Pharmacological and Parenteral Therapies Dena Evans MPH BSN

Pharmacological and Parenteral Therapies Dena Evans, MPH, BSN, RN Assistant Professor Department of Nursing The University of North Carolina at Pembroke

Aminoglycosides n What are they? n Give examples n What do they treat specifically? n Toxicity n Labs associated n Routes of administration

Answers n They are bacteriocidal antibiotics n Amikacin; gentamicin; neomycin; streptomycin n Gram negative bacteria like pseudomonas, enterobacter and TB

Toxicity n Dose related n Given based on client’s weight n Can cause ototoxicity and nephrotoxicity n Why: ½ life in renal cortex is 100 hours so----- -

Labs n What labs should we monitor and why?

Normal Creatinine n 0. 6 to 1. 3 mg/d. L

Drug Interactions n Cephalosporins (Keflex; Ceclor) increase the risk of nephrotoxicity n Loop diuretics (Lasix) increase the risk of ototoxicity

Questions n The nurse is reviewing the client’s record and notes that the physician has documented that the client has a renal disorder. On review of the laboratory results, the nurse would most likely expect to see which of the following: a. Decreased hgb b. Elevated creatinine c. Decreased RBCs d. Decreased WBCs

Dosage Calculation Based on Weight n The MD orders Gentamycin 50 mg/kg/day and the recommended dosage is 200 -500 mg/kg/day. Your patient weighs 10 kg. n Question 1: How many mg has the MD ordered? n Question 2: Is the dosage safe: n Question 3: How do you know if it is safe?

Dosage Calculation Tobramycin n The physician order tobramycin 15 mg IV q 6 h for a child with a severe systemic infection who weighs 10 kg. You have on hand 20 mg/2 m. L. Recommended pediatric parameters are 6 -7. 5 mg/kg/day in four divided doses. n Question 1: How many m. L will you give? n Question 2: Is the order safe? n Question 3: How do you know?

Drug Question-Kidney n Following kidney transplantation, cyclosporine is prescribed for a patient. Which lab result would indicate an adverse effect from the use of this medication? a. b. c. d. Decreased creatinine level Decreased hemoglobin level Elevated blood urea nitrogen level Decreased white blood cell count

Drug Question-Kidney n Following kidney transplantation, cyclosporine is prescribed for a patient. Which lab result would indicate an adverse effect from the use of this medication? a. b. c. d. Decreased creatinine level Decreased hemoglobin level Elevated blood urea nitrogen level Decreased white blood cell count Indicates nephrotoxicity

Drug Therapy-Kidney n A client with chronic renal failure is receiving epoetin alfa (Epogen, Procrit). Which lab result would indicate a therapeutic effect of the medication? a. Hematocrit of 32% b. Platelet count of 400, 000 cells/mm 3 c. BUN of 15 mg/d. L d. WBC of 6, 000 cells/mm 3

Drug Therapy-Kidney n A client with chronic renal failure is receiving epoetin alfa (Epogen, Procrit). Which lab result would indicate a therapeutic effect of the medication? a. Hematocrit of 32% b. Platelet count of 400, 000 cells/mm 3 c. BUN of 15 mg/d. L d. WBC of 6, 000 cells/mm 3 This is the intended effect of the drug

Drug Therapy-Steroids n Prednisone is prescribed for a client with diabetes mellitus who is taking daily NPH insulin. Which of the following medication changes would the nurse anticipate during therapy with prednisone: a. An additional daily prednisone dose b. A decreased amount of daily NPH c. An increased amount of daily NPH d. The addition of an oral hypoglycemic agent

Drug Therapy-Steroids n Prednisone is prescribed for a client with diabetes mellitus who is taking daily NPH insulin. Which of the following medication changes would the nurse anticipate during therapy with prednisone: a. An additional daily prednisone dose b. A decreased amount of daily NPH c. An increased amount of daily NPH d. The addition of an oral hypoglycemic agent Steroids can trigger diabetes and worsen in existing cases

TPN Total Parenteral Nutrition

What is it? n Mixture n Specifically designed— individualized n Sugar, carbs, protein, lipids, electrolytes, trace elements n Should be clear—no sediment

Why would someone need it? n Can’t eat n Needs nutritional support n Cancer patient; transplant patient; stabilization of electrolytes in the elderly

How is it administered? Pay attention

Electrolytes--revisited n Sodium n Potassium n Chloride n Phosphate n Calcium n Magnesium

Question n Does having too much or too little of any electrolyte have the potential to cause health problems? n Give me an example

So… n If you have a patient who is already nutritionally challenged and you are giving them a solution of electrolytes via a central line, what signs and symptoms would you observe for?

Possibilities n Could you see an EKG changes? Why? What specifically? n Could you see issues with muscle strength? Why? What specifically? n Could you see an problems with mental status? Why? What specifically?

EKG Changes n Hyperkalemia may cause spiked “T” waves

Muscles n Hypocalcemia n Chvostek’s Sign n Trousseau’s www. sohnurse. com

Mental Status n Hypomagnesemia n Psychotic behavior/sedation/confusion

Side Effects of TPN n Mouth sores; skin changes; *fever, chills, stomach pain, *SOB, rapid wt. loss or gain; muscle weakness or twitching, jumpy reflexes, swelling of hands or feet n What type of patient do you think TPN should be use cautiously with?

Answer n Renal n Cardiac Insufficiency n Diabetics n Remember: Fluid overload (report SOB/ rapid wt. gain/swelling of hands and feet). n Hypokalemia: ESRD and poor nutrition coupled with extra fluid, sodium, potassium. n And TPN has a lot of sugar in it

What labs will you monitor? n Electrolytes n Kidney specific n ? Infection at site of central line? WBCs n Blood sugar due to high amounts of sugar in the mixture

Storage n Should be kept in fridge or freezer n Remove 4 -6 hours before giving (why)? n Do not refreeze

TPN Question n A patient with Chron’s disease is receiving TPN via a subclavian triple lumen catheter. The nurse recognizes that a priority is to: a. b. c. d. Assess the insertion site for signs of infection Complete the administration within 8 hours Discontinue the infusion if the patient experiences hyperglycemia Change the IV tubing and dressing every 72 hrs. Coonan, P. R. (2006). NCLEX for dummies.

Rationale n Infection is a major concern for clients receiving TPN n Usually given continuous drip n Never stop abruptly (hy. POglycemia n Change bag each time and dsg. Per policy

TPN Question n When caring for a patient who is receiving TPN, what should the nurse do to prevent infection in the patient? a. b. c. d. Encourage the patient to take fluids by mouth each day Monitor the serum blood urea nitrogen and blood sugar daily Maintain strict I&O records Use strict aseptic technique when caring for the IV site

TPN Question n A patient is started on TPN. Which of the following lab tests should the nurse monitor several times a day? a. b. c. d. Serum calcium and magnesium Urine specific gravity Blood glucose Serum total protein

Rocephin and Clostridium Difficile

Questions n What is Clostridium Difficile? n Where is it found? n What is Rocephin? n What is it used for?

Answers n Clostridium Difficile is a resident flora of your intestinal tract. n It is not the most abundant flora n Rocephin is a broad-spectrum antibiotic. n What does that mean?

Rocephin and C-Diff n Give broad spectrum antibiotics—potentially wipe out good bacteria that keep flora in check (C-Diff). n This allows C-Diff, usually a minority bacteria, to multiply. n Causes pseudomembranous enter colitis.

What is that? n Condition marked by diarrhea, abdominal pain and foul smelling stool. n AKA: Antibiotic-Associated colitis

Question n How do you diagnose pseudomembranous entercolitis?

Stool Sample-Sterile Container

Question n How do you think you would treat C-Diff?

Treatment n Stop the broad spectrum antibiotics n Give Flagyl or Vancomycin

Long term use of Steroids Side Effects

Questions n What are steroids commonly used to treat? n What hormone do they mimic? n Where does this hormone come from? n What does this hormone do?

Answers n Anti-inflammatory n COPD; Asthma; Infections n Mimic cortisol n Comes from the adrenal cortex n Cortisol helps body cope during times of stress: illness/surgery/infection n Also triggers insulin release

Pathway n Stressor – Pituitary – “Send down some ACTH” – Adrenal cortex = Cortisol

Problem with LT Use of Steroids n They mimic body’s natural production of cortisol n Pituitary can’t tell the difference n Taken LT potential that the body will essentially stop or decrease natural production—bad thing. n Short-term: Usually taper off so the adrenals can adjust and resume work

Side Effects of Steroids n Mimic Cushings disease (Over production of cortisol). n Moon-face and buffalo hump n Increased appetite; diabetes; wt. gain; fat deposits on face and back; Na and H 2 O retention; HTN, slow healing

Question n A patient is receiving methylprednisone (Solu-Medrol) to treat a spinal cord injury at L-1. What action should the nurse take to monitor one of the adverse effects of this medication: a. Monitor LOC every hour b. Conduct a 24 -hour creatinine clearance c. Take blood glucose readings every 4 hours d. Check skin turgor every two hours

Question n A nursing instructor asks a student to describe the pathophysiology of Cushing’s disease. Which statement by the student indicates an accurate understanding of the disorder? a. “Cushing’s disease results from an undersecretion of corticotropic hormones. ” b. “Cushing’s disease results from an oversecretion of insulin. ” c. “Cushing’s disease results from an undersecretion of mineralocorticoids. ” d. “Cushing’s disease results from an increased pituitary secretion of adrenocorticotropic hormone. ”

Question n The nurse is teaching a patient with chronic COPD about the side effects of long-term corticosteroid therapy. The nurse realizes that the patient will need further teaching when he states: a. b. c. d. I may experience some facial swelling I will need to take the drug every day to avoid serious side effects My doctor will be checking my blood sugar regularly I will heal faster if I get injured

Side Effects of Tricyclic Antidepressants

Question n What is a tricyclic antidepressant? n Give examples n How do they work?

Answers n Called tricyclic because of their structural makeup (3 atoms) n Inhibit the reuptake of serotonin, norepinephrine and dopamine n Also increase histamine which is why they have more sedative effects n Elavil, Anafranil, Tofranil n Can be used to treat OCD

Side Effects n Drowsiness, dry mouth, constipation, impaired sexual function, low BP, photophobia, tachycardia n These are old school antidepressants

Keep in Mind n May reduce effectiveness of HTN meds n Don’t use with ETOH or Benadryl (antihistamines) n Using with MAOIs = HTN crisis n Takes several weeks for therapeutic effects n Monitor for suicidal ideations n Long term: Renal and liver function-monitor n Taper off

Question n The home health nurse visits a client who takes Anafranil. The nurse notices that the client has not taken the medication in 2 months. What behavior observed in this client would validate his noncompliance: a. b. c. d. Complaints of insomnia Complaints of hunger and fatigue Pulse rate less than 60 beats per minute Frequent hand washing with hot soapy water

Question n The nurse is teaching a client who is being started on imipramine hydrochloride (Tofranil) about the medication. The nurse informs the client that the maximum desired effects may: a. b. c. d. Start during the first week of administration Not occur for 2 -3 weeks of administration Start during the second week of administration Not occur until after 2 months of administration

Question n The client receiving tricyclic antidepressants arrives at the mental health clinic. Which observation would indicate that the client is following the medication plan correctly: a. b. c. d. Client reports not going to work for this past week Client arrives at the clinic neat and appropriate in appearance Client complains of not being able to do anything anymore Client reports sleeping 12 hours per night and 3 -4 hours during the day

Identifying the need for Additional Pain Medication

Pain (The 5 th vital sign) n Believe the patient n Assess the patient n Use a combination of drug and nondrug therapies n Don’t wait until severe pain strikes n Be aware of side effects n Teach your patient

Assessing your Client n Use a pain scale n Be aware of nonverbal indicators n Reassess after administration n Narcotics: Respiratory rate

Questions n A client with metastatic breast cancer and bone metastasis has continuous, poorly localized pain. The nurse teaches the patient to use pain medications: a. As often as needed to keep pain under control b. On an around the clock basis c. By alternating two different types to avoid addiction d. When the pain cannot be controlled with complementary therapies

Questions n A postoperative patient is receiving IV morphine via a PCA pump for severe incisional pain. Nursing assessment will include what parameters. Select all that apply: a. b. c. d. e. f. Respiratory rate and depth Level of sedation Pain level and quality Frequency of bowel movements Urine output Serum glucose level

Pharmacological Interactions Lasix TB Meds and Dilantin

Lasix (Not all inclusive) n Lasix and aminoglycosides (ototoxicity) n Lasix and salicylates (rheumatoid patients) drugs compete with excretory sites in kidney = salicylate toxicity n Lasix and Lithium can lead to Lithium toxicity n Carafate and Lasix may reduce antihypertensive effect of Lasix

TB Medications and Dilantin (Phenytoin) n Clients receiving TB medications and dilantin may be at risk for Dilantin toxicity because the TB medication (Isoniazid) increases serum Dilantin levels. n Theophylline also increases the risk of Dilantin toxicity

Signs and Symptoms of Dilantin Toxicity n Rapid eye movements n Difficulty speaking or slurred speech n Lethargy n Problems with coordination or balance n Dizziness n Drowsiness n Unusual body movements or shakiness n And seizures!

Pudendal Blocks

Perforating the sacrospinous ligament and injecting 1% Lidocaine. www. brooksidepress. com

Why are they used? n Less painful delivery n Painless episiotomy repair n Lasts for 30 minutes n Has no impact on contractions n Usually given at 2 nd stage of labor

Risks n Infection n Hematoma n Anesthetic toxicity

Medication Dosage Adjustments Based on Age

Questions n Can everyone take the same dosage of medication? n Should adjustments be based entirely on age? n What are the formulas used for determining dosages for children?

Answers n No n Actually the least accurate n Weight is actually better mg/kg n However---

Clark’s Rule n An old rule for an approximate child's dose, obtained by dividing the child's weight in pounds by 150 and multiplying the result by the adult dose. n example a child weighs 14 lbs. the adult dose is 100 mg. Using clarks rule 14/150 =. 09 x adult dose =. 09 x 100 =9. 3 mg www. wikianswers. com

Young’s Rule n It is a way of calculating pediatric doses for children over the age of 2 based on the adult dose. Take the age of the child in years and divide that by their age plus 12. Multiply this number times the adult dose. Pediatric dose = [age/(age + 12)] x adult dose

Body Surface Area—The Best n Order: Gantrisn 2 g/m 2 daily in 4 divided doses. The client weighs 110 lbs and is 60 inches tall. How many mg will the client receive per dose? n Need Nomogram n 1. 5 m 2 x 2 g = 3 g/day or 3000 mg/day divided by 4 is 750 mg per dose.

Cardiac Glycosides Client Education to Reduce Risk

What are they? n Used to tx. CHF and arrhythmias n Inhibit the Na/K ATPase which balances cell membrane potential (ionic concentration) n Improves contraction n Increases cardiac output n Reduces heart distention

Example n Digoxin (Lanoxin)

n Inhibit the Na/K ATPase which balances cell membrane potential (ionic concentration) n Moves sodium out of the cell and pulls potassium in n Digoxin competes with K for binding sites on Na/K ATPase. If a client has low K this frees up more binding sites for Digoxin and can cause Digoxin toxicity

Biggest Threat n Overdose/Toxicity n Digoxin—classic sign-yellow/green halos around objects n Apathy, blurred vision, slow, irregular heart beat, weakness, confusion.

Question n A patient with a history of atrial fibrillation is currently receiving digoxin (Lanoxin) 0. 25 mg po daily. Before administering the medication, the nurse will assess the patient carefully for which condition that may precipitate digoxin toxicity: a. b. c. d. Hypokalemia Hypocalcemia Hyperthyroidism Hypotension

References n Coonan, P. R. (2006). NCLEX-RN for dummies. New Jersey: Wiley Publishing Inc. n Kee, J. L. , & Marshall, S. M. (2004). Clinical calculations with applications to general and specialty areas (5 th ed. ). St. Louis, MO: Elsevier. n Silvestri, L. A. (2008). Comprehensive review for the NCLEX-RN examination (4 th ed. ). St. Louis, MO: Elsevier.