Pharmacological and Parenteral Therapies

Dena Evans, MPH, BSN, RNAssistant Professor

Department of NursingThe University of North Carolina at Pembroke

Aminoglycosides

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

Answers

They are bacteriocidal antibiotics Amikacin; gentamicin; neomycin;

streptomycin Gram negative bacteria like pseudomonas,

enterobacter and TB

Toxicity

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

so------

Labs

What labs should we monitor and why?

Normal Creatinine

0.6 to 1.3 mg/dL

Drug Interactions

Cephalosporins (Keflex; Ceclor) increase the risk of nephrotoxicity

Loop diuretics (Lasix) increase the risk of ototoxicity

Questions

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

The MD orders Gentamycin 50mg/kg/day and the recommended dosage is 200-500 mg/kg/day. Your patient weighs 10 kg.

Question 1: How many mg has the MD ordered?

Question 2: Is the dosage safe: Question 3: How do you know if it is safe?

Dosage Calculation Tobramycin

The physician order tobramycin 15mg IV q 6h for a child with a severe systemic infection who weighs 10kg. You have on hand 20mg/2mL. Recommended pediatric parameters are 6-7.5 mg/kg/day in four divided doses.

Question 1: How many mL will you give? Question 2: Is the order safe? Question 3: How do you know?

Drug Question-Kidney

Following kidney transplantation, cyclosporine is prescribed for a patient. Which lab result would indicate an adverse effect from the use of this medication?

a. Decreased creatinine level

b. Decreased hemoglobin level

c. Elevated blood urea nitrogen level

d. Decreased white blood cell count

Drug Question-Kidney

Following kidney transplantation, cyclosporine is prescribed for a patient. Which lab result would indicate an adverse effect from the use of this medication?

a. Decreased creatinine level

b. Decreased hemoglobin level

c. Elevated blood urea nitrogen level

d. Decreased white blood cell count

Indicates nephrotoxicity

Drug Therapy-Kidney

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/mm3

c. BUN of 15mg/dL

d. WBC of 6,000 cells/mm3

Drug Therapy-Kidney

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/mm3

c. BUN of 15mg/dL

d. WBC of 6,000 cells/mm3

This is the intended effect of the drug

Drug Therapy-Steroids

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

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 NPHc. An increased amount of daily NPHd. The addition of an oral hypoglycemic

agent

Steroids can trigger diabetes and worsen in existing cases

TPN

Total Parenteral Nutrition

What is it?

Mixture Specifically designed—

individualized Sugar, carbs, protein,

lipids, electrolytes, trace elements

Should be clear—no sediment

Why would someone need it?

Can’t eat Needs nutritional support Cancer patient; transplant patient;

stabilization of electrolytes in the elderly

How is it administered? Pay attention

Electrolytes--revisited

Sodium Potassium Chloride Phosphate Calcium Magnesium

Question

Does having too much or too little of any electrolyte have the potential to cause health problems?

Give me an example

So…

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

Could you see an EKG changes? Why? What specifically?

Could you see issues with muscle strength? Why? What specifically?

Could you see an problems with mental status? Why? What specifically?

EKG Changes

Hyperkalemia may cause spiked “T” waves

Muscles

Hypocalcemia Chvostek’s Sign Trousseau’s

www.sohnurse.com

Mental Status

Hypomagnesemia Psychotic behavior/sedation/confusion

Side Effects of TPN

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

What type of patient do you think TPN should be use cautiously with?

Answer

Renal Cardiac Insufficiency Diabetics Remember: Fluid overload (report SOB/ rapid

wt. gain/swelling of hands and feet). Hypokalemia: ESRD and poor nutrition

coupled with extra fluid, sodium, potassium. And TPN has a lot of sugar in it

What labs will you monitor?

Electrolytes Kidney specific ?Infection at site of central line? WBCs Blood sugar due to high amounts of sugar in

the mixture

Storage

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

TPN Question

A patient with Chron’s disease is receiving TPN via a subclavian triple lumen catheter. The nurse recognizes that a priority is to:

a. Assess the insertion site for signs of infection

b. Complete the administration within 8 hours

c. Discontinue the infusion if the patient experiences hyperglycemia

d. Change the IV tubing and dressing every 72 hrs.

Coonan, P.R. (2006). NCLEX for dummies.

TPN Question

A patient with Chron’s disease is receiving TPN via a subclavian triple lumen catheter. The nurse recognizes that a priority is to:

a. Assess the insertion site for signs of infection

b. Complete the administration within 8 hours

c. Discontinue the infusion if the patient experiences hyperglycemia

d. Change the IV tubing and dressing every 72 hrs.

Coonan, P.R. (2006). NCLEX for dummies.

Rationale

Infection is a major concern for clients receiving TPN

Usually given continuous drip Never stop abruptly (hyPOglycemia Change bag each time and dsg. Per policy

TPN Question

When caring for a patient who is receiving TPN, what should the nurse do to prevent infection in the patient?

a. Encourage the patient to take fluids by mouth each day

b. Monitor the serum blood urea nitrogen and

blood sugar daily

c. Maintain strict I&O records

d. Use strict aseptic technique when caring for

the IV site

TPN Question

When caring for a patient who is receiving TPN, what should the nurse do to prevent infection in the patient?

a. Encourage the patient to take fluids by mouth each day

b. Monitor the serum blood urea nitrogen and

blood sugar daily

c. Maintain strict I&O records

d. Use strict aseptic technique when caring for

the IV site

TPN Question

A patient is started on TPN. Which of the following lab tests should the nurse monitor several times a day?

a. Serum calcium and magnesium

b. Urine specific gravity

c. Blood glucose

d. Serum total protein

TPN Question

A patient is started on TPN. Which of the following lab tests should the nurse monitor several times a day?

a. Serum calcium and magnesium

b. Urine specific gravity

c. Blood glucose

d. Serum total protein

Rocephin and Clostridium Difficile

Questions

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

Answers

Clostridium Difficile is a resident flora of your intestinal tract.

It is not the most abundant flora Rocephin is a broad-spectrum antibiotic. What does that mean?

Rocephin and C-Diff

Give broad spectrum antibiotics—potentially wipe out good bacteria that keep flora in check (C-Diff).

This allows C-Diff, usually a minority bacteria, to multiply.

Causes pseudomembranous enter colitis.

What is that?

Condition marked by diarrhea, abdominal pain and foul smelling stool.

AKA: Antibiotic-Associated colitis

Question

How do you diagnose pseudomembranous entercolitis?

Stool Sample-Sterile Container

Question

How do you think you would treat C-Diff?

Treatment

Stop the broad spectrum antibiotics Give Flagyl or Vancomycin

Long term use of Steroids

Side Effects

Questions

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

Answers

Anti-inflammatory COPD; Asthma; Infections Mimic cortisol Comes from the adrenal cortex Cortisol helps body cope during times of

stress: illness/surgery/infection Also triggers insulin release

Pathway

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

Problem with LT Use of Steroids

They mimic body’s natural production of cortisol

Pituitary can’t tell the difference Taken LT potential that the body will

essentially stop or decrease natural production—bad thing.

Short-term: Usually taper off so the adrenals can adjust and resume work

Side Effects of Steroids

Mimic Cushings disease (Over production of cortisol).

Moon-face and buffalo hump Increased appetite; diabetes; wt. gain; fat

deposits on face and back; Na and H2O retention; HTN, slow healing

Question

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

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

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

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

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. I may experience some facial swellingb. I will need to take the drug every day to

avoid serious side effectsc. My doctor will be checking my blood

sugar regularlyd. I will heal faster if I get injured

Question

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. I may experience some facial swellingb. I will need to take the drug every day to

avoid serious side effectsc. My doctor will be checking my blood

sugar regularlyd. I will heal faster if I get injured

Side Effects of Tricyclic Antidepressants

Question

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

Answers

Called tricyclic because of their structural makeup (3 atoms)

Inhibit the reuptake of serotonin, norepinephrine and dopamine

Also increase histamine which is why they have more sedative effects

Elavil, Anafranil, Tofranil Can be used to treat OCD

Side Effects

Drowsiness, dry mouth, constipation, impaired sexual function, low BP, photophobia, tachycardia

These are old school antidepressants

Keep in Mind

May reduce effectiveness of HTN meds Don’t use with ETOH or Benadryl

(antihistamines) Using with MAOIs = HTN crisis Takes several weeks for therapeutic effects Monitor for suicidal ideations Long term: Renal and liver function-monitor Taper off

Question

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. Complaints of insomnia

b. Complaints of hunger and fatigue

c. Pulse rate less than 60 beats per minute

d. Frequent hand washing with hot soapy water

Question

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. Complaints of insomnia

b. Complaints of hunger and fatigue

c. Pulse rate less than 60 beats per minute

d. Frequent hand washing with hot soapy water

Question

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. Start during the first week of administration

b. Not occur for 2-3 weeks of administration

c. Start during the second week of administration

d. Not occur until after 2 months of administration

Question

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. Start during the first week of administration

b. Not occur for 2-3 weeks of administration

c. Start during the second week of administration

d. Not occur until after 2 months of administration

Question

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. Client reports not going to work for this past week

b. Client arrives at the clinic neat and appropriate in appearance

c. Client complains of not being able to do anything anymore

d. Client reports sleeping 12 hours per night and 3-4 hours during the day

Question

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. Client reports not going to work for this past week

b. Client arrives at the clinic neat and appropriate in appearance

c. Client complains of not being able to do anything anymore

d. Client reports sleeping 12 hours per night and 3-4 hours during the day

Identifying the need for Additional Pain Medication

Pain (The 5th vital sign)

Believe the patient Assess the patient Use a combination of drug and nondrug

therapies Don’t wait until severe pain strikes Be aware of side effects Teach your patient

Assessing your Client

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

Questions

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

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

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. Respiratory rate and depthb. Level of sedationc. Pain level and qualityd. Frequency of bowel movementse. Urine outputf. Serum glucose level

Questions

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. Respiratory rate and depthb. Level of sedationc. Pain level and qualityd. Frequency of bowel movementse. Urine outputf. Serum glucose level

Pharmacological Interactions

Lasix

TB Meds and Dilantin

Lasix (Not all inclusive)

Lasix and aminoglycosides (ototoxicity) Lasix and salicylates (rheumatoid patients)

drugs compete with excretory sites in kidney = salicylate toxicity

Lasix and Lithium can lead to Lithium toxicity Carafate and Lasix may reduce

antihypertensive effect of Lasix

TB Medications and Dilantin (Phenytoin) Clients receiving TB medications and dilantin

may be at risk for Dilantin toxicity because the TB medication (Isoniazid) increases serum Dilantin levels.

Theophylline also increases the risk of Dilantin toxicity

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

Pudendal Blocks

Perforating the sacrospinous ligament and injecting 1% Lidocaine.

www.brooksidepress.com

Why are they used?

Less painful delivery Painless episiotomy repair Lasts for 30 minutes Has no impact on contractions Usually given at 2nd stage of labor

Risks

Infection Hematoma Anesthetic toxicity

Medication Dosage Adjustments Based on Age

Questions

Can everyone take the same dosage of medication?

Should adjustments be based entirely on age?

What are the formulas used for determining dosages for children?

Answers

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

Clark’s Rule

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.

example a child weighs 14 lbs. the adult dose is 100 mg. Using clarks rule 14/150 = .09 x adult dose = .09x100 =9.3 mg

www.wikianswers.com

Young’s Rule

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

Order: Gantrisn 2g/m2 daily in 4 divided doses. The client weighs 110 lbs and is 60 inches tall. How many mg will the client receive per dose?

Need Nomogram 1.5m2 x 2g = 3g/day or 3000 mg/day divided

by 4 is 750 mg per dose.

Cardiac Glycosides

Client Education to Reduce Risk

What are they?

Used to tx. CHF and arrhythmias Inhibit the Na/K ATPase which balances cell

membrane potential (ionic concentration) Improves contraction Increases cardiac output Reduces heart distention

Example

Digoxin (Lanoxin)

Inhibit the Na/K ATPase which balances cell membrane potential (ionic concentration)

Moves sodium out of the cell and pulls potassium in

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

Overdose/Toxicity Digoxin—classic sign-yellow/green halos

around objects Apathy, blurred vision, slow, irregular heart

beat, weakness, confusion.

Question

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. Hypokalemia

b. Hypocalcemia

c. Hyperthyroidism

d. Hypotension

Question

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. Hypokalemia

b. Hypocalcemia

c. Hyperthyroidism

d. Hypotension

References

Coonan, P.R. (2006). NCLEX-RN for dummies. New Jersey: Wiley Publishing

Inc. Kee, J.L., & Marshall, S.M. (2004). Clinical

calculations with applications to general and specialty areas (5th ed.). St. Louis, MO: Elsevier.

Silvestri, L.A. (2008). Comprehensive review for the NCLEX-RN examination (4th

ed.). St. Louis, MO: Elsevier.