouth, fatigue

• AE: heart block

• CI: large doses could block beta 2 receptors = inc. airway resistance in pt. with asthma

• Ex. labetalol (normodyne), carteolol (cartrol)

• Pressure (blood) monitor

• Rise slowly

• Eating must be considered

• Stay on medication

• Skipping or abrupt stopping is No-No

• Undesirable responses

• Remind to exercise, dec. alcohol

• Eliminate smoking

• produces increased urine flow by inhibiting sodium and water reabsorption from kidney tubules

• decrease hypertension, edema

• Indication: CHF, pulmonary edema, liver failure & cirrhosis, renal diseases, hypertension, glaucoma

• CI: allergy, fluid & electrolyte imbalances, several renal diseases, SLE, DM

• MOA: increase Na & water excretion, inhibiting Na reabsorption in the distal tubule of kidney

• Uses: mild-moderate HPN, edema associated with CHF, cirrhosis with ascites

• Warning - decrease K, renal/hepatic dysfunction, gout

• DI:

  • +lithium = lithium toxicity (N: 0.6-1.2 mEqs/L)

  • +digoxin = digoxin toxicity (signs: bradycardia, N/V, visual changes; 1.0 to 2.6 nmol/l)

  • +corticosteroids, amphotericin, ticarcillin = hypokalemia

  • +sulfonamides = cross sensitivity

• SE/AE: hypokalemia, hyponatremia, hypomagnesemia, hypotension, bicarbonate loss, hypercalcemia, hyperglycemia, hyperuricemia, N/V, constipation, rashes, dizziness, weakness, increase LDL, photosensitivity, HA, dehydration, blood dyscrasias

• Ex. Chlorothiazide (diuril), hydrochlorothiazide (hydroduril), metalazone (zaroxolyn)

• monitor BP, wt. OD, urine output, edema

• monitor K, Na, blood glucose, LDL, triglycerides

• change position slowly

• no alcohol

• take with meals, preferably in AM

• eat foods high in K

• signs of hypokalemia (muscle weakness, cardiac dysrythmias, cramps, dizziness, N/V, tingling sensation, “U” wave on the ECG (3.5- 5.0 mEq/L)

• manage photosensitivity

• weight the patient in same clothes, same time w/o meals

Take time to check VS

Hyperglycemia, hypokalemia, hyperuricemia monitoring

Instruct to weigh in daily

Avoid sudden position

Zugar monitoring

I&O monitoring

Diuresis is expected

Eat potassium rich foods

• MOA: inhibits Na & CI absorption from the loop of Henle and distal tubules, causes rapid diuresis, little effect on glucose

• Uses: HPN, edema associated with CHF, cirrhosis with ascites, hypercalcemia

• DI: same with thiazides

• SE/AE: hypokalemia, hyponatremia, hypocalcemia, hypomagnesemia, hypochloremia, hyperuricemia, orthostatic hypotension, constipation, N/V, decrease platelet, ototoxicity (IV bumetanide), dehydration, photosensitivity, thiamine deficiency, hyperglycemia (glycogenolysis), elevated BUN & creatinine

• Ex. furosemide (lasix)

• Monitor VS, edema, urine output, serum K, Na, Ca, Cl, thiamine, blood glucose & platelet levels, Mx of digoxin & lithium toxicity

• Potassium rich foods

• Give slow IVTT (2 mins) to prevent hearing loss

• With food, in AM to avoid sleep disruption

Check for weight gain/loss

Ensure VS prior to administration

I& O monitoring

Laboratory values assessment

Instruct to rise slowly

Nocturia prevention: frequent voiding during night time

Give it with meals

• MOA: increase osmotic pressure in the glomerular filtrate, preventing reabsorption of water & electrolytes

• Uses: increase ICP (Intracranial Pressure 7-15 mmHg), edema, prevention of renal failure, oliguria (low urine output), inducing diuresis during chemotherapy

• CI: anuria (absence of urine)

• DI: increase hypokalemia which may increase digoxin toxicity

• SE/AE: pulmonary edema d/T rapid fluid shifting, NV, tachycardia, decrease Na, K, Cl, Ca, dehydration

• Ex. mannitol (osmitrol) - prone for crystallization; glycerin (osmoglyn) - dec. IOP

• Monitor VS, wt, urine output, serum Na, K, Cl, Ca

• Watch for rapid inc in BP & rapid sympathetic overactivity (inc HR, tremor, agitation)

• Assess lung and heart sounds

• Check skin turgor, LOC, Mx of dec ICP

• Mannitol: check bottle or vial for crystallization, warm bottle & shake vigorously to dissolve crystals, if it doesn’t dissolve= DO NOT administer

:use IV line with filter

:infuse for 30-60 minutes

\n Cushing’s Triad

• ICP: inc. systolic BP, dec. pulse, respirations [HYPER, BRADY, BRADY]

• Shock: dec. BP, inc. pulse, respirations [HYPO TACHY TACHY]

• MOA: acts on the distal tubule to promote Na and water excretion & prevent potassium excretion; AKA: Aldosterone antagonist

• Uses: HPN, edema = CHF, nephrotic syndrome (too much protein in urine) to counteract hypokalemia caused by other diuretics

• CI: severe renal disease, severe hyperkalemia

• DI:

  • +lithium= lithium toxicity

  • +ACE inhibitor= hyperkalemia

  • +digoxin= digoxin toxicity

  • +K supplements (eg kalium durule)= hyperkalemia

• SE/AE: hyperkalemia, N/V, diarrhea, dry mouth, rash, dizziness, weakness, bluish colored urine (triamterene) hypotension, increase potassium level result in peaked T wave in ECG

• AE: HA, photosensitivity, anemia, decrease platelet

• Ex. Spironolactone (aldactone)

• Monitor VS, urine output, serum K level

• Inform client that hypotensive effects may not be seen for 2 weeks

• Avoid potassium rich foods

• Manage photosensitivity

• Avoid salt substitutes

• Take with meals

• Bluish colored urine is harmless

• Administer in AM

Interventions

Diet; decrease sodium intake

Intake & output monitoring

Undesirable effects

Reduction of edema

Electrolytes review

Take early in the day; with meals

Interactions; digoxin, lithium

Cause/aggravate diabetes

Sensitivity to sunlight

• “-cycline” drugs

• effective against gram (+) and most organisms; ineffective against S. aureus, Pseudomonas, Proteus

• • metronidazole and bismuth subsalicylate = treat Helicobacter pylori (peptic ulcer)

• ORAL and TOPICAL tetracycline = treat severe acne vulgaris

• MOA: inhibit bacterial protein synthesis

• Classifications:

  • short acting - HL 6-12 hrs, ex. tetracyn, panmycin, terramycin, broad spectrum indication

  • immediate - HL 10-17 hrs, ex. declomycin, broad spectrum indication

  • long acting - HL 11-20 hrs, ex. vibramycin, minocin, bacterial infection and acne indication

• ROUTE:

  • oral - frequently prescribed

  • IM - can cause pain at injection site, tissue irritation

  • IV - treat severe infections

• SE: N/V, diarrhea, teratogenic, discolors teeth, balance difficulty, nephrotoxicity with high doses, superinfection, photosensitivity

• DI:

  • +antacids, iron containing drugs, milk = prevent absorption

  • +oral contraceptive = lessened effect of OCP

  • +penicillin = decreased activity of penicillin

  • +aminoglycosides = increased risk nephrotoxicity

• Sunlight sensitivity - drug decomposes in time

• Take full glass of water - could cause gastritis

• Antacids, Iron, Milk - stop, it will only decrease absorption

• Put on empty stomach - for faster absorption (primary)

• Mgt. for GI symptoms - small frequent feeding, ice chips, replace fluids

• Mgt. Safety precaution for ambulation

• Mgt. oral hygiene

• Mgt. sunblock, dark clothing, store out of light and heat

• Do not give to pregnant clients and children <8 years old

• “-mycin” drugs

• MOA: inhibit bacterial protein synthesis (bactericidal)

• effective against gram (+)

• ROUTE: primarily administered IV, PO [given to treat bacteria in bowel], IM

• treats tularemia and bubonic plague

• SE: N/V, rash, numbness, tremors, visual disturbances, tinnitus, muscle cramps or weakness, photosensitivity

• AE: urticaria/hives, palpitations, ototoxicity, nephrotoxicity, neurotoxicity

• DI:

  • +penicillin = less effective aminoglycoside

  • +anticoagulant (warfarin) = increased activity

• Monitor periodical audiograms, BUN/creatinine & vestibule function studies over 10 days therapy

• Adjust renal insufficiency

• Monitor VS. peak and serum levels

• For IV admin., dilute and administer slowly to prevent toxicity

• Monitor I&O, hydrate well before and during therapy (flush in between)

• If anorexia or nausea occurs, SFF (small frequent feeding) meals

• Establish plan for safely if vestibular nerve effects occur (ototoxicity)

• Administer other antibiotics 1 hour before/after aminoglycoside

• Recommend using sunblock & protective clothing when exposed to the sun

• “-thromycin” drugs

• MOA: inhibits protein synthesis, bacteriostatic (low dose) or bactericidal (high dose)

• used for mild-moderate infections of the respiratory tract, sinuses, GIT, skin, soft tissues; treat diphtheria, impetigo, STD

• No IM or IV = too painful, ROUTE: PO

• SE: hepatotoxic, superinfection

• AE: superinfection, urticaria, hearing loss, hepatotoxicity “yellow sclera”, anaphylaxis

• DI:

  • +acetaminophen, phenothiazine, sulfonamide = inc. hepatotoxicity

  • +antacid = dec. absorption

  • +erythromycin & verapamil, diltiazem, clarithromycin, fluconazole = inc. erythrocyte concentration

  • +digoxin, carbamazepine, theophylline, cyclosporine, warfarin, triazolam = inc. effect

  • +penicillin, clindamycin = dec. effect

• Do not refrigerate suspension form of Clarithromycin

• Monitor liver enzymes - signs & symptoms of hepatotoxicity (check liver function tests)

• Administer IV slowly (prevent phlebitis)

• GIve IM into deep muscle

• Avoid fruit juices (reduced absorption)

• Manage NAVDA

• Check for superinfections. (Give YOGURT / BUTTERMILK)

• Check drug interactions

• Evaluate effectiveness (Check WBC level, temperature, cultures)

• MOA: change protein function & prevent cell division or cause cell death (both)

• more toxic but similar to macrolides

• Clindamycin

  • widely prescribed against most gram (+) organism; absorbed better, more effective, fewer toxicity

  • for severe infections caused by same strains of bacteria that are susceptible to macrolides

• Lincomycin

  • to treat severe infections when penicillin cannot be given

• AE: GI reaction, pain, skin infection, bone marrow depression

• Do not refrigerate suspension form of Clarithromycin

• Monitor liver enzymes - signs & symptoms of hepatotoxicity (check liver function tests)

• Administer IV slowly (prevent phlebitis)

• GIve IM into deep muscle

• Avoid fruit juices (reduced absorption)

• Manage NAVDA

• Check for superinfections. (Give YOGURT / BUTTERMILK)

• Check drug interactions

• Evaluate effectiveness (Check WBC level, temperature, cultures)

• Careful monitoring

• GI activity & fluid balance

• STOP if with bloody diarrhea

• MOA: inhibits bacterial cell wall synthesis

• Used against staphylococcal infections drug-resistant S. aureus and in cardiac surgical prophylaxis with Penicillin allergies

• Oral form - not absorbed systemically, excreted in the feces

• IV form - for severe infections due to MRSA, septicemia, bone, skin and lower respiratory tract infections that are resistant to other antibiotics

• DI:

  • +amphotericin B, polymycin, furosemide, cisplatin = inc. nephrotoxicity

  • +methotrexate = inc. methotrexate toxicity

• SE/AE: Chills, dizziness, fever, rashes, nausea, vomiting, thrombophlebitis at injection site

• DOSE-RELATED TOXICITY: Tinnitus, high tone deafness, hearing loss & nephrotoxicity

• RAPID IV INFUSION

  “RED-NECK or RED MAN SYNDROME” resulting in Histamine release & chills, fever, tachycardia, profound fall in BP, pruritus or red nose / neck / arms / back

• Refrigerate IV solution after reconstruction, use within 96 hrs

• Flush IV line in between antibacterials. Evaluate IV site for phlebitis, avoid extraversion.

• Ensure safety

• Check baseline hearing. Refer to ENT. Report ringing in ears or hearing loss, fever and sore throat.

• Monitor blood pressure during administration

• Monitor renal function tests - creatinine, BUN and urine output and liver enzymes

• Yogurt for superinfection

• Check for pregnancy & lactation

• MOA: interfere with the enzyme DNA gyrase (needed to synthesize bacterial DNA) = broad spectrum bactericidal

• TYPES

  • Negram, cinobac - for UTI, LRTI, skin, soft tissue, bone, joint infections

  • Cipro, noroxin - broad spectrum targeting P. aueroginosa

  • Levaquin, zagam - resp. problems, acute sinusitis, UTI, skin infection

  • Tequin, avelox - more active against S. pneumoniae

• SE: photosensitivity, dizziness, N/V, diarrhea, flatulence, abdominal cramps, tinnitus, rash

• Assess RENAL function: I/O, BUN, Creatinine

• Drug & diet history

• Avoid caffeine

• Antacids & Iron prep = decreases absorption of Fluoroquinolones

• Monitor serum theophylline & blood glucose levels - with Theo, caffeine, oral hypoglycemics  = INCREASE their effects

• With NSAIDS = CNS reactions = seizure

• Administer 2 hrs ac or after antacids

• If with IRON preparation = give with full glass of water

• IV - infuse over 30 mins, dilute with approximate amount

• Check S/S of SUPERINFECTIONS (stomatitis, furry black tongue, genital discharge, itching)

• Check symptoms of CNS stimulation = nervousness, insomnia, anxiety & tachycardia (avoid hazardous machinery)

• “sulfa” drugs

• MOA: Inhibit bacterial synthesis of FOLIC ACID, essential for bacterial growth, necessary for synthesis of PURINE & PYRIMIDINES, which are precursors of RNA & DNA

• well absorbed in GIT, excreted in urine

• common route: oral, may be ophthalmic ointment or in cream

• two types:

  • short acting - sulfadiazine, sulfisoxazole

  • intermediate - sulfamethoxazole, sulfasalazine, cotrimoxazole

• DI:

  • Increase effects of Warfarin

  • Decrease absorption if taken with antacids

  • Increase hypoglycemic effect of sulfonylureas

  • Decrease effectiveness of contraceptives

Sunlight sensitivity (limit sun exposure), stomach upset (small frequent feeding), skin reactions (rash), superinfections (frequent oral care, ice chips, sugarless candy- to relieve discomfort), STEVEN’S JOHNSONS SYNDROME (D/C drug).

Undesirable effects - Renal toxicity (check creatinine BUN), CNS effects (HA, dizziness, vertigo, ataxia, convulsions, depression (d/t effect to nerves), hepatotoxic (liver enzymes (AST, ALT, alkaline, phosphatase); monitor for jaundice, icteric sclera).

Look for urine output (Crystalluria, Hematuria-Increase OFI), fever, sore throat & bleeding.

Fluids galore - prevent kidney damage due to poor solubility of drugs

Anorexia, anemia (hemolytic anemia, aplastic anemia, pancytopenia (prolonged and high dosages)- due to BM depression).

\n

a rare and serious disorder that affects skin, mucous membranes, genitals and eyes. It causes flu like symptoms along with painful rash that spreads and blisters

• AKA Chloromycetin

• MOA: bacteriostatic - inhibits bacterial protein synthesis; broad spectrum

• Uses: serious infections of SKIN, SOFT TISSUE, CNS infections- including meningitis, ophthalmic infections— when less toxic drugs cannot be used.

• SE:

  • BM depression- blood dyscrasias

  • NEURO- confusion, peripheral neuritis, depression

  • GRAY SYNDROME- in newborn characterized by: abdominal distention, vomiting, pallor, cyanosis; NB may die due to immature liver function.

NURSING CARE:

• Monitor infection, bleeding

• Monitor for anemia,CBC

• Monitor level of consciousness (LOC)

• AKA Trobicin

• For allergic to PCN, Cephalosporins, Tetracycline

• Administered IM single dose- BACTERIOSTATICS

PREGNANCY CATEGORY: B

• AKA Synercid

• Treat VREF- Vancomycin-resistant Enterococcus faecium bacteremia & skin infected by S. eus & S. pyogenes.

• Disrupts CHON synthesis of the organism.

• When administered through peripheral IV line= PAIN, EDEMA & PHLEBITIS

• SE: N/V, diarrhea, pseudomembranous colitis, HA, anaphylaxis, elevated AST & ALT

NURSING CARE:

• Check for dehydration, monitor stools

• Check for patency of IV line; infuse over 1 hr mix in D5W (Dextrose 5% in water)

• Check for S/S of anaphylaxis

• Monitor ALT, AST, jaundice, icteric sclerae

• Give ice chips, SFF

• Ex. polymyxin

• MOA: interferes with cellular membrane; bactericidal

• affects gram (-)

• recommended route: IV (slow admin.)

• SE/AE: dizziness, nephrotoxicity, neurotoxicity

• ex. bacitracin

• MOA: inhibits cell wall synthesis; bactericidal/bacteriostatic

• effective against most gram (+), some gram (-)

• given IM/IV

• SE/AE: N/V, nephrotoxicity, respiratory paralysis, blood dyscrasia, anaphylaxis

Medications:

• Amantadine (Symmetrel) - PO

• Oseltamivir (Tamiflu) - PO

• Ribavirin (Virazole) - aerosol inhalation

• Rimantadine (Flumadine) - PO

• Zanamivir (Relenza) - inhaler

MOA: inhibit viral replication by interfering viral nucleic acid synthesis in the cell (STEP 3)

CI: allergy, pregnancy & lactation, renal & liver disease

AE: lightheadedness, dizziness, insomnia, nausea, orthostatic hypotension & urinary retention

DI: with anticholinergic drugs = increase atropine like effect

Nursing Considerations

• Start regimen as soon after the exposure to the virus as possible (achieve best effectiveness and decrease the risk of complications)

• Administer the full course of drug

• Provide safety measures (protect patient from injury)

Medications:

• Acyclovir (Zovirax)

• Famciclovir (Famvir)

• Valacyclovir (Valtrex)

• Cidofovir (Vistide)

• Foscarnet (Foscavir) = both; IV

• Ganciclovir (Cytovene) = long term treatment & prevention of CytomegaloVirus; IV

TOPICAL ANTIVIRALS (HSV)

• Idoxuridine

• Penciclovir

• Trifluridine \n

CI: CNS disorders, allergy, pregnancy & lactation, renal disease

SE: N/V, HA, depression, rash, hair loss, inflammation & burning sensation at the site of injection and topical

AE: renal dysfunction

DI: + other nephrotoxic meds = increase toxicity

• Zidovudine = increase drowsiness

Nursing Considerations

• Extreme caution to children (carcinogenic); foscarnet (affect bone growth & development)

• Good hydration (decrease toxic effects of the kidney)

• Administer as soon as possible, monitor for compliance

• Wear protective gloves when applying the drug topically (to decrease risk of exposure to the drug and inadvertent absorption)

• Safety precautions = CNS effects (monitor orientation, raise side rails, provide good lighting. Offer assistance)

• Warn that GI upset, N/V can occur (prevent undue anxiety, increase awareness of the importance of nutrition)

• Monitor renal function

• Avoid sexual intercourse if with genital herpes

• Avoid driving and hazardous tasks if with dizziness & drowsiness

AKA Nucleoside / Nucleotide Reverse Transcriptase Inhibitors

• MOA: blocks the reverse transcriptase enzyme needed for viral replication

• Fixed dose: combinations of antiretrovirals are multiple antiretroviral drugs combined into a single pill, which helps reduce pill burden

• SE: less tenofovir = renal toxicity, GI - nausea, diarrhea, abdominal pain (transient 2 weeks), mitochondrial toxicity, lactic acidosis, peripheral neuropathy, myopathy, pancreatitis, lipoatrophy

Nursing Considerations

• Should be taken with food except Didanosine (60 min AC or 2 hours PC)

• Requires dosage adjustment except abacavir (creatinine clearance < 50mL/min)

• Fixed dose avoided if with renal insufficiency

AKA Non-nucleoside Reverse Transcriptase Inhibitors

• MOA: prevent viral replication by competing with binding of the reverse transcriptase enzyme at the active site

  • Used to reserve protease inhibitors (resistance)

• Ex. Efavirenz [Sustiva] (rec.)

  • first choice; preg. cat. D

  • CNS toxicities: dizziness, sedation, nightmares, euphoria, loss of concentration

  • Administered as a component of Atripia (fixed dose)

  • Taken once a day at hour of sleep

  • Take on empty stomach / with low fat meal (prevent excessive drug absorption)

• Ex. Nevirapine [Viramune] (alt.)

  • Pregnancy (1st tri)

  • Recommended for those planning to conceive

  • For those not using effective / consistent contraception

  • < risk: rash hepatotoxicity

• MOA: act at the end of the HIV cycle to inhibit the production of infectious HIV virus

• Note

  • Ritonavir boosting - mainstay of Protease Inhibitor therapy (potent inhibitory effect)

  • Take with food

  • • didanosine = one hour before or two hours after ritonavir

• MOA: prevents HIV cell entry (fusion of HIV and CD4)

• Enfuvirtide - the only agent approved

  • Indicated in combination with 3 - 5 other antiretroviral agents (for clients with limited treatment option)

  • Expensive

  • Recommended dose: 90mg subcutaneous twice a day

  • Injection site reaction

    • subcutaneous nodules, redness

    • Others: rash, diarrhea, serious allergic reaction (anaphylaxis)

• MOA: inhibits Na-K pump which increases intracellular calcium and allows contraction (inc. myocardial contraction, dec. heart rate, dec. conduction velocity)

• Uses: CHF, Atrial fibrillation, atrial flutter

• Digoxin toxicity - rapid onset excreted thru kidney, narrow margin of safety

  • anorexia, diarrhea, N/V, bradycardia, cardiac dysrhythmias, HA, malaise, blurred vision, visual illusion (white, green, yellow halos around objects), confusion and delirium

  • Antidote: digoxin immune Fab (intoxication with serum level of > 10ng/mL)

• CI: hypersensitivity, ventricular tachycardia and fibrillation, heart block, renal insufficiency, electrolyte imbalance

• DI:

  • +verapamil, quinidine, quinine, erythromycin, tetracycline, cyclosporine = inc. toxic effect

  • +loop diuretics / hydrochlorothiazide = hypokalemia

  • +cortisone preparations = sodium retention & potassium excretion

  • +thyroid hormones, metoclopramide = less effect

  • +antacids = dec. digitalis absorption

• Consult prescriber about loading dose (large dose for first set then next is lower doses Na).

• Monitor apical pulse in one full minute, monitor for quality and rhythm.

• Check dosage & preparation carefully.

• Check pediatric dose with extreme care.

• Follow dilution carefully for IV preparation.

• Administer IV dose very slow over at least 5 minutes.

• Weigh patient.

• Avoid administering oral drug with food or antacid.

• Maintain emergency equipments on standby = lidocaine (arrhythmias), phenytoin (seizure), atropine SO4 (inc cardiac rate), cardiac monitor (to monitor cardiac heart rhythm)

• Monitor therapeutic level of digoxin (0.5 - 2 ng/mL). Digoxin toxicity

1. Classic (stable) - occurs with stress exertion.

• may prior activity kung bakit nag chest pain si pt.

2. Unstable (preinfarction) - occurs frequently over the course of a day with progressive severity.

• nagluluto lng tapos bigla nag chest pain and throughout the day pasikip ng pasikip ang chest pain

3. Variant (Prinzmetal, vasospastic) - occurs during rest.

• naka upo lng pero biglang nag chest pain

• natutulog pero nag chest pain

CAD, Angina Pectoris, MI

Types:

• Non-nitrates (beta blockers, calcium channel blockers)

• Nitrates: isosorbide mononitrate (Imdur, isoket, isordil); nitroglycerin (Deponit, Nitrostat)

• MOA: dilation of the veins = less blood return to the heart (decrease preload), dilation of arteries = less vasoconstriction and resistance (dec. afterload)

• Uses: treatment & prevention of angina, decrease BP

• SE: HA, dizziness, hypotension, reflex tachycardia, decrease CR, GI distress, flushing

• AE: some degree of hepatotoxicity / nephrotoxicity

• Assess  chest pain: Precipitation factors, Quality, Radiation, Severity/ symptoms, and Time

• PO: take on empty stomach; undergoes hepatic first pass effect

• SL: every 5 min x 3(maximum) doses; effects lasts for 10 minutes

  • store in dry & dark bottle (it is photosensitive)

  • check expiration date

  • take sips of water BEFORE administration

  • allow drug to dissolve before taking anything PO

  • burning / stinging sensation means the drug is potent or taking effect (normal)

• Buccal: place drug between upper lip and gum or between cheek and gum

• IV infusion: dilute drug in glass IVF bottles via infusion pump, onset 1-3 minutes same with SL

• Topical Ointment: (put ointment directly) remove previous application

  • spread drug over 6x6 in. area on chest, back, upper arm, and cover with a plastic wrap

  • rotate site, avoid touching the ointment

• Patch: patch is waterproof

  • apply working gloves, non hairy portion

  • you can shave it (in some institutions) or clip it shorter

  • remove previous patch, rotate sites

  • anterior chest wall (common site)

  • remove after 12 hours to prevent tolerance

  • do not apply defibrillator paddles over the drug, may cause burn

    • If flatline CPR agad, don’t defibrillate

    • Do not place defibrillator on patch, will cause burn

• Spray: lift tongue then spray, avoid inhaling the drug

• General: withhold: BP < 90/60, HR <60, acetaminophen for HA, reassess chest pain after 2-5 minutes (SL, spray, except PO) \n

• MOA: works by interfering with the formation of vitamin K- dependent clotting factors and prolongation of clotting times

• Uses: AF, artificial heart valves, prevent thrombus and embolization affecting MI and pulmonary embolism

• Antidote:  phytonadione (Aquamephyton) - a form of vitamin K

• LAB: prothrombin time (PT) - maintained at 1.25-2.5 times the laboratory control value; INR 2:3

• MOA: inhibits the conversion of prothrombin to thrombin, thus blocking the conversion of fibrinogen to fibrin which is the final step of clot formation

• Route: SQ, IV

• DOES NOT cross placenta and NOT enter breastmilk

• Uses**:** treatment and prevention of venous thrombosis and pulmonary embolism, AF with embolization, prevent clotting of blood samples in dialysis and venous tubing

• Antidote: protamine sulfate - reverses effect by forming stable salt with heparin

• LAB: Whole blood clotting time (WBCT) 2.5-3 x control, Activated partial thromboplastin time (aPTT - has reagent) up to 40 sec, Partial Thromboplastin time (PTT) 1.5-2.5 x control in secs

• CI: hypersensitivity, bleeding tendencies, psychosis , diarrhea (loss of vitamin K or plasminogen)

• AE: bleeding, warfarin = alopecia, dermatitis, prolonged & painful erections (less frequent)

• DI:

  • +aspirin, NSAIDs, sulfonamides = inc. effect

  • +nitroglycerine, protamine = dec. effect

  • +oral contraceptives, phenytoin, rifampin = dec. effect

  • +alcohol = inc. bleeding

• Avoid large amount of green leafy vegetables, fish (OMEGA 3), liver, coffee, and tea (inhibits/blocks platelets which inc. of anticoagulants) ; NO alcohol

• Evaluate therapeutic levels

• Signs of bleeding - epistaxis, hematochezia, melena

• Safety precautions (electric razor, avoid contact sports, use pressure dressing, no IM injection, inform dentist, soft bristled toothbrush)

• Maintain antidote standby

• Medic alert card, do not smoke, NO aspirin

• MOA: alter formation of platelet plug

• Uses: adjunct (pampadag dag) to thrombolytic therapy in the treatment of MI & prevention of re-infarct, prevention of MI and stroke

• Ex.

  • aspirin (generic), PO

  • cilostazol (Pletaal), PO

  • clopidogrel (Plavix), PO

• CI: hypersensitivity, pregnancy, lactation, bleeding disorder, recent surgery

• AE: bleeding, GI discomfort, HA

• Avoid large amount of green leafy vegetables, fish (OMEGA 3), liver, coffee, and tea (inhibits/blocks platelets which inc. of anticoagulants) ; NO alcohol

• Evaluate therapeutic levels

• Signs of bleeding - epistaxis, hematochezia, melena

• Safety precautions (electric razor, avoid contact sports, use pressure dressing, no IM injection, inform dentist, soft bristled toothbrush)

• Maintain antidote standby

• Medic alert card, do not smoke, NO aspirin

• MOA: converts plasminogen to plasmin to dissolve clot

• Uses: pulmonary embolism, DVT, MI, acute ischemic CVA (stroke)

• CI: severe hypertension, active bleeding, hemophilia (excessive bleeding), thrombocytopenia, GI bleed, hypersensitivity

• DI: inc bleeding with NSAIDs, antiplatelet, anticoagulant

• SE: bleeding, rash (streptokinase), febrile reaction, N/V, flushing, hypotension

• AE: hemorrhage

• Ex.

  • Streptokinase (Kabikinase, Streptase)

  • Urokinase (Abbokinase)

  • Anistreplase

• Check BP prior (if mababa wag ibigay)

• Monitor bleeding time, hgb, platelet count, APTT

• Monitor signs of bleeding up to 24 hrs post the last dose

• Check for allergic reactions esp to streptokinase (Benadryl may be given prior)

• IV drugs that are mixed should be used within 24 hrs, infusion pump

• Avoid invasive procedure

• Apply pressure for 5-10 mins on all discontinued IV

• ANTIDOTE: aminocaproic acid (Amicar)

• Prevent bleeding

• MOA: hasten clotting of blood (pinapabilis ang clotting process) by inhibiting the substance that activate plasminogen

• Uses: to stop bleeding

• CI: elevated BP, clotting disorder

• SE: increase BP (most common), HA, N/V, abdominal cramps, diarrhea, fatigue, muscle pain

• AE: intrarenal obstruction d/t clot formation, anaphylaxis (esp with aprotinin)

• DI: aminocaproic acid + oral contraceptives = increase coagulation

• Ex. - Systemic hemostatic

  • Vitamin K

  • Aminocaproic acid

  • Tranexamic acid

  • Somatostatin

• Ex. Topical drug form

  • Gelfilm / gelfoam

  • Microfibrillar collagen

  • Thrombin

  • Oxidized cellulose

• Monitor clotting time, urine output (increase or hematuria), signs of anaphylaxis (hematuria-  presence of blood in a person's urine.

• Leave gelfoam until bleeding stops, remove immediately after bleeding is controlled & wash the site to decrease risk for infection

• Check BP prior (defer if >140/90)

Narcotics - relieves pain and induces drowsiness, stupor or insensibility [commonly abused], affects mood or behavior ex. morphine

Opioid - broad group of pain-relieving drugs, interact with opioid receptors in cells by blocking pain signals between brain and body

• non-narc/ non-op

• MOA: inhibit synthesis of prostaglandin

• analgesic, antipyretic, anti-inflammatory, anti-platelet

• Not rec. due to bleeding tendencies, diet modification; rec. for antiplatelet

• CI: children < 12 y.o (Reye’s syndrome)

• DI:

  • +warfarin, heparin, thrombolytics = inc. bleeding

  • ibuprofen + insulin / OHA = hypoglycemia

• SE: gastric irritation, excess bleeding during first 2 days of menstruation

• take with food (gastric irritant)

• with glass of water

• monitor platelet bleeding time PT (how fast clotting)

• discontinue 7 days prior to surgery

• non-narc / non-op

• MOA: weakly inhibits prostaglandin synthesis which decreases pain sensation and heat

• analgesic, antipyretic

• no gastric distress, not anti-inflammatory

• CI: severe hepatic / renal disease, alcoholism, hypersensitivity

• DI:

  • +caffeine = inc. effect

  • +oral contraceptive, anticholinergics = dec. effects

• SE/AE: hepatotoxicity, early symptoms of hepatic damage (N/V, diarrhea, abdominal pain = NVDA)

• If hepatotoxic si pt - Check liver enzymes, self medication should not alabe used or more than 10 days for adults & 5 days for children

• Keep out of children’s reach

• Acetylcysteine (antidote) acetaminophen toxicity *overdose sa biogesic

• No alcohol when pt. is on med

• MOA: binds to opiate receptors in the CNS, reduces stimuli from sensory nerve end, pain threshold is increased

• Uses: moderate to severe pain, suppresses pain in muscles, resp. and coughing (acts on medulla), antitussive property (except meperidine), levo (analgesic) and dextro (prevent dependence) isomers = antitussive response

• CI: with respiratory dysfunction, head injuries, increase ICP (increased intracranial pressure), hepatic & renal disease, alcoholism

• DI: + Alcohol, sedatives, hypnotics & other CNs depressants = inc. CNS depression

• SE: N/V, constipation, moderate dec. of BP, orthostatic hypotension, antitussive effect, CNS - drowsiness, dizziness, confusion, sedation

• TOXICITY = pupil constriction / pinpoint pupil (less than 2-3mm)

Codeine: not as potent as morphine

Morphine sulfate: potent analgesics (can depress respiration) effective against MI, dyspnea - pulmonary edema, pre-op meds

• *if pt has chest pain give morphine (pwede siya sa pt with heart problem pero with precautions)

Meperidine (demorol): shorter duration of action tha morphine, potency varies according to dosage

• AKA Demerol

• alleviate post-op pain, no antitussive property

• Abstinence syndrome : withdrawal symptoms occurring 23-48 hours after last narcotic dose ex. irritability, diaphoresis, restlessness, muscle twitching, tachycardia, hypertension