D. Managing musculoskeletal conditions 1. Neuromuscular blocking agents 1. type: non-depolarizing a.

action: competes with Ach at cholinergic receptor sites to block nerve impulse transmission; histamine releasing properties b. example i. tubocurarine chloride ii. atracurium (Tracrium loading dose 0.3-0.5 mg/kg IV followed by continuous infusion 0.25-0.35 mg/kg IV) c. uses i. adjunct to mechanical ventilation ii. reduce intensity of muscle contractions in tetany, botulism, and electroconvulsive therapy d. adverse effects i. malignant hyperthermia, cardiopulmonary arrest, hyperkalemia ii. histamine release: bronchospasm, hypotension, excessive secretions e. contraindications i. acidosis, renal dysfunction ii. when histamine release is a hazard iii. hyperthermia, electrolyte imbalances f. nursing care i. do not use discolored solutions, do not mix with alkaline solutions ii. establish baseline data and monitor serum electrolytes, RFT iii. continuously monitor vital signs, EKG, SaO2 during therapy iv. muscle function is usually restored within 90 minutes after therapy v. client teaching: promptly report any muscle weakness (retained in the body long after the effects have worn off) 2. type: depolarizing a. action: competes with Ach for Ach-receptor sites resulting in muscle cell depolarization, initial contraction, and flaccid paralysis b. example: succinylcholine (Anectine 2.5 mg/min IV infusion) c. uses i. muscle relaxation during surgery ii. adjunct to mechanical ventilation iii. facilitate intubation, electroconvulsive therapy iv. postoperative shivering when meperidine chloride is contraindicated and myocardial oxygen consumption must be minimized 2. Skeletal muscle relaxing agents

a. type: cyclobenzaprine
i. centrally acting

action: acts on CNS at the brain stem to relieve muscle spasm without loss of function; similar in structure to tricyclic antidepressant examples
o

cyclobenzaprine (Flexeril 10-20 mg by mouth three times daily) carisoprodol (Soma 350 mg by mouth three times daily)

uses
o o o

short-term therapy painful musculoskeletal conditions, tetanus spasticity associated with nerve compression or irritation, and degenerative neuromuscular disease such as multiple sclerosis

adverse effects
o

tongue and facial edema, hypotension, tachycardia nausea, dry mouth, constipation, urgency drowsiness, confusion, headache shares toxicity potential of tricyclic antidepressants (See also III.D.2. antidepressants

o o o

contraindications
o o o o

hyperthyroidism hepatic or renal dysfunction spasticity due to rheumatic conditions acute MI, dysrhythmias, heart block, heart failure

nursing care
o

assist HCT to establish baseline data and check before beginning therapy and periodically thereafter establish baseline data and monitor

airway, heart rate, EKG level of consciousness, LFTs and RFTs muscle strength, pain level, bowel pattern

o o o

provide frequent oral care withhold drug for rash, pruritus carefully administer opioid analgesia with concurrent use of muscle relaxants collaborate with physical therapy and provider for adjunct therapy to decrease need for muscle relaxant assist HCT to implement client teaching plan client teaching

change positions slowly, ask for help before getting up avoid dangerous activity, avoid alcohol and other CNS depressants establish regular bowel habits including fluids, fiber, and physical activity

ii.

direct acting action: interferes with calcium release in muscle fiber to prevent muscle contraction examples
o

dantrolene (Dantrium) (See also II.C.D.3.iv. perioperative emergency drugs: type dantrolene) botulinum toxin type A and B

uses
o

long-term use for spasticity associated with cerebral palsy and spastic complications of neuromuscular disease prevention of malignant hyperthermia (dantrolene) relaxation of facial muscles to reduce wrinkles

adverse effects
o o o o

hepatocellular damage and hepatitis warming syndrome sedation, dizziness, fainting GI upset including diarrhea, CNS depression

 contraindications: hepatic dysfunction, concurrent administration with estrogen nursing care

o

assist HCT to establish baseline data and check prior to beginning therapy and at regular intervals during therapy establish baseline data and monitor

vital signs especially respirations and temperature LFTs, bowel patterns, and muscle strength and spasticity

o o

prevent constipation provide client safety (See also I.F.7. Client protection) prevent extravasation when administered IV discontinue drug for 2-4 days periodically to prevent tolerance warming syndrome

o o

associated with hepatocellular damage indicated by anorexia, nausea, and fatigue; more common in females

assist HCT to implement client teaching plan client teaching

avoid dangerous activity ask for help before getting up avoid alcohol and other CNS depressants take only as directed, need for follow-up care report fever, rash, dark urine or stool, jaundice

establish regular bowel habits including fluids, fiber, and physical activity b. type: benzodiazepine (See also IV.D.3. anxiolytics and hypnotics)

ii. iii.

example: diazepam (Valium) very effective muscle relaxant (in addition to effective antianxiety agent and anticonvulsant)

3. Type: nonsteroidal anti-inflammatory drugs (NSAIDs) a. sub-type: cyclooxygenase inhibitor (COX-1 inhibitor)
i. information common to NSAIDs action o inhibits synthesis of prostaglandins o analgesic, antipyretic, anti-inflammatory agent uses o mild to moderate pain of musculoskeletal disorders including osteoarthritis and rheumatoid arthritis o pleuritis, pericarditis o primary dysmenorrhea, uterine relaxation adverse effects o bleeding, bone marrow depression, fluid retention, hypertension, decreased renal blood flow (especially in older clients) o irritation and erosion of GI tract resulting in bleeding, nausea o headache, fatigue, rash, oral lesions, anaphylaxis contraindications o hypertension, renal dysfunction o bleeding disorders, recent trauma or surgery nursing care o establish baseline data and monitor blood pressure, appearance of stool, CBC, renal function o client teaching take only as directed drink 6-8 glasses of water daily report use of NSAIDs to all providers avoid OTC drugs, monitor for bleeding do not crush or chew sustained release forms report headache, weight gain, fever, rash, or swelling sub-type: salicylate examples o aspirin (See also: II.A.6.a antiplatelet agents) (Ecotrin 2.6-5.2 grams/day by mouth in divided doses) o choline salicylate (Arthropan 870-1740 mg by mouth daily in 4-6 doses) iii. sub-type: propionic acid examples o ibuprofen (Motrin 400-800 mg by mouth 3-4 times daily, not to exceed 3600 mg in 24 hours) o naproxen (Naprosyn 250-500 mg by mouth twice daily, up to 1.5 grams in 24 hours) sub-type: acetic acid examples o diclofenac (Voltaren) o ketorolac (Toradol) adverse effects: tinnitus, hyperglycemia, elevated liver enzymes contraindications: hypersensitivity to aspirin nursing care: establish baseline data and monitor LFTS, PT and INR, blood sugar, potassium

ii.

iv.

client teaching: remain upright for 30 minutes after taking v. sub-type: fenamate example: piroxicam (Feldene 10-20 mg by mouth in 2 doses daily) adverse effects o tinnitus, angioedema, syncope o acute renal failure, bronchospasm o higher side effect profile than most NSAIDs nursing care o monitor for drug induced anemia o client teaching: if dose is missed by more than 6 hours, skip that dose; take at same time every day c. sub-type: COX-2 inhibitor
o

action: selectively inhibits COX-2; inhibits synthesis of prostaglandins; analgesic, antipyretic, antiinflammatory example: celecoxib (!high alert drug) (Celebrex 100-200 mg by mouth in 1-2 doses) o rofecoxib (Vioxx): withdrawn from U.S. market adverse effects o dizziness, insomnia, pharyngitis, rash o decreased risk of GI bleeding with higher risk of death due to GI bleeding contraindications o hypersensitivity to aspirin, asthma o renal dysfunction o concurrent use of diuretics or ACE inhibitors nursing care o establish baseline data and monitor pain, CBC, LFTs, and RFTs, GI upset and bleeding 1. closely monitor lithium levels 2. closely monitor PT/INR with concurrent use of warfarin o administer 2 hours before or after substances containing magnesium o client teaching 1. promptly report weight gain, rash, nausea, fatigue, itching, jaundice flulike findings

4. Related anti-inflammatory therapies a. type: heavy metal (gold) i. action: modulates immune response and inhibits inflammation; may suppress phagocytosis and prostaglandin synthesis ii. examples aurothioglucose (Solganal 10 mg/week IM, titrated over 4 weeks to maintenance dose every 3-4 weeks up to 1 gram total) gold sodium thiomalate (Myochrysine 10-25 mg/week IM, titrated over 4 weeks to maintenance dose every 3-4 weeks up to 1 gram total) iii. uses: treatment of pain and inflammation of rheumatoid arthritis (RA); slow deterioration of joint in RA; most effective in early course of disease iv. adverse effects

v.

vi.

bone marrow depression, nephrotic syndrome; gold bronchitis and pneumonitis colitis, diarrhea, dermatitis hypersensitivity: flushing, fainting, dizziness therapeutic effect may take 2 months to appear inflammation and irritation of upper respiratory and GI tracts nitritoid reaction: giddiness, vertigo, flushing, fainting contraindications HTN, blood diseases, recent radiation severe DM, debilitation, renal and hepatic dysfunction concurrent therapy with lithium or immunosuppressive agents nursing care establish baseline data and monitor pain, breath sounds, respiratory rate, skin, UA, CBC, platelets toxicity: leukopenia, rapid drop in Hgb, thrombocytopenia, gently rotate shake vial to uniformly mix suspension administration o may give deep IM injection o do not use injectable if darker than pale yellow o client to remain seated or in bed for 30 minutes following injection transient pruritus, dermatitis antidote: dimercaprol (British anti-lewisite, BAL in oil 3-4 mg/kg IV every 4 hours for 2-7 days) client teaching o protect skin from sun with sunscreen or clothing o report rapid improvement in joint edema, pruritus, easy bruising

b. type: tumor necrosis factor (TNF) (genetically engineered)

antagonist i. action: acts as receptor for TNF to prevent related damage ii. example: etanercept (Enbrel 25 mg subcutaneous injection 2 times weekly) iii. uses: early stages of RA iv. adverse effects severe myelosuppression, development of CNS diseases including multiple sclerosis, cancer, serious infections, heart failure, MI upper respiratory disorders erythema, itching, pain, edema v. contraindications: immunosuppressed clients, in presence of severe infection, malignancy, recent vaccinations vi. nursing care establish baseline data and monitor o pain, joint range of motion, edema o CBC, Mantoux test o weight, edema, neuro status, temperature, blood pressure, dyspnea administration: rotate sites, reconstitute slowly and gently rotate vial for clear solution client teaching o treatment must continue uninterrupted to achieve therapeutic effect

o o

avoid aspirin, alcohol, driving subcutaneous injection technique rotate injection site by at least 1 inch for each injection

c. type: chelating agent

action: combines with cystine hydrochlorideto prevent stone formation and inhibit collagen formation; related to penicillin without antimicrobial properties ii. example: penicillamine (Depen 250-1500 mg by mouth daily) iii. use: in RA when other therapies have failed iv. adverse effects pruritus, rash, impaired sense of taste therapeutic effect may take 3 months to appear anorexia, nausea, vomiting, diarrhea, oral lesions hemolytic anemia, proteinuria, bone marrow depression v. contraindications hypersensitivity to penicillin concurrent use with antimalarial, gold salt, or immunosuppressants renal insufficiency, history of bone marrow suppression or hemolytic anemia vi. nursing care establish baseline data and monitor LFTs, skin, temperature, UA for protein, CBC every 3 days for first month of therapy may administer in 15-30 ml of fruit juice withhold therapy for thrombocytopenia < 3500/mm3 neutropenia administer on empty stomach 1 hour before or 2 hours after meals client teaching o skin care o take temperature at bedtime o report bleeding, rash, sore throat, fever o take as directed, do not interrupt therapy Anti-gout agents b. type: uricosuric agent i. action: inhibits tubular reabsorption of uric acid, increases its excretion, and lowers serum uric acid level ii. example: probenecid (Benemid 250-1500 mg by mouth twice daily, do not exceed 3 grams total daily dose) iii. use: hyperuricemia associated with gouty arthritis iv. adverse effects hemolytic anemia, bone marrow depression, respiratory depression dermatitis, pruritus, uric acid nephrolithiasis increased frequency of gouty attacks during first 612 months of therapy v. contraindications hypoglycemia hyperuricemia secondary to cancer within 2-3 weeks of a gouty arthritis attack blood disease, history of uric acid nephrolithiasis renal dysfunction especially with concurrent use of penicillinv vi. nursing care

i.

establish baseline data and monitor pain, uric acid levels, urinary pH administer lowest effective dose collaborate with provider for purine-restricted diet may require concurrent administration of colchicine or acetazolamide administer with 8 oz. of water; may give after meals, with food, or with antacids to decrease GI upset client teaching o do not interrupt therapy o avoid alcohol, caffeinated beverages, and OTC drugs especially aspirin o drink 3000 ml of fluids each day to keep urine dilute, especially during the night c. type: antigout agent i. action: inhibits formation of lactic acid in leukocytes resulting in decreased phagocytosis and joint inflammation ii. example: colchicine (1-1.2 mg by mouth every 2 hours during acute attack, reduce by for maintenance therapy) iii. uses: prevention and treatment of gouty arthritis; slow progression of multiple sclerosis iv. adverse effects myelosuppression dermatitis, pruritus poor absorption of B12 oliguria, renal dysfunction metallic taste, GI complaints v. contraindications: serious co-morbidities, peripheral neuritis vi. nursing care establish baseline date and monitor pain, urine output and renal function, CBC collaborate with dietician and provide for purinerestricted diet administration o may give with food o IV: do not give in dextrose, infuse over 2-5 minutes o allow at least one week between full courses of therapy client teaching o report pain, rash, erythema, sore throat, bleeding or bruising o avoid alcohol and OTC drugs d. type: antihyperuricemic agent, xanthine oxidase inhibitor i. action: reduces endogenous uric acid inhibiting xanthine oxidase (converts hypoxanthine to uric acid in purine metabolism) ii. example: allopurinol (Zyloprim 100-200 mg by mouth 2-3 times daily) iii. uses control primary hyperuricemia prevent chronic calcium oxalate stones reduce severity of hyperuricemia associated with cancer iv. adverse effects GI upset bone marrow depression cataracts, hepatotoxicity v. contraindications

vi.

initial treatment for gout idiopathic hemochromatosis children except when hyperuricemia is associated with cancer or chemotherapy nursing care establish baseline data and monitor pain, serum uric acid, size of tophi, CBC, LFTs and RFTs do not exceed administering concentration > 6 mg/ml of dilutant; administer over 30-60 minutes

client teaching o promptly report rash, fever o protect eyes from UV rays o need for follow-up care and testing o drink 3000 ml of fluid daily, avoid alcohol and caffeinated beverages o life threatening reaction may occur 2-4 weeks after initiation of therapy: malaise, fever, aching, rash, deteriorating renal function e. type: antihyperuricemic agent, enzyme

action: facilitates conversion of uric acid to allantoin example: rasburicase (Elitek 0.15-2 mg/kg IV daily for 3 days) uses: initial treatment for hyperuricemia in children with leukemia and lymphoma to reduce uric acid levels adverse effects o anaphylaxis, fever o rash, hemolysis, methoglobinemia o headache, abdominal pain, constipation and diarrhea contraindications o G6-PD deficiency o hemolysis or anoxia nursing care o establish baseline data and monitor for pain, hemolysis, anoxia, uric acid levels o ice-down blood specimens for serum uric acid level before sending to lab o administration: gently rotate vial, do not shake or swirl, should be colorless, dilute in 0.9% NaCl

6. Bone resorption inhibitors a. type: calcitonin i. action: opposes action of parathyroid hormone to decrease
serum calcium and increase bone density with calcium deposition

ii.

iii.
iv.

v.
vi.

example human calcitonin (Cibacalcin) salmon calcitonin (Miacalcin) uses: hypercalcemia, Paget's disease, post-menopausal osteoporosis adverse effects inflammation at injection site skin rash, flushing of face and hands nausea and vomiting urinary frequency contraindications: renal dysfunction, pernicious anemia nursing care establish baseline data and monitor o bone density, RFTs, serum electrolytes, UA, drug level o GI upset, polyuria, flushing, headache o hypocalcemia: paresthesias, twitching, seizures keep calcium gluconate immediately available

administer as nasal spray or subcutaneous injection client teaching o subcutaneous injection technique o include weight bearing exercise in daily routine o include calcium and vitamin D rich foods in diet

b. type: bisphosphonates i. action: inhibit bone resorption and do not inhibit bone formation and mineralization ii. examples alendronate (Fosamax 10 mg by mouth daily or 70 mg by mouth weekly) risedronate (Actonel 5 mg by mouth daily or 35 mg by mouth weekly 30 minutes before breakfast) zoledronic acid (Zometa 4 mg IV every 3-4 weeks for up to 15 months) iii. uses hypercalcemia of malignancies glucocorticoid induced osteoporosis osteolytic lesions of multiple myeloma post-menopausal osteoporosis, Pagets disease iv. adverse effects tetany bone pain, abdominal pain, anorexia, nausea esophagitis and erosion, gastroesophageal reflux v. contraindications allergy to aspirin renal dysfunction, hypocalcemia inability to sit upright for 30 minutes after administration vi. nursing care establish baseline data and monitor o bone density o RFTs, Ca++, P, Mg++, K+, alkaline phosphatase o paresthesias, twitching, Chvosteks and Trousseaus sign client teaching o maintain daily intake of Ca++ and Vitamin D o therapy most effective when combined with weight bearing exercise o administer with 8 oz. of water on an empty stomach: do not use mineral water allow 30 minutes before eating, or taking calcium or antacids must remain upright for 30 minutes following administration if dose is missed, skip dose; do not double dose

E. Managing integumentary conditions 1. Therapeutic class: scabicide, pediculicide a. type: chlorinated hydrocarbon i. action: stimulates nervous system of arthropods to death ii. examples lindane (Kwell)

 permethrin (Nix, Elimite) uses: topical, scabies and lice adverse effects ventricular fibrillation, myelosuppression, liver dysfunction itching, rash CNS toxicity: nausea, vomiting, seizures v. contraindications: infants, seizure disorders, breaks in the skin vi. nursing care perform full body scan for nits, lice, or scabies do not apply to broken skin, avoid application to eyes cleanse and dry skin before application client teaching o wear rubber gloves to administer o treat sexual contacts simultaneously o itching may continue for 4-6 weeks after treatment o wash clothing in hot water, dry thoroughly o pediatric use, frequency of treatment refer to package insert allow proper time span between applications o remove drug from skin after specified period to prevent toxicity o do not apply to face or mucus membranes gently and thoroughly cleanse area for accidental application, rinse very well 2. Therapeutic class: antipruritics, topical a. type: local anesthetic agents (See also: II.C.4 local anesthetic agents) b. type: glucocorticoids (See also: II.K.1 glucocorticoids) c. type: antihistamines (See also: II.K.2 antihistamines)

iii. iv.

3. Therapeutic class: anti-infectives, topical a. type: antibiotic i. action: interferes with bacterial protein synthesis ii. examples sulfa drugs: silver sulfadiazine (Silvadene apply 1-2 times daily: 1.5 mm thickness) bacitracin (Bacitracin) neomycin (Neomycin Sulfate apply 1-5 times daily) iii. uses: skin infections, minor burns, otitis externa iv. adverse effects: rash, urticaria, fungal overgrowth v. contraindications: large surface areas, ulcerations vi. nursing care establish baseline data and monitor fever, thrush, abnormal vaginal discharge and itching; painful, reddened rash do not apply to broken skin, avoid application to eyes cleanse and dry skin before application application o cover entire surface o cleanse surface before application; remove old ointment before applying new

apply ointment to sterile gauze before applying to surface to prevent contamination of agent

b. antifungal, topical
i. ii. action: interferes with fungal cell permeability examples metronidazole (MetroGel apply thin film twice daily to affected area) ketoconazole (Nizoral apply once or twice daily) selenium (Selsun Blue) amphotericin B cholesteryl sulfate, amphotericin deoxycholate (Fungizone apply 2-4 times daily) uses: fungal infections of scalp, nails, skin; diaper rash adverse effects: local irritation nursing care assess surface before administration for breaks in the skin, infection client teaching o use sunscreen o avoid alcohol o long-term therapy is usually required o wear gloves to prevent spread of fungus o avoid concurrent use of other OTC agents o report worsening of findings or fever, sore throat, rash

iii. iv. v.

c. type: antiviral
action: interferes with viral DNA replication examples acyclovir (Zovirax 400 mg by mouth twice daily, IV 5 mg/kg every 8 hours) penciclovir (Denavir apply 1% cream every 2 hours while awake for 4 days) iii. uses: mucocutaneous herpes simplex virus, herpes genitalis iv. adverse effects: rash, itching, burning, vulvitis v. nursing care establish baseline data and monitor for ototoxicity or nephrotoxicity apply ointment to glove to prevention contamination of drug and spread of infection cover lesions completely with agent; do not get in eyes gently cleanse area before application to remove old agent 5. Therapeutic class: anti-inflammatory agents, topical (See also: II.L Managing eye conditions) a. type: glucocorticoids b. examples 1. fluocinolone (Lidex) 2. hydrocortisone (Dermacort) 3. triamcinolone (Kenalog) c. nursing care establish baseline data and monitor skin ii. client teaching avoid OTC drugs i. i. ii.

cleanse and dry skin before application initiate therapy as soon as findings appear do not apply to broken skin, avoid application to eyes continue to apply agent until directed to stop; interrupted therapy may result in ineffective therapy 6. Type: anesthetic agents, local anesthetics, topical (See also: II.C.4 Local anesthetics) i. ii. examples: lidocaine (Lidocaine viscous, Numby Stuff, Derma Flex) nursing care protect airway when used for esophagitis: impairs gag reflex protect client from injury due to impaired cutaneous sensation

F. Managing gastrointestinal conditions 1. Therapeutic class: antiemetics 1. information common to antiemetics 1. action: depresses vomiting center 2. adverse effects 1. tachycardia, hypotension, sedation 2. dry mouth, dry eyes, blurred vision, constipation, urinary retention 3. uses: motion sickness, nausea, nausea associated with chemotherapy 4. contraindications: narrow angle glaucoma, liver disease, intestinal obstruction, depression 5. nursing care 1. establish baseline data and monitor vital signs, fluid and electrolyte balance, bowel sounds 2. provide oral care for dry mouth 3. verify gag reflex before administration of oral nonpharmacologic measures (tea, carbonated beverages, crackers) 4. client teaching 1. avoid alcohol and other CNS depressants 2. do not engage in dangerous activities; be prepared for sedation 2. type: antihistamines (See also: II.K.2 antihistamines) 1. action: decreases vestibular stimulation by competing with histamine for H1-receptors 2. examples 1. mild agent: dimenhyDRINATE (!high alert drug) [Dramamine 50-100 mg by mouth every 4 hours; do not confuse with diphenhydrAMINE (Benadryl)] iii. iv. uses: antiemetic adverse effects dizziness, drowsiness, constipation decreases effectiveness of anticoagulants

sedation potentiated with CNS depressants and other antihistamines nursing care o establish baseline data and monitor airway, respiratory rate, level of consciousness, relief of itching, nausea, cough o administer IM, IV if vomiting o assist with ambulation client teaching o ask for help before getting up o take 30 minutes before traveling d. type: anticholinergics action: inhibits Ach at receptor sites to decrease secretions and stomach acids, blocks pupillary accommodation example: scopolamine (Transderm-Scop apply transdermal patch 4-5 hours before travel; remove old patch and apply new patch every 3 days) uses: antiemetic, preoperative control of secretions, decrease effects of Parkinsons, surgical amnesia adverse effects o tachycardia, paralytic ileus, tardive dyskinesia, increased risk of toxicity and toxic psychosis in children o classic anticholinergic effects: dry mouth, constipation, blurred vision o decreased sweating, narrow angle glaucoma contraindications: narrow angle glaucoma, myasthenia gravis, allergy to belladonna or barbiturates nursing care o establish baseline data and monitor nausea, vomiting, extrapyramidal findings, urinary retention, bowel pattern, fluid and electrolyte balance o safely position client before subcutaneous or IV administration o client teaching 1. apply patch to hairless area behind the ear; avoid getting drug on hands 2. avoid OTC drugs; ophthalmic forms must be tapered before discontinuing 3. discontinue drug and report blurred vision, severe dizziness, dyspnea, inhibition of sweating d. type: phenothiazines iii. action: depresses cerebral cortex, hypothalamus, and limbic system with strong alpha-adrenergic, cholinergic, antipsychotic, and antiemetic properties iv. example prochlorperazine [do not confuse with chlorproMAZINE (!high alert drug) (Thorazine)] (Compazine 2.5-10 mg by mouth, IM, IV 3-4 times daily) promethazine (antihistamine, antipsychotic agent) (Phenergan 12.5-25 mg by mouth, IM, IV, rectally every 4-6 hours) e. type: serotonin (5-HT3) receptor antagonist

iii. iv. v. vi.

vii.

action: blocks peripheral and central serotonin action example: ondansetron (Zofran 0.15 mg/kg or 32 mg IV 30 minutes before starting chemotherapy infusion) uses: prevention and treatment of nausea, vomiting associated with chemotherapy and postoperative nausea and vomiting adverse effects bronchospasm rash, shivering, fever headache, drowsiness, extrapyramidal findings nursing care establish baseline data and monitor nausea, vomiting, fluid and electrolyte balance, extrapyramidal findings administer IV over 15 minutes client teaching: report diarrhea, constipation, rash, changes in breathing

type: combined cholinergic receptor agonist and dopamine receptor antagonist i. action: enhances GI response to Ach resulting in increased peristalsis, relaxation of pyloric sphincter, and blockage of chemoreceptor zone in brain ii. example: metoclopramide (Reglan 10-20 mg by mouth, IM 4 times daily; IV 1-2 mg/kg every two hours, start 30 minutes before starting chemotherapy infusion) iii. uses: postoperative nausea, nausea associated with chemotherapy, delayed gastric emptying, hiccups iv. adverse effects seizures, supraventricular tachycardia, myelosuppression anticholinergic effects, decreased libido sedation, restlessness, headache, dizziness v. contraindications: hypersensitivity to procaine or procainamide, seizure disorder, pheochromocytoma, prolactin dependent breast cancer, GI obstruction vi. nursing care establish baseline data and monitor nausea, vomiting, extrapyramidal findings, tardive dyskinesia, mental status older clients: adverse effects more common do not confuse with methotrexate or metolazone administration o IV push over 2 minutes up to 10 mg o > 10 mg: dilute in 50 ml and infuse over at least 15 minutes client teaching: report involuntary movements 2. Therapeutic class: antacids f. information common to antacids i. action: neutralize gastric acid (hydrochloric acid) ii. uses: PUD, inflammatory conditions of GI tract, concurrent steroid therapy iii. adverse effects inhibits absorption of other drugs constipation, diarrhea acid rebound, metabolic acidosis electrolyte excess, fluid retention, heart failure iv. contraindications: electrolyte imbalance, gastroparesis, renal dysfunction v. nursing care establish baseline data and monitor serum electrolytes, acid-base balance, bowel pattern

f.

must be given 7 times daily to be effective: before and after meals and at bedtime administer 1 hour before or 2 hours after other drugs; do not give with enteric coated medications client teaching o time antacids around other medication o chew tablets thoroughly, follow with 8 oz. of water g. type: sodium bicarbonate i. example: baking soda (2-5 mEq/kg IV over 4-8 hours depending on CO2, pH) ii. uses: correct metabolic acidosis from blood gases report iii. adverse effects cardiac arrest, respiratory depression, seizures eructations, abdominal distention twitching, hyperreflexia, seizures, paralytic ileus iv. contraindications hypocalcemia, renal disease undocumented acidosis, empirical therapy, HTN, peptic ulcer disease (PUD) v. nursing care establish baseline data and monitor o vital signs, fluid and electrolyte balance, EKG o alkalosis: irritability, confusion, twitching, bradypnea o hypokalemia: broad T wave, tachycardia, ectopic beats, hypoventilation o hyponatremia: HTN, abdominal cramps, lethargy administration o follow oral administration with 8 oz. of water o prevent extravasation o may administer IV bolus after documented metabolic acidosis o do not administer in same IV tubing as other medications without flushing before and after h. type: calcium carbonate i. example calcium carbonate (Tums 0.5-1.5 grams by mouth daily in divided doses) ii. uses: hyperphosphatemia, calcium supplement, osteoporosis, in combination with other antacids iii. adverse effects: constipation iv. contraindications: hypercalcemia, hyperparathyroidism v. nursing care: establish baseline data and monitor serum Ca++ i. type: magnesium salt i. examples magnesium citrate (Citrate of Magnesium) magnesium hydroxide (Milk of Magnesia, MOM 3060 ml by mouth at bedtime) uses: constipation, preop bowel prep, anticonvulsant in eclampsia; in combination with other antacids ii. adverse effects circulatory collapse, flaccid paralysis, hypothermia nausea, vomiting, anorexia, cramps increases effect of neuromuscular blockers iii. contraindications: rectal bleeding, acute abdomen,

iv.

nursing care establish baseline date and monitor for o bowel pattern o magnesium toxicity: thirst, confusion, hyporeflexia o fluid and electrolyte balance, mental status, vital signs

f.

IV administration not to exceed 150 mg/min keep calcium gluconate at the bedside during IV infusion client teaching o take only as directed o discontinue anticoagulants 2 weeks prior to surgery if taken concurrently o report fluid retention, decreased urine output, jaundice, bleeding type: aluminum salt

example: aluminum hydroxide gel (Ampho Gel 600 mg by mouth after meals, chew with milk or water) uses: hyperphosphatemia associated with renal failure, GERD adverse effects o hypophosphatemia: anorexia, weakness, bone pain, hyperreflexia o hypercalciuria o constipation, obstruction nursing care o establish baseline data and monitor fluid and electrolyte balance, deep tendon reflexes (DTRs), bowel pattern o client teaching 1. report black tarry stools 2. include cheese, corn, lentils, pasta, prunes in diet avoid foods containing phosphorus: dairy products, eggs, carbonated beverages

3. Therapeutic class: anti-ulcer agents a. type: proton pump inhibitor i. action: suppress the gastric acid pump by inhibiting
ii. hydrochloric acid (HCl) secretion by gastric parietal cells examples omeprazole (Prilosec 20-40 mg by mouth daily) esomeprazole (Nexium 20-40 mg by mouth daily) lansoprazole (Prevacid 15-30 mg by mouth once or twice daily) pantoprazole (Protonix 40 mg by mouth once or twice daily) uses short-term treatment of PUD, GERD long-term hypersecretory conditions in combination with amoxicillin and clarithromycin for H. pylori (See also: II.K.5.a antibiotics) adverse effects gastric cancer dry mouth, tongue atrophy dizziness, headache, insomnia upper respiratory tract congestion

iii.

iv.

v.

may inhibit medications that require acid medium: digoxin, ampicillin, ketoconazole nursing care establish baseline data and monitor abdominal pain, regurgitation, heartburn, CBC, LFTs and RFTs administer before meals client teaching o do not chew or crush capsules o avoid eating 2 hours before reclining o avoid smoking, spicy food, caffeinated beverages and alcohol for effective therapy

b. type: H2-receptor antagonists i. action: reduction in HCl production (by blocking H2

receptors) and pepsin secretion examples famotidine (Pepcid 20 mg by mouth once or twice daily, 40 mg by mouth daily) ranitidine (Zantac 150 mg by mouth once or twice daily, 300 mg by mouth daily) iii. uses: short-term treatment of PUD, GERD long-term hypersecretory conditions iv. adverse effects thrombocytopenia rash, acne dizziness, headache increased BUN and creatinine v. nursing care establish baseline data and monitor GI bleeding, abdominal pain, platelets administer IV infusion over 30 minutes avoid cimetidine in older clients administer with food, may be given with antacid client teaching o pain relief may take several days; avoid smoking, spicy food, caffeinated beverages and alcohol for effective therapy c. type: pepsin inhibitor i. action: forms a viscous substance with HCl that adheres to the gastric mucosa ii. example: sucralfate (Carafate 1 gram by mouth before meals and at bedtime) iii. uses: gastritis, short term therapy for PUD iv. adverse effects: GI upset v. nursing care establish baseline data and monitor bowel pattern abdominal pain, GI bleeding contains aluminum administer antacids 30 minutes before or after Sucralfate avoid administering quinolones, digoxin, phenytoin, or tetracycline at same time client teaching o establish regular bowel habits including increased fluids, fiber, and exercise o avoid smoking, spicy food, caffeinated beverages and alcohol for effective therapy ii.

4. Therapeutic class: antidiarrheal agents

a. type: fluid absorbent i. example: kaolin and pectin (Kaopectate 2 tabs or 30 ml by mouth every 30 minutes up to 4.2 grams in 24 hours) ii. adverse effect: transient constipation iii. contraindications obstructed bowel, pseudomembranous colitis diarrhea associated with bacterial toxins with fever or > 48 hours of therapy iv. nursing establish baseline data and monitor bowel pattern administer 2-4 hours after other oral medication client teaching: do not exceed dosage recommendation; report diarrhea lasting for > 48 hours b. type: motility suppressant i. action: slows speed of peristalsis ii. examples loperamide hydrochloride (Imodium 2-4 mg/day in divided doses not to exceed 8 mg/24 hours) diphenoxylate hydrochloride with atropine (Lomotil 1-2 tabs every 3-4 hours up to 8 tabs/24 hours) iii. adverse effects increased risk of toxicity and toxic psychosis in children, toxic megacolon urinary retention, paralytic ileus, palpitations restlessness, euphoria, sedation, dizziness, numbness of extremities iv. contraindications dehydration, electrolyte imbalance liver disease, obstructive jaundice, glaucoma antibiotic induced pseudomembranous colitis v. nursing care establish baseline data and monitor bowel pattern, fluid and electrolyte balance monitor for dehydration in children and older clients client teaching o take only as directed o report bloody stool, fever, palpitations o avoid dangerous activity jimson weed and thorn apple c. type: enteric bacteria i. action: restore normal intestinal flora depleted by diarrhea or anti-infective therapy ii. example: lactobacillus acidophilus (Bacid, active yogurt cultures) iii. nursing care effective initial therapy for children d. type: opioid derivatives (See also: III.A.2 opioids) e. type: bismuth subsalicylate i. action: coats intestinal mucosa and soothes irritants ii. example: bismuth subsalicylate (Pepto-Bismol 524 mg by mouth every 30 minutes up to 4.2 grams/24 hours)

5. Therapeutic class: laxatives

a. information common to laxatives i. uses: prevention and short-term treatment of constipation when staining is undesirable or contraindicated; preoperative bowel evacuation ii. adverse effects dependence diarrhea, cramping, nausea

 dehydration, electrolyte imbalance nursing care establish baseline data and monitor bowel pattern, fluid and electrolyte balance most effective when taken with fluid client teaching o avoid combining different laxatives simultaneously o establish regular bowel habits including fiber, fluids, ambulation, regular pattern of defecation b. type: lubricant i. action: coats stool and colon to facilitate bowel movement without stimulating the GI tract ii. example: mineral oil iii. uses: postop hemorrhoidectomy, postpartum; cardiac disease; fecal impaction c. type: stool softener i. action: stool becomes softer by detergent or osmotic action without stimulation of GI tract ii. examples docusate sodium (Colace 50-300 by mouth daily) glycerin suppository per rectum iii. uses: short-term use in postoperative and postpartum periods iv. adverse effects: low side effect profile; diarrhea with excessive use v. contraindications: bowel obstruction, fecal impaction; concurrent administration with mineral oil vi. nursing care monitor bowel pattern similar to expectorants: effective when taken with fluids client teaching: must be taken with adequate fluids d. type: bulk-forming i. action: increase fluid content and bulk of stool stimulating stretch receptors in bowel and peristalsis ii. examples polycarbophil (FiberCon 1 gram by mouth 1-4 times up to 6 grams in 24 hours) psyllium (Metamucil 3-6 grams in 8 oz. of water by mouth 2-3 times daily, up to 30 grams/day) iii. uses facilitate bowel movement and regular bowel patterns chronic constipation, Crohns disease, IBS iv. adverse effects increased blood sugar anorexia, diarrhea, bloating altered absorption of drugs, vitamins, and minerals taken simultaneously v. contraindications: bowel obstruction, fecal impaction, dehydration vi. nursing care establish baseline data and monitor blood sugar provide adequate fluid administer other medications one hour before or 2 hours after client teaching o take immediately after mixing in water o establish regular bowel pattern

iii.

o o o

do not use with abdominal pain, nausea, vomiting take one hour before or 2 hours after other medication establish regular bowel habits including fiber, fluid, and ambulation

e. type: osmotic i. action: exert osmotic pull of fluid through intestinal wall to increase fluid in intestinal contents, increase bulk, and stimulate bowel evacuation ii. examples lactulose (Chronulac 15-30 ml/day by mouth up to 60 ml/day) magnesium citrate (Citrate of Magnesia 270-400 mg by mouth daily) magnesium hydroxide (Milk of Magnesia 270-400 mg by mouth daily) (See also: II.F.2.d antacids: magnesium) magnesium salt (Epsom Salts) iii. uses: short-term moderate to aggressive bowel evacuation

adverse effects CNS effects from fluid shifts palpitations, diaphoresis, fainting impaired absorption of other drugs nausea, diarrhea, cramping, dehydration v. contraindications preterm labor, high risk pregnancy painful or inflammatory conditions of GI tract or peritoneum vi. nursing care establish baseline data and monitor vital signs provide comfort measures and perineal skin care after bowel evacuation client teaching o for short-term use only o take oral forms with a full glass of water o after bowel movement, ask for help before getting up o effects may be sudden and forceful; remain close to bathroom facilities g. type: chemical irritants

iv.

action: stimulate nerves of intestinal wall resulting in increased peristalsis and fluid content of stool examples o bisacodyl (Dulcolax 15-30 mg by mouth daily, up to 60 mg by mouth daily) o cascara sagrada(325 mg by mouth daily) o senna (Senokot 1-8 tabs daily by mouth in divided doses) uses: short-term treatment of constipation, preop and pre-procedural bowel prep adverse effects o protein losing enteropathy, tetany o dehydration and electrolyte imbalance o cramping, nausea, explosive diarrhea, postevacuation rectal discomfort contraindications

biliary or bowel obstruction acute hepatitis, fecal impaction rectal disorders, acute abdomen nursing care o give alone and with a full glass of water o administer 1 hour before or 2 hours after antacid o client teaching 1. retain suppositories for 30 minutes 2. avoid using to establish regular bowel habits
o o o

6. Therapeutic class: digestive enzymes

a. type: pancreatic i. action: increases absorption of fat, carbohydrate, and protein ii. examples pancrelipase (Pancrease, Ultrase 1-3 capsules by mouth before or with meals up to 8 capsules/day) iii. uses: cystic fibrosis and pancreatic enzyme deficiencies, steatorrhea iv. adverse effects: anorexia, diarrhea, hyperuricuria, hyperuricemia v. contraindications: allergy to pork vi. nursing care establish baseline data and monitor stools for fat, serum ammonia, PT, polyphagia, polyuria, and polydipsia do not give with antacids or iron client teaching o do not inhale powder o report allergy, abdominal pain, cramping, hematuria o collaborate with dietitian and provider for low-fat diet b. type: saliva substitute i. example: saliva substitute (MouthKote, Salivart) ii. uses: dry mouth due to stroke, radiation, chemotherapy, and other illnesses

7. Therapeutic class: inflammatory bowel disease agents

a. type: aminosalicylates i. action: anti-inflammatory action on the colon, splits into 5acetylsalicylic acid and sulfapyridine ii. examples sulfasalazine (Azulfidine 500-1000 mg by mouth every 6-8 hours) mesalamine (Asacol 1 gram by mouth 4 times daily) iii. uses rheumatoid arthritis (RA), juvenile RA gold standard for ulcerative colitis and Crohns disease to induce and sustain remission iv. adverse effects anaphylaxis, myelosuppression, allergic myocarditis hepatitis, pancreatitis, renal failure, toxic nephrosis, Stevens-Johnson syndrome rash, bleeding, diarrhea, orange-yellow coloring to skin

contraindications: allergy to sulfonamides, sulfa drugs, salicylates; term pregnancy, children < 2 years-old, intestinal or urinary obstruction vi. nursing care establish baseline data and monitor bowel pattern, abdominal pain, temperature, fluid and electrolyte balance, CBC, urine output oral and rectal administration available may impair iron and folic acid absorption client teaching o avoid sunlight, protect skin o drink 2000 ml of water daily o report bleeding, rash, fever, sore throat o store in airtight, light-resistant container o instill rectal suspension at bedtime and retain during sleep b. type: glucocorticoids (See also: II.K.1.b anti-inflammatory agents: glucocorticoids) i. action: powerful and effective anti-inflammatory effect on bowel ii. examples budesonide (Entocort 9 mg by mouth daily for up to 8 weeks, taper to 6 mg by mouth daily for 2 weeks before discontinuing) predniSONE (Deltasone 5-20 mg by mouth daily or in divided doses) prednisoLONE (Prelone 2-15 mg by mouth daily in 2-4 doses, IV 2-30 mg every 12 hours) hydrocortisone sodium succinate (Solu-Cortef 500 mg-2 grams IV every 2-6 hours, 100 mg enema daily at bedtime) iii. uses

v.

sustains remission for short-term gold standard to induce remission quickest and most effective method of control iv. adverse effects: very high side effect profile with potential for long-term effects, systemic absorption via oral, IV, and rectal administration v. nursing care administered once daily for 8 week course of therapy, may be repeated taper therapy over two week period before discontinuing d. type: anticholinergic agents action: blocks muscarinic receptors to reduce gastric motility examples 1. atropine (Atropine 0.5 mg-1 mg IV) 2. scopolamine (See also: II.F.1.c antiemetics: anticholinergics) d. type: anxiolytic agents chlordiazepoxide (See also: III.D.3.a.ii anxiolytic agents: benzodiazepines) (Librium) phenobarbital (See also: II.C.1.b.ii anxiolytic agents: barbiturates) (Luminal) d. type: immunosuppressants (See also: II.B.4 immunosuppressants) e. type: monoclonal antibodies (See also: II.K.4.c immunosuppressants: monoclonal antibodies)

G. Managing endocrine conditions

1. Therapeutic class: antidiabetic agents a. information common to antidiabetic agents i. nursing care oral agents contraindicated in pregnancy establish baseline data and monitor o renal and hepatic function o blood sugar, serum pH, electrolytes o hypoglycemia, hyperglycemia, ketones, and acidosis o visual acuity, CV status including peripheral perfusion ii. client teaching common to antidiabetic agents need for follow-up care and testing use and frequency of blood glucose testing avoid OTC drugs, herbal remedies, and alcohol beta-adrenergic blockers may mask signs of hypoglycemia facilitate glycemic control with diet and weight loss (if indicated) keep easily accessible: antidiabetic medication, equipment, high calorie snack recognition of hypoglycemia, hyperglycemia, and ketoacidosis by client and significant others monitor compliance with therapy or success of treatment plan with glycosylated hemoglobin (Hgb A1-C) antidiabetic medication requirements may increase during illness or infection; clients with type 2 diabetes (NIDDM) may require insulin periodically tight glycemic control: key to preventing complications of DM o anti-diabetic medication only 1 part of effective glycemic control o must combine with consistent exercise and consistent diet coordinate antidiabetic agent administration and dietary carbohydrates o carbohydrate intake must be coordinated with drug onset, peak action, and duration o client must have calories in the body during peak action time of insulin b. type: insulin i. action: lowers blood sugar; drives metabolites and ions into cells, stimulates formation of glycogen, protein, and fat; recombinant DNA replacement insulin made from human insulin ii. examples

Onset, peak, and duration of common insulins

iii.

uses diabetes mellitus type 1 and 2; hyperkalemia lispro in combination with sulfonylurea in children ketoacidosis, diabetes mellitus associated with pregnancy adverse effects anaphylaxis, hypoglycemia Somogyi phenomena swelling, redness, rash lipodystrophy, lipohypertrophy contraindications: allergy to protamine nursing care establish baseline data and monitor blood sugar, anorexia verify blood sugar before administration mixing >1 insulin in a syringe: draw regular insulin first regular insulin and NPH insulin require 15 gm carbohydrate snack at peak action time allow refrigerated insulin to warm to room temperature before injection: roll between palms of hands IV insulin: regular insulin only o small amounts suitable for IV push o use infusion control device to deliver units/hour o prime tubing with 50 ml of insulin solution before infusing; required to coat lumen of tubing

iv.

v. vi.

client teaching o wear MedicAlert tag o need for follow-up care and testing o blood glucose testing technique and frequency o subcutaneous injection technique; need to rotate injection sites o single-use vials of insulin may be stored at room temperature for 30 days: keep away from heat and light 2. type: oral antidiabetic agents iii. sub-type: sulfonylureas action: increase insulin secretion by binding to K+ receptors on pancreatic beta cells (beta cells) examples o first-generation: chlorpropamide (Diabinese) o second-generation: glipizide (Glucotrol) o glimepiride (Amaryl) uses o increase number of receptors o adjunct therapy with diet and exercise o reduce need for insulin; decrease insulin resistance o clients with functional beta cells to increase insulin release adverse effects o hypoglycemia, GI distress, rash o possible increased risk of cardiovascular deaths contraindications o use in children, IDDM, severe liver or renal dysfunction o DM complicated by fever, severe infection, ketoacidosis nursing care: o establish baseline data and monitor blood sugar, anorexia o avoid use of urine acidifiers o use lower doses with older clients 3. sub-type: non-sulfonylureas [alpha-glucosidase inhibitor] iii. action: delay glucose absorption by inhibiting an enzyme that breaks down glucose into smaller molecules for absorption iv. examples metformin (Glucophage, a biguanide) repaglinide (Prandin, a meglitinide) rosiglitazone (Avandia, a thiazolidinediones) v. uses: in combination with insulin and sulfonylureas vi. adverse effects (See also: II.G.1.c.i sulfonylureas: adverse effects) vii. contraindications (See also: II.G.1.c.i sulfonylureas: contraindications) viii. nursing care administer just before meals much less likely to cause hypoglycemia 4. sub-type: glucose-elevating agents iii. action: decrease release of insulin and facilitate glycogen breakdown and release from the liver iv. example glucagon (GlucaGen 20-25 mg subcutaneous, IM, IV, may need to repeat in 15 minutes)

v. vi.

vii.

diazoxide (Hyperstat, Proglycem 3-8 mg/kg/day by mouth in 2-3 doses daily) uses: hypoglycemia and hypoglycemic disorders adverse effects diazoxide o rapid, profound hypotension (diazoxide), shock, MI, supraventricular tachycardia, edema, thrombocytopenia glucagon o anaphylaxis o GI upset, nausea, vomiting nursing care: establish baseline data and monitor blood sugar, blood pressure o continuously monitor vital signs and EKG during diazoxide infusion keep insulin at bedside maintain client safety until acute episode is resolved

2. Therapeutic class: thyroid agents a. type: thyroid replacement, synthetic i. action regulation of protein synthesis increases rate of caloric turnover to increase cardiac output, renal blood flow, oxygen consumption, and production of the by-products of metabolism: CO2, H2O, and heat. ii. examples levothyroxine sodium (Synthroid, T4 75 mcg by mouth daily, titrated to blood level) liothyronine sodium (Cytomel, T3 25-75 mg by mouth daily) iii. uses: hypothyroidism, myxedema coma, cretinism, thyrotoxicosis iv. adverse effects thyroid storm tachycardia, palpitations, angina, dysrhythmias, intolerance to heat, weight loss tremors, headache, insomnia, rash; transient, minimal hair loss unexpected cardiac problems in older clients v. contraindications hypersensitivity to tartrazine or aspirin adrenal insufficiency, recent MI, thyrotoxicosis vi. nursing care establish baseline data and monitor vital signs, daily weight, T3 and T4, TSH, PT IV push: rate not to exceed 0.1 mg over 1 minute client teaching o report excitability, insomnia, sweating, heat intolerance o wear MedicAlert tag o take in am as a single dose o need for follow-up care and testing o notify provider if generic form is switched o does not cure thyroid problems, treatment is long-term o may crush tablet and mix in water or nonsoy based formula

avoid stimulants, caffeinated beverages, and iodine rich foods such as seafood, fish liver oils, and iodized salt o take only as directed, do not stop taking drug without notifying provider b. type: antithyroid agents i. sub-type: thioamides action: blocks production of thyroid hormone by inhibiting the conversion of T4 to T3 examples o propylthiouracil (PTU 100-300 mg by mouth 1-3 times daily) o methimazole (Tapazole) uses: preparation for thyroidectomy, thyrotoxicosis, hyperthyroidism adverse effects o drowsiness, paresthesias o nausea, jaundice, loss of taste o myelosuppression, lymphadenopathy o rash, alopecia, lupus-like syndrome, osteoporosis nursing care o establish baseline data and monitor vital signs, thyroid function, weight, CBC with differential, platelets o monitor for overdose: muscle hyperexcitability, depression, hand, nonpitting edema, intolerance to cold o client teaching 1. take at same time daily 2. avoid iodine containing foods 3. do not discontinue taking drug 4. increase fluids to 3000 ml to 4000 ml daily 5. report bleeding and unusual bruising, fluid gain, edema, DOE, cold intolerance, depression ii. sub-type: iodine solutions action: blocks thyroid function in high doses by saturating thyroid cells with iodine examples o potassium iodide (SSKI, Thyro-Block) o sodium iodide 131 uses: o blocks thyroid function in radiation exposure and during radiation therapy o non-surgical candidates with hyperthyroidism, women who cannot conceive, and older clients with severe, complicated co-morbidities o diagnosis and treatment of hyperthyroidism in clients > 30 years-old adverse effects o teeth-staining, rash, goiter o hypothyroidism, angioneurotic edema o iodism: metallic taste, stomatitis, salivation contraindications: hyperkalemia, pulmonary edema and tuberculosis nursing care
o

o o

establish baseline data and monitor thyroid function, serum potassium, renal function, urine output taper dose before discontinuing therapy administration 1. avoid giving with milk 2. administer with 8 oz. water or fruit juice at bedtime 3. place container in warm solution if crystals present before administration client teaching 1. may take with food 2. do not abruptly stop therapy 3. drink water to thin secretions 4. need for follow-up care and testing 5. report bleeding, abdominal pain, iodism 6. avoid iodine rich foods, wear MedicAlert tag 7. avoid OTC including vitamins and herbal supplements without consulting provider

3. Therapeutic class: adrenocortical agents a. type: glucocorticoids (See also: II.K.1.b immunosuppressants: steroidal anti-inflammatory agents, glucocorticoids) uses: adrenal insufficiency [Addison's Disease], adrenal crisis b. type: mineralocorticoids i. action: increase sodium reabsorption in renal tubules to increase H+ and K+ and water retention ii. example: fludrocortisone acetate (Florinef 0.1-0.2 mg by mouth daily) iii. uses: in combination with glucocorticoids for adrenal insufficiency, salt-wasting syndromes iv. adverse effects circulatory collapse, thrombophlebitis, embolism flushing, sweating, hypokalemia rash, hypervolemia, hypertension, heart failure, and pulmonary edema v. contraindications using without glucocorticoids severe hypertension, heart failure, cardiac disease, use in children vi. nursing care establish baseline data and monitor vital signs fluid and electrolyte balance (especially hypokalemia), weight, I & O decreased effectiveness when given with salicylates and hydantoins collaborate with provider for potassium-rich diet, low-sodium diet vii. client teaching report weight gain, peripheral edema, abdominal cramping, nausea, anorexia do not stop taking this drug abruptly wear MedicAlert tag identifying steroid user 4. Therapeutic class: hypothalamic hormones a. type: growth hormone i. example: nafarelin (Synarel 1-2 sprays per nostril once or twice daily)

uses: endometriosis, precocious puberty iii. adverse effects edema emotional lability, headaches, nasal irritation, vaginal dryness, acne, hot flashes, decreased libido iv. nursing care establish baseline data and monitor signs of puberty, hot flashes, mood client teaching 1. report rhinitis, signs of puberty after 1st month of therapy 2. nasal spray technique 3. use barrier contraception 4. 1st month of therapy, signs of puberty: vaginal bleeding, breast enlargement 5. Therapeutic class: anterior pituitary agents a. type: adrenocortical hormone i. example: corticotropin (Acthar 20-40 units/day IM, taper dose over 9 weeks) use: stimulate release adrenal hormones diagnostically adverse effects 1. heart failure, thromboembolism 2. depression, nausea, impaired wound healing ii. example: menotropin (Pergonal combination therapy with luteinizing hormone, follicle stimulating hormone and human chorionic gonadotropin) use: to stimulate ovulation in infertile women adverse effects 1. thromboembolism 2. abdominal pain, bloating, pelvic pain iii. example: somatotropin (Nutropin up to 0.3 mg (0.9 units)/kg each week) use: growth failure adverse effects: pain at injection site, edema, hyperglycemia, hypothyroidism 6. Therapeutic class: posterior pituitary agents a. type: synthetic antidiuretic hormone i. action: increases reabsorption of water in renal tubules to decrease urine formation and increases plasma levels of factor VIII ii. examples vasopressin (Pitressin 5-10 units subcutaneously, IM 2-4 times daily) desmopressin acetate (DDAVP 0.1-1.2 mg/day by mouth in 2-3 doses) iii. uses: diabetes insipidus, nocturnal enuresis, hemophilia A, von Willebrand's disease, cardiopulmonary arrest iv. adverse effects water intoxication: drowsiness, headache, seizures abdominal cramps, nausea, vomiting v. contraindication: renal dysfunction vi. nursing care establish baseline data and monitor fluid overload, urine output, serum osmolality, factor VIII level serum blood levels may appear low due to hemodilution client teaching 1. wear MedicAlert tag

ii.

2. avoid alcohol and OTC drugs 3. use of nasal spray or injection technique 4. missed doses: take up to 1 hour before next dose, otherwise skip dose, do not double dose 7. Therapeutic class: parathyroid agents a. type: antihypercalcemic agents (See also: bone resorption inhibitors II.D.6) i. action: inhibits bone resorption by binding to bone hydroxyapatite to inhibit osteoclast activity ii. examples bisphosphonates: risedronate (Actonel) calcitonins (Cibacalcin, Calcimar) iii. uses: osteoporosis, osteomalacia, Pagets disease iv. adverse effects GI upset, gastroesophageal reflux, abdominal pain, diarrhea dry eyes, eye pain, flu-like symptoms v. contraindications: client cannot sit upright for 30 minutes, hypocalcemia, renal impairment vi. nursing care establish baseline data and monitor bone density scan, Ca++ intake collaborate with dietitian for calcium-rich foods Ca++, Mg++, and Al substances will interfere with absorption client teaching 1. take on an empty stomach in the AM with 68 oz of water 2. remain upright for at least 30 minutes after taking 3. take Ca++ supplements if daily requirements cannot be attained with diet alone

H. Managing renal and urinary tract conditions (diuretic types) 1. Therapeutic class: diuretics 1. information common to diuretics (except potassium-sparing diuretics) 1. action: increases the rate of urine flow by effecting a section of the renal tubules to excrete Na+; alters renal handling of other electrolytes 2. uses 1. increase rate of urine flow, Na+ and Cl- excretion 2. heart failure, hypertension, hyperkalemia 3. rapid fluid excretion, severe edema, pulmonary edema 3. adverse effects 1. circulatory collapse, myelosuppression 2. hypokalemia, hyponatremia, hypocalcemia, hypercalcemia, hyperglycemia 4. contraindications 1. hypokalemia, hypovolemia, anuria 2. allergy to sulfonamide, electrolyte depletion 5. nursing care 1. establish baseline data and monitor intake, urine output, serum electrolytes especially potassium, blood pressure, cardiac rhythm, serum glucose and pH 2. increased risk of digoxin toxicity

3. client teaching 1. may take with food or milk 2. avoid alcohol and OTC drugs 3. do not stop taking when feeling well 4. administer in early AM to avoid nocturia 5. potassium-rich diet (may need to avoid or take) 6. report irregular heartbeat, low urine output, dizziness, rash, muscle cramps, twitching, weakness

b. type: loop diuretics, sulfonamide derivative i. action: blocks sodium-chloride pump in renal tubules preventing reabsorption of Na+ and chloride in the ascending loop of Henle and distal convoluted tubules, and to increase urine and solute excretion ii. examples furosemide (Lasix 20-80 mg by mouth daily) bumetanide (Bumex 0.5-2 mg by mouth daily, IV 0.5-1 mg, may repeat in 2-3 hours) torsemide (Demadex 10-20 mg by mouth daily) iii. adverse effects: ototoxicity, alkalosis, hypotension, fluid rebound iv. contraindication: infants v. nursing care establish baseline data and monitor hearing, electrolyte depletion administration o verify serum potassium, blood pressure, and urine output before administration o IV push rate 20-40 mg not to exceed 20 mg/minute >40 mg not to exceed 4 mg/min rapid IV push associated with increased risk of ototoxicity c. type: thiazide diuretics, sulfonamides i. action: chloride pump in renal tubules prevents reabsorption of Na+ and Cl- in the ascending loop of Henle and distal tubules ii. examples thiazide o hydrochlorothiazide (HydroDIURIL 12.5-100 mg by mouth daily in 1-2 doses) o chlorothiazide (Diuril 250-1000 mg by mouth daily in 1-2 doses) thiazide-like: chlorthalidone (Hygroton 25-100 mg by mouth daily)

iii.

uses

first-line monotherapy for HTN edema associated with heart failure, liver or renal dysfunction iv. adverse effects: bladder infections from alkaline urine v. contraindication: hyperchloremia e. type: carbonic anhydrase inhibitors action: mild diuretic action by inhibiting the movement of HCO3- resulting in increased loss of sodium and HCO3 example: acetazolamide (Diamox 250-1000 mg by mouth daily in 1-4 doses) uses: in combination with other diuretics as adjunct therapy; glaucoma, seizures adverse effects 1. metabolic acidosis, hypokalemia, 2. paresthesias, confusion, drowsiness e. type: potassium-sparing diuretics

action: antagonizes aldosterone to maintain Na+ excretion in the distal tubule and retain potassium examples 1. spironolactone (Aldactone 25-400 mg by mouth daily in 2-4 doses) 2. triamterene (Dyrenium 100-300 mg by mouth daily in 2 doses) 3. amiloride (Midamor 5-20 mg by mouth daily) uses 1. clients with high risk of hypokalemia requiring diuretic therapy 2. heart failure, hyperaldosteronism, liver failure, nephrotic syndrome adverse effects: hyperkalemia, hyperchloremia, hypovolemia, bradycardia, cardiac dysrhythmias, myelosuppression contraindications: hyperkalemia, renal failure

nursing care o establish baseline data and monitor blood pressure, serum potassium, neuro status o carefully review medication profile for other drugs associated with hyperkalemia: ACE inhibitors, angiotensin II receptor blockers, salt substitute o client teaching 1. avoid potassium rich foods 2. take with food or milk in early AM 3. avoid alcohol, OTC drugs, and herbal remedies g. type: osmotic diuretics

action: pulls large amount of fluid into renal tubules by osmotic pressure examples o mannitol (Osmitrol 50-100 grams of 5-25% solution IV over 30-60 minutes) o isosorbide (Ismotic 80-120 mg by mouth three times daily)

uses prevent oliguric phase in renal failure decrease intraocular and intracranial pressure o facilitate movement of toxins through kidney for excretion adverse effects o hearing loss o nausea, vomiting, hypotension, acidosis o confusion, headache, seizures, rebound increased ICP o sudden, massive fluid shift, tachycardia, hypervolemia contraindications: intracranial bleeding, anuria, severe dehydration, renal failure nursing care o establish baseline data and monitor 1. hearing, serum electrolytes, CBC 2. neuro status, ICP, heart rate and blood pressure o give with food or milk o administer IV drug slowly with in-line filter 1. dissolve crystals in warm-water bath 2. bring to room temperature before administration
o o

2. Managing urinary tract disorders a. therapeutic class: anti-infectives specific for urinary tract i. information common to urinary tract anti-infectives: obtain urine cultures before initial administration ii. type: antibiotics action: interferes with DNA metabolism of pathogen examples o sub-type: fosfomycin (Monurol 3 grams by mouth for 1 dose) o sub-type, quinolone derivative: norfloxacin (Noroxin 400 mg by mouth every 12 hours) o sub-type: sulfonamides (See also: II.K.5.b.12 antibiotics: sulfonamides) examples: sulfisoxazole (Gantrisin 1.5-4 grams by mouth every 4 hours) sulfamethoxazole and trimethoprim [Bactrim, Septra: 1 tab (sulfamethoxazole 800 mg and trimethoprim 160 mg) every 12 hours] uses: pyelonephritis, cystitis adverse effects o secondary urinary tract infection o GI upset, hepatic necrosis, anaphylaxis o exfoliative dermatitis; severe, irreversible peripheral neuropathy o interstitial pneumonitis, pulmonary fibrosis; more common in older clients contraindications o G6PD deficiency, infants < 3 months-old o significant impairment of renal dysfunction nursing care o establish baseline data and monitor urine output, pulmonary function

o o

temperature, pain, urine output decreased absorption with antacids client teaching: may turn urine brown

iv.

nursing care: quinolones (See also: II.K.5.b.v antibiotics: fluoroquinolones) o examples ciprofloxacin o give 1 hour before or 2 hours after meals o give at least 2 hours after antacid o client teaching take at same time every day drink 2500-3000 ml water daily type: urinary acidifiers action: kills pathogens in bladder examples o methenamine (Hiprex) o methylene blue (Urolene blue) uses: chronic UTI, adjunct therapy in cystitis and pyelonephritis adverse effects o pruritus, headache, dizziness o GI upset, bladder upset, dysuria contraindication: renal dysfunction nursing care o establish baseline data and monitor low urinary pH o avoid overhydration o administer after meals and at bedtime o avoid suspension in older and debilitated clients o client teaching avoid vegetables, fruit, and fruit juice avoid alcohol and OTC drugs especially antacids take urinary acidifiers: cranberry, plums, and prunes

b. therapeutic class: urinary tract anti-spasmodics i. action: inhibits action of Ach; anticholinergics, muscarinic receptor antagonist increases bladder capacity and reduces frequency of bladder contractions ii. examples tolterodine (Detrol 2 mg by mouth twice daily) solifenacin (Vesicare 5-10 mg by mouth daily) oxybutynin (Ditropan 5 mg by mouth 2-4 times daily) (Oxytrol, transdermal 3.9 mg/day) trospium chloride (Sanctura 20 mg by mouth twice daily) iii. iv. uses: symptomatic relief of uninhibited or reflex bladder adverse effects severe allergic reaction, psychotic behavior (overdose) anticholinergic effects: dry mouth and eyes, constipation, blurred vision, decreased sweating drowsiness, weakness, insomnia contraindications narrow angle glaucoma, myasthenia gravis GI obstruction, severe colitis, urinary retention nursing care

v. vi.

establish baseline data and monitor urinary pattern, urinary retention interrupt therapy periodically to determine continued need monitor clients with enterostomies: diarrhea or distention may be early sign of intestinal obstruction client teaching o avoid hot environments o do not engage in dangerous activities d. therapeutic class: cholinergic agent (See also: II.C.5 cholinergic agents) action: increases bladder tone to increase stimulus for micturition examples: bethanechol (Urecholine 25-50 mg by mouth three times daily) use: urinary retention and neurogenic bladder adverse effects o hypotension o nausea and vomiting d. therapeutic class: urinary tract analgesic

action: direct topical analgesia on urinary tract mucosa example: phenazopyridine (Pyridium 200 mg by mouth daily for 2 days) uses: symptomatic relief from infection, surgery, trauma adverse effects 1. headache, nausea, vomiting 2. reddish-orange colored urine 3. renal or hepatic dysfunction contraindication: serious renal dysfunction nursing effects

establish baseline data and monitor dysuria treat underlying UTI client teaching urine will stain report jaundice, take with food discontinue drug when pain is relieved
o o o

f.

treatment of benign prostatic hypertrophy (BPH)

therapeutic class: alpha1-adrenergic receptor blocker (See also: I.A.4.h alpha1-adrenergic receptor blockers) examples o tamsulosin (Flomax 0.4 mg by mouth daily after a meal) o terazosin (Hytrin 1-5 mg by mouth daily up to 20 mg/day in 2 doses) therapeutic class: 5-alpha1-reductase inhibitor

o o

o o

action: inhibits the enzyme responsible for conversion of testosterone to an androgen examples finasteride (Proscar 5 mg by mouth daily) (Propecia 1 mg by mouth daily) dutasteride (Duagen 0.5 mg by mouth daily) use: long-term treatment to shrink the prostate and relieve problems of BPH, male-patterned baldness adverse effects: decreased libido, impotence nursing care establish baseline data and monitor urinary flow and pattern, residual urinary volume may give with meals for GI upset client teaching 1. must take for at least 6 months 2. keep out the hands of pregnant women 3. Propecia: therapeutic effect may take 3 months 4. Proscar therapeutic effects may take > 6 months

I.

Managing conditions of the reproductive tract

1. Female reproductive system a. therapeutic class: female hormones

i.

type: estrogen action: necessary for proper functioning of female reproductive system, development of secondary sexual characteristics, and endometrial proliferation: stimulates release of pituitary gonadotrophins, inhibits ovulation, promotes calcification of bones examples
o

estradiol (Estrace 0.5-2 mg by mouth daily) estradiol cypionate (Depogen 0.5-2 mg by mouth daily) estrogen, conjugated (Premarin 0.3-1.25 mg by mouth daily) conjugated-A (Cenestin 0.3-1.25 mg by mouth daily)

uses
o

used in combination for contraception

o o o

estrogen replacement therapy, hypogonadism relief of post-menopausal symptoms, dysmennorhea prevention and treatment of osteoporosis, prostate cancer

adverse effects
o

thromboembolic disorders, increased risk of breast and endometrial cancer, hyperglycemia, hypercalcemia, depression, seizures GI upset, cholestatic jaundice, hepatic adenoma

contraindicatons
o o

> 35 years-old with smoking breast or reproductive cancer

nursing care
o

establish baseline data and monitor serum lipids, drug level, HTN, fluid status, EKG, LFT, mental status initiate transdermal therapy 7 days before discontinuing oral therapy action inhibited by grapefruit juice, increases effect of glucocorticoids may be used with or without uterus, ovaries; must be combined with progesterone for intact uterus client teaching report fluid retention, leg pain, jaundice, breast lumps, headache, blurred vision may decrease libido, take only as directed need for follow-up care and testing: pelvic exam and Pap smear non-pharmacological comfort measures for the adverse effects of menopause do not combine with herbal supplements including black cohosh, borage, soy, wild yam drug delivery instructions: vaginal tablets, cream, ring; oral tablets, transdermal patch (apply patch to non-hairy area near pelvis: firmly hold in place for > 10 seconds) type: progesterone
o action: inhibit secretion of pituitary gonadotrophins

iii.

preventing the maturation of ovarian follicles, stimulating breast tissue growth example: progesterone (Prometrium 200-400 mg by mouth daily for 10-21 days) uses: contraception, amenorrhea, premenstrual syndrome, prevention of endometrial hyperplasia

 adverse effects: spontaneous abortion contraindications: cerebral hemorrhage nursing care (See also: II.I.1.a.i estrogen: nursing

care) 2. therapeutic class: hormone modulators ii. type: estrogen receptor modulators action: stimulates some and blocks other estrogen receptor sites to elicit some of the positive effects of estrogen therapy examples o raloxifene (Evista 60 mg by mouth daily) o toremifene (Fareston 60 mg by mouth daily) uses: antineoplastic, increase bone mineral density, post-menopausal osteoporosis adverse effects o thromboembolic disorders o GI upset, fluid retention o headache, dizziness, mental changes contraindications: clients who smoke, thromboembolic disease or history nursing care o establish baseline data and monitor serum lipids, drug level, HTN, fluid status, EKG, LFT, mental status o client teaching: report fluid retention, leg pain, jaundice, breast lumps, headache, blurred vision; need for follow-up care and testing 3. therapeutic class: contraceptives ii. type: oral contraceptives (See also: female hormones II.I.1.a and b) action: release of ovum and endometrial proliferation inhibited, increased viscosity of cervical mucus examples o ethinyl estradiol is combined with progesterone vary according to amount of estradiol and form of progesterone used day-one start and Sunday start methods o estradiol and levonorgestrel (Avian 28) o estradiol and norgestrel (Ortho-Cyclen) o estradiol and norgestimate (Ortho-TriCyclen) uses: contraception, acne, premenstrual syndrome adverse effects: spotting, pregnancy client teaching o day-one start start taking one pill daily on first day of menstrual flow back-up contraception not needed o Sunday start start taking one pill daily on the first Sunday after the beginning of menstrual flow back-up contraception is required for 1 month iii. type: implanted systems, progesterone only (See also: II.I.1.c oral contraceptives)

 effective for up to 5 years increased incidence of ovarian cysts client teaching: requires surgical procedure to insert

and remove implants type: intrauterine levonorgestrel (See also: II.I.1.c oral contraceptives) inserted into uterus effective for 5 years v. type: vaginal ring (See also: II.I.1.c oral contraceptives) inserted vaginally and left in place for 3 weeks 1 week without ring: insert next vaginal ring after this week vi. type: IM long-acting progesterone example: depot-medroxyprogesterone acetate, DMPA (Depo-Provera) nursing care o effective for 3 months o IM injection o safe for nursing mothers vii. type: transdermal patch (See also: oral contraceptives II.I.1.c) most effective for women <198 lbs. higher estrogen exposure than other combination agents apply firm pressure to patch for at least 10 seconds when applying use one patch per week for 3 weeks; apply to pelvic region; 1 week without patch, then resume cycle 4. therapeutic class: fertility drugs ii. action: enhance an aspect of follicular development or ovulation iii. examples type: gonadotrophins-releasing antagonist o cetrorelix (Cetrotide 0.25 mg subcutaneous injection on stimulation day 5, in am or pm, or day 6 am; then daily until hCG is given) type: chorionic gonadotropin (Pregnyl) type: clomiphene (Clomid 50-100 mg by mouth daily for 5 days) type: follicle stimulators o follitropin alfa (Gonal-F 75-300 units/day subcutaneous injection for 14 days) o follitropin beta (Follistim 75-300 units/day subcutaneous injection for 14 days) iv. uses: infertility in males and females, in combination with hCG v. adverse effects abdominal pain, distention, effusion headache, fluid retention, nausea, bloating uterine bleeding, ovarian enlargement, gynecomastia vi. contraindications primary ovarian failure thyroid, adrenal, hypothalamic, or pituitary disease thromboembolic disorders vii. nursing care establish baseline data and monitor estrogen and estradiol levels, pregnancy administer with hCG client teaching o need for follow-up care and testing

iv.

subcutaneous or IM injection technique record treatment days and days for sexual intercourse on client calendar 5. therapeutic class: uterine stimulants ii. action: oxytocic, stimulates neuro-receptor sites to cause uterine contractions iii. examples oxytocin, IV (!high alert drug) (Pitocin 5-6 milliunits/min IV, titrate to frequency and strength of uterine contractions) ergonovine, IM (Ergotrate 0.2-0.4 mg by mouth every 6-12 hours for 48 hours) methylergonovine (Methergine 200-400 mcg every 6-12 hours by mouth) iv. uses: prevention and treatment of uterine atony and postpartum bleeding; induce labor, stimulate letdown reflex v. adverse effects abruption placenta, seizures usually dose related uterine hypertonicity uterine rupture, decreased uterine blood flow fetal asphyxia, hypoxia and intracranial hemorrhage vi. contraindications: pregnancy-induced hypertension (PIH), cephalopelvic disproportion, fetal distress, hypertonic uterus vii. nursing care establish baseline data and continuously monitor uterine contractions, maternal vital signs, and FHTs monitor frequency, intensity, and duration of contractions discontinue infusion with abnormal fetal deceleration patterns, hemorrhage, maternal hypotension administration o administer on infusion control device o causes cramping, may increase intensity of labor pain o postpartum bleeding: titrate to response, dilute 10-40 units per liter o induction of labor: begin at 1-2 units/min and increase slowly to induce; dilute in 1 liter client teaching: report blood loss. sustained contractions, lack of fetal movement 6. therapeutic class: tocolytics ii. action: relax uterine smooth muscle iii. examples type: beta-agonist (See also: II.B.1.b bronchodilators) o ritodrine (Yutopar) type: magnesium sulfate(magnesium sulfate 9.9% solution 4 grams IV followed by continuous infusion at 1-2 grams/hr IV not to exceed 40 grams/day; titrate to uterine contractions, deep tendon reflexes, seizure activity, and blood pressure) type: calcium channel blocker (See also: II.A.4.d antihypertensives: calcium channel blockers) o NIFEdipine (Procardia 10-30 mg by mouth 3 times/day) type: prostaglandin synthesis inhibitors o dinoprostone (Cervidil Vaginal Insert 0.5 mg vaginally inserted to touch cervix, may
o o

repeat in 6 hours; remove insert when desired effect is achieved) iv. use: premature labor, increase gestational age of fetus v. adverse effects maternal o flaccid paralysis, tachycardia, hypotension, pulmonary edema, hyperglycemia o anxiety, tremors, insomnia o headache, nausea, dry mouth, lethargy fetal: hypotonia and respiratory depression vi. contraindications: eminent birth, fetal distress, maternal hypotension or hyporeflexia vii. nursing care establish baseline data and monitor o maternal: blood pressure, DTRs, urine output, serum magnesium level o frequency, intensity, duration of contractions o fetal: FHTs, fetal movement magnesium sulfate: keep 1 gram calcium gluconate at bedside for antidote do not administer magnesium with calcium channel blockers client teaching o report bleeding, unusual decrease in fetal movement o for contractions assume supine position, empty bladder drink fluids, and time contractions call provider if symptoms persist or intensify or decreased fetal movement 7. therapeutic class: abortifacients ii. action: cause intense uterine contractions leading to uterine evacuation iii. examples type: prostaglandin o dinoprostone (Cervidil, Prostin E2) (See also: II.I.1.f tocolytics: dinoprostone) o carboprost (Hemabate) type: antiprogesterone o mifepristone (RU-486, Mifeprex) type: estradiol and levonorgestrel combination, morning after pill (Preven 1 tab within 72 hours of unprotected intercourse, then 1 tab 12 hours later) levonorgestrel (Plan-B 1 tab within 72 hours of unprotected intercourse, then 1 tab 12 hours later) iv. uses: ripen cervix for childbirth induction, prevent implantation of fertilized eggs v. adverse effects heavy uterine bleeding, perforated uterus headache, nausea, diaphoresis, rash, abdominal cramping vi. contraindications gestational age >7 weeks history of asthma, HTN, adrenal disease pelvic inflammatory, cardiac, renal, or pulmonary disease vii. nursing care establish baseline data and monitor blood pressure, uterine tone, uterine bleeding confirm gestational age before administration

 client teaching o do not use abortifacients for birth control o use of delivery method and timing of o o

administration need for follow-up care and testing report heavy bleeding, temperature, foulsmelling lochia

2. Male reproductive system 1. therapeutic class: hormones ii. type: androgenic anabolic steroid growth and development of male external genitalia and secondary sexual characteristics; increase protein anabolism and muscle mass examples o testosterone enanthate (Testone 50-400 mg IM 2-3 times/week) o testosterone cypionate (depAndro 50-400 mg IM 2-3 times/week) o danazol (Danocrine 100-500 mg by mouth twice daily for 3-9 months of uninterrupted therapy) uses: low testosterone levels, eunuchoidism, oligospermia, impotence, female breast cancer, endometriosis adverse effects o hypertension, aggression o rash, acne vulgaris, oily hair and skin, anxiety, lability, insomnia o cholestatic jaundice, menstrual irregularities o females: deepening of voice, clitoral enlargement contraindications: severe renal, cardiac, hepatic disease nursing care o establish baseline data and monitor weight, urine output, serum electrolytes, mental status, and blood pressure, blood sugar o duration of therapy: 1-3 month required for breast cancer o most effective when administered with high caloric diet o administration IM: give deep IM injection gel: apply gel to clean, dry area on shoulders, arms abdomen patch: apply according to manufacturers directions o client teaching do not abruptly discontinue therapy 2. therapeutic class: anabolic steroids ii. action: develop muscle mass without androgenic effects iii. example: oxandrolone (Oxandrin) iv. uses anemia associated with renal disease in children increase strength and endurance, promote weight gain in debilitated clients, increase protein anabolism with clients on glucocorticoids v. adverse effects heart failure, hypertension decreased testicular function and atrophy, alopecia, phallic enlargement, hirsutism

 priapism, aggravates BPH females: deepening of voice, clitoral enlargement,

increased libido vi. contraindications: severe renal, cardiac, hepatic disease vii. nursing care establish baseline data and monitor weight, urine output, serum electrolytes, mental status, and blood pressure, blood sugar, LFT administer with food for GI upset pediatric use: x-ray long bones every 3-6 months to avoid growth retardation client teaching o injection technique o masculinization in females will fade when therapy is discontinued 3. therapeutic class: erectile dysfunction agents ii. action: activates or prevents the breakdown of cGMPPDE5 causing smooth muscle relaxation and blood to fill the corpus carvernosum iii. examples: type: prostaglandin o alprostadil (Caverject 1.25-2.5 mcg intracavernosal injection, titrate to desired effect) type: cGMP-PDE5 inhibitor o sildenafil (Viagra 25-100 mg by mouth 30 minutes -1 hour before desired sexual activity) o tadalafil (Cialis 5-20 mg by mouth before desired sexual activity) iv. uses: erectile dysfunction v. adverse effects MI, sudden death, CV collapse headache, dizziness, pain at injection site hypotension with amlodipine UTI, dyspepsia, nasal congestion vi. contraindications use in females with penile implants concurrent nitrate therapy vii. nursing care review medication profile for nitrates and antihypertensives

J. Managing hematological conditions 1. Therapeutic class: antianemic agents a. type: erythropoietin i. action: stimulates RBC production in bone marrow ii. examples epoetin alfa (Epogen, Procrit 50-100 units subcutaneous injection, IV 3 times/week) darbopoetin alfa (Aranesp 0.45 mcg/kg subcutaneous injection, IV weekly, may increase or decrease dosage by 25% once a month) iii. uses: anemia associated with renal failure, cancer, AIDS, chemotherapy iv. adverse effects HTN, edema, chest pain, seizures

GI upset, headache, fatigue, asthenia, dizziness rebound anemia when given with normal renal function v. contraindications: normal renal function, severe HTN, allergy to mammalian cell derivatives vi. nursing care establish baseline data and monitor CBC, renal function, blood pressure, transferrin, ferritin, erythropoietin level, neuro status target Hct: 30%-36% most effective when combined with iron, folic acid, or other supplements and balanced-diet administration o IV: do not shake vial o administer at the end of dialysis o subcu: may be diluted with 0.9% NaCl before administration to decrease discomfort client teaching o avoid pregnancy o injection technique b. type: iron preparations i. action: critical element in hemoglobin molecule and establishes its affinity for oxygen ii. examples ferrous fumarate (Feostat 100-200 mg by mouth 3 times/day) iii. uses: iron deficiency anemia, menstruating and pregnant women, rapidly growing adolescents, malnourished infants, GI bleeding iv. adverse effects severe anaphylaxis, CNS toxicity, coma, death GI irritation: anorexia, nausea, dark stools, constipation v. vi. contraindications: hemochromatosis, hemolytic anemia, normal serum iron, inflammatory bowel disorders nursing care establish baseline data and monitor Hgb, Hct, bilirubin, bowel pattern encourage intake of iron-rich foods

therapeutic effect may take 2-3 weeks, therapy may last 6-12 months administration o IV: administer over 1 hour o IM: must be administered with Z-track technique o orally

administer 1 hour before or after antacid best absorption on empty stomach with Vitamin C-rich substance

do not crush or chew tablets stools will be black and sticky may take with food if GI upset is severe prevent constipation with fluids, ambulation, and fiber o take at least 1 hour before bedtime and avoid reclining for at least 30 minutes d. type: folic acid [vitamin B complex group]
o o o o

action: required for red bone marrow function of RBCs, WBCs, and platelets example: folic acid (Folate 0.4 mg by mouth daily, pregnancy: 1 mg by mouth daily) uses o liver disease, alcoholism, hemolysis o pregnancy to prevent neural tube defects o megaloblastic or macrocytic anemia caused by folic acid deficiency adverse effects: bronchospasm, flushing contraindications: other anemias, vitamin B12 deficiency anemia, uncorrected pernicious anemia nursing care o establish baseline data and monitor fatigue, dyspnea, DOE, Hct and Hgb, folate level, nutritional status o collaborate with dietitian for folate-rich diet (see Table: Vitamin-rich foods on previous page) o administer IV push over at least one minute o review medication profile for oral contraceptives, estrogen, glucocorticoids, and hydantoins as contributors to folic acid deficiency o client teaching 1. report rash or fever 2. urine may become more yellow 3. most effective when combined with folate-rich diet d. type: vitamin B12 action: essential for cell growth and division, nerve function, protein and carbohydrate metabolism, RBC development and reproduction examples o vitamin B12: cyanocobalamin (vitamin B12 30100 mcg by mouth subcutaneous injection, IM daily for 7 days) o vitamin B12a: hydroxocobalamin (Hydroxocobalamin 30-100 mcg by mouth, subcutaneous injection, IM daily for 7 days) 30-100 mcg subcutaneous injection, IM daily for 7 days) uses o vitamin B12 deficiency

pernicious anemia, hemolytic anemia, Schilling test o malabsorption syndrome, pregnancy, thyrotoxicosis adverse effects o thromboembolic disorders, pulmonary edema, anaphylaxis, optic nerve atrophy o diarrhea, pruritus, rash contraindications: optic nerve atrophy nursing care o establish baseline data and monitor potassium, CBC, folic acid level, vitamin B12 level o collaborate with dietitian for diet rich in vitamin B12 o may be mixed with TPN, IV administration not recommended o client teaching 1. take with meals 2. IM therapy: may require life-long treatment 3. do not exceed recommended dosage 4. take in juice to disguise taste, take immediately after mixing
o

2. Therapeutic class: hemostatic agents a. type: heparin antagonist i. action: binds to heparin and renders it ineffective ii. example: protamine sulfate (Protamine 1 mg/100 units of heparin given IV) iii. uses: heparin overdose, reverse anticoagulation due to heparin iv. adverse effects CV collapse, pulmonary edema, severe respiratory distress, hypotension, bradycardia nausea, anorexia, rash v. contraindication: allergy to salmon vi. nursing care establish baseline data and monitor aPTT, Hct., platelets, occult blood, blood pressure and pulse administration o IV push over 1-3 min, dilute with water for injection, shake well o IV infusion: titrate to aPTT level client teaching: avoid activity that may result in bleeding or bruising b. type: warfarin antagonist i. action: promotes hepatic production of several clotting factors ii. example: form of vitamin K, phytonadione (aquaMEPHYTON 2.5-10 mg by mouth, subcutaneous injection, IM for 1 dose; may repeat in 12 hours) iii. uses: reverse anticoagulation induced by warfarin, vitamin K malabsorption, hemorrhagic disease of the newborn iv. adverse effects brain damage, hemolytic anemia, hemoglobinuria renders warfarin ineffective for > 10 days hyperbilirubinemia, rash

v.

nursing care establish baseline data and monitor INR, PT, bleeding, Hgb and Hct o INR most effective for monitoring effects collaborate with dietitian for foods rich in vitamin K IM administration in neonates 0.5-1.0 mg within 1 hour of birth IV administration not recommended client teaching o report bleeding o avoid alcohol and OTC drugs o need for follow-up care and testing o use soft toothbrush, avoid hazardous activity until INR is within normal limits

c. type: systemic hemostatic agents i. action: inhibits plasminogen activating substances to stop the endogenous system for dissolving clots ii. example: aminocaproic acid (Amicar 5 grams by mouth, IV for 1st hour, the 1-1.25 grams by mouth, IV every hour for 8 hours) iii. uses: hyperfibrinolytic states, prevent subarachnoid hemorrhage recurrence iv. adverse effects excessive clotting weakness, fatigue, muscle pain, renal dysfunction hallucinations, drowsiness, psychosis related to reduced cerebral blood flow nausea, diarrhea related to excessive thrombi formation in GI vasculature v. contraindications: acute DIC vi. nursing care establish baseline data and monitor neuro status, vital signs, peripheral perfusion, coagulation profile, RFT and LFT d. type: topical hemostatic agents i. action: stops superficial bleeding ii. examples absorbable gelatin (Gelfoam) o sponge is applied directly to affected area until bleeding stops o may increase risk of infection thrombin (Thrombinar, Thrombostat) o contraindicated in bovine allergy o mixed with clients blood to achieve hemostasis microfibrillar collagen (Avitene) o apply in dry form o apply pressure for 3-5 minutes after application 2. Therapeutic class: clotting factors c. action: replacement therapy for clotting factor deficiency d. examples and uses i. factor VIIa: coagulation factor VIIa for hemophilia A or B (! high alert drug) (NovoSeven 90 mcg/kg IV bolus every 2 hours until desired effect achieved) ii. factor VIII antihemophilic factor for hemophilia A (!high alert drug) (Bioclate 15-25 units/kg IV every 8-12 hours for 3 days)

desmopressin (DDAVP) (See also: II.G.6.a desmopressin) iii. factor IX: factor IX complex, hemophilia A, hemophilia B (Christmas disease) (!high alert drug) (Benefix) e. adverse effects i. nausea, stinging, itching, and burning ii. headache, flushing, chills, fever, lethargy iii. risks similar to blood products: hepatitis, HIV f. contraindications i. liver disease, DIC, fibrinolysis ii. allergy to mice, hamsters, and bovine products g. nursing care i. administer by IV infusion: slow rate if fever, chills, headache appear ii. establish baseline data and monitor vital signs, peripheral perfusion, clotting factor levels, LFT 3. Therapeutic class: agents for sickle cell anemia c. type: antineoplastic i. action: inhibits DNA synthesis ii. example: hydroxyurea (Hydrea 15 mg/kg/day by mouth daily) iii. use: leukemia, sickle cell anemia, ovarian cancer iv. adverse effects seizures, myelosuppression rash v. contraindications: thrombocytopenia, leukopenia vi. nursing care establish baseline data and monitor o temperature, bleeding, skin o CBC with differential, SaO2 o uric acid level, RFTs, LFTs, I & O provide oral care administration o avoid contact with skin o premedicate with antiemetic client teaching o report fainting, shortness of breath, bleeding, cough o avoid aspirin, ibuprofen o avoid shaving, dangerous activities, and sick people 4. Therapeutic class: granulocyte colony stimulator c. action: stimulates neutrophil production d. example: filgrastim (Neupogen) e. uses: decrease risk of infection for clients on antineoplastics, myelosuppressed, or drug-induced neutropenia f. adverse effects i. thrombocytopenia, respiratory distress syndrome ii. fever, nausea, diarrhea, mucositis g. contraindications: allergy to Escherichia coli protein h. nursing care i. establish baseline data and monitor vital signs, CBC, platelets, neutrophils continue therapy until ANC > 10,000/mm3 ii. administration infuse over <1 minute store in refrigerator, do not freeze restrict puncture of drug vials to 1 allow to warm to room temperature iii. client teaching injection technique avoid sick people, watch for signs of infection

K. Managing immunological conditions 1. Therapeutic class: anti-inflammatory agents a. type: non-steroidal anti-inflammatory agents (See also: II.D.3) b. type: steroidal anti-inflammatory agents i. action: powerful suppression of inflammation by inhibiting the mobilization leukocytes, fibroblasts, and inflammatory mediators, prevents increased capillary permeability ii. examples short-acting o hydrocortisone (Hydrocortone 20-240 mg by mouth daily in divided doses) o hydrocortisone sodium succinate (SoluCortef 20-120 mg/m2 IV every 12-24 hours) intermediate-acting: predniSONE (Deltasone 5-60 mg by mouth daily in 1-4 doses) long-acting: dexamethasone (Decadron 0.75-90 mg/kg by mouth daily every 6-12 hours, IV 1-6 mg every 2-6 hours for 72 hours) iii. uses gold standard for anti-inflammatory action septic shock, allergy, neoplasms, cerebral edema inflammatory diseases such as RA, severe COPD iv. adverse effects suppression of hypothalamic-pituitary-adrenal axis opportunistic infections, hyperglycemia, hemorrhage, gastritis, HTN, thromboembolic disorders, edema emotional lability, seizures, insomnia osteoporosis, poor wound healing, fragile skin hidden infection: client may not display expected findings associated with infection including fever and leukocytosis v. contraindications active infection, psychosis children < 2 years-old, AIDS, TB idiopathic thrombocytopenia, acute glomerulonephritis vi. nursing care establish baseline data and monitor o occult infection o serum glucose, potassium, cortisol level, WBCs o temperature, blood pressure, urine output, mental status frequently monitor for infection administration o undiluted IV push o suspension: give deep IM injection, do not give suspension IV o oral: administer with food or milk client teaching o take daily therapy in AM o report infection, fever, surgery, anorexia, fatigue, dizziness, joint pain o need for follow-up care and testing o do not abruptly discontinue therapy o wear MedicAlert tag, take only as directed o protect skin and avoid sick people, hand washing

injection technique for insulin to control hyperglycemia o avoid OTC drugs and herbal remedies including aloe and licorice 2. Therapeutic class: antihistamines a. first generation (associated with drowsiness) i. type: H1-receptor blockers action: compete with histamine for receptor sites to decrease allergic response examples o brompheniramine (Dimetane, Dimetapp 4 mg by mouth every 4-6 hours) o clemastine (Tavist 1.34 mg by mouth twice daily) o diphenhydrAMINE (Benadryl 12.5-50 mg by mouth every 4-6 hours) o promethazine (Phenergan) o see Therapeutic class: typical antipsychotic drugs uses o allergy, pruritus, allergic rhinitis o motion sickness, antiparkinson, infant colic o ameliorate allergic response during invasive procedures using contrast medium adverse effects o anaphylaxis, thrombocytopenia, hemolytic anemia o drowsiness, poor coordination o blurred vision, dry mouth, urinary retention, seizures o nightmares when used as hypnotic, especially with older clients contraindications: acute asthma nursing care o establish baseline data and monitor breath sounds and respiratory secretions, temperature, level of consciousness o assist for ambulation o do not confuse with dimenhyDRINATE o client teaching 1. may take with food 2. drink 2000 ml fluids daily 3. use sunscreen, ask for help when getting up 4. avoid alcohol, OTC drugs, CNS depressants 5. do not drive or engage in hazardous activities b. second generation (associated with less drowsiness and anticholinergic effects) (See also: II.B.6.b) c. type: mast cell stabilizers (See also: II.B.5) 3. Therapeutic class: immune modulators, stimulants a. type: interferons i. action: prevent viral replication in host cells, stimulate production of antiviral proteins, inhibits tumor growth, and increases aggressiveness of phagocytes ii. examples interferon beta-1a (Avonex) interferon alfa-n 1 lymphoblastoid (Wellferon) interferon alfa-2a/interferon alfa-2b (Roferon-A)
o

iii. iv.

v.

uses: chronic hepatitis C, malignant melanoma, Kaposis sarcoma, leukemia in clients > 18 years-old adverse effects myelosuppression, seizures, MI, heart failure, edema, blood pressure changes flushing, photosensitivity, flu-like symptoms GI upset, weight loss, xerostomia, impotence nursing care establish baseline data and monitor o vital signs, EKG, breath sounds: very frequently o CBC, weight o bleeding, oral mucosa, mental status avoid contact with skin clients may become hemodynamically unstable during therapy different interferons are not interchangeable: each has individual indications, dosing, and administration guidelines administer at bedtime with acetaminophen administration o given subcutaneously, IM, and intralesional o reconstitute and mix gently, solution may be stored for 30 days o only by qualified personnel, in controlled conditions, wearing gown, gloves, and mask client teaching o avoid hazardous activity o report signs of infection

b. type: interleukins (IL) i. action: stimulates cellular immunity of helper T cell to

inhibit tumor growth acts on lymphocytes to stimulate mitogenesis and cytotoxicity initiates killer T cell activity and interferon-? production examples aldesleukin (IL-2, interleukin-2) oprelvekin (Neumega) uses renal cell carcinoma, melanoma in combination with zidovudine for HIV adverse effects MI, cardiopulmonary arrest, capillary leak syndrome, CVA, myelosuppression, pulmonary edema, intestinal perforation or ileus, renal dysfunction muscle and joint pain, change in mood and mental status, dizziness, impaired motor function contraindications: abnormal thallium stress test, pulmonary function test, organ allografts nursing care establish baseline data and monitor o continuous blood pressure, EKG, SaO2, PAP, RAP o RFT, urine output, LFT, bleeding, acidosis o CBC, differential, platelets; maintain platelets > 75,000/mm3 and leukocytes > 2,000/ mm3 o clients may become hemodynamically unstable during therapy

ii. iii. iv.

v. vi.

do not confuse with Prokine may store unused solution in refrigerator within 48 hours, do not freeze administration o do not shake o infuse over 15 minutes without inline filter in plastic IV bag o be prepared to administer hydrocortisone for extravasation DOPamine for blood pressure support client teaching o report changes in breathing, cough o watch for infection avoid pregnancy o avoid shaving, aspirin, ibuprofen, alcohol c. type: T- and B-cell modulator i. action: stimulates B-cells leading to increased antibody formation which enhances T-cell, monocyte, and macrophage activity ii. example: levamisole (Ergamisol) iii. use: colon cancer in combination with fluorouracil iv. adverse effects myelosuppression GI upset, taste perversions, alopecia flu-like symptoms, dizziness, headache v. nursing care establish baseline data and monitor CBC and differential avoid concurrent administration of phenytoin or alcohol client teaching o avoid pregnancy o injection technique 2. Therapeutic class: immune modulators, immunosuppressants b. information common to immunosuppressive agents i. action: impair an aspect of the immune system most responsible for or likely to stimulate allograft rejection while exposing the individual to risks of immunosuppression ii. adverse effects susceptibility to opportunistic infections and malignancies, masks signs of infection, stimulates latent infection nephrotoxicity, hepatic dysfunction, hyperglycemia, hyperlipidemia, thrombocytopenia, dysrhythmias, embryotoxic and teratogenic anorexia, nausea, diarrhea potentiates the action and adverse effects of other immunosuppressants iii. contraindications: when risk of immunosuppression outweighs benefit of drug; tolerance iv. nursing care establish baseline data and monitor o drug levels, RFT, LFT, CBC, immune markers, tissue biopsy, CXR o allograft function cardiac: cardiac output, blood pressure, EKG, PAP, PCWP pulmonary: SaO2, PaCO2, PFT renal: creatinine, creatinine clearance

o o

hepatic: bilirubin, ALT, AST, prothrombin time search for infection client teaching need for follow-up care and testing avoid pregnancy, promptly report signs of infection follow manufactures instructions on mixing and administration, take only as directed, and take until instructed to stop hand-washing and infection control 1. wear tight fitting mask on windy days 2. cook meat, poultry, and fish until well-done 3. avoid sick people, ceiling fans and room fans 4. avoid digging in dirt, cat litter box, birds and bird cages 5. restrict fresh fruits and vegetables to items that are easily peeled or washed in soap and water such as bananas, oranges, apples, carrots, tomatoes, potatoes

b. type: T- and B-cell suppressants

action: suppress antibody production, suppressor and helper T-cells, and release of interleukins ii. examples: cyclosporine (Sandimmune, Neoral) mycophenolate mofetil (CellCept) sirolimus (Rapamune) (macrolide) tacrolimus (Prograf) iii. uses: prevention and treatment of transplant allograft rejection in combination with other immunosuppressants and glucocorticoids prevention of allograft vasculopathy autoimmune disorders, non-Hodgkins lymphoma, Crohns disease iv. adverse effects (See also: II.K.4.a.ii) lower risk of hyperlipidemia with tacrolimus (Prograf) v. nursing care (See also: II.K.4.a.iv) c. type: monoclonal antibodies i. action: impairs the effects of tumor necrosis factor alpha, competes with IL-2 for receptor sites, and impairs immunological response to antigens ii. examples muromonab-CD3 (Orthoclone OKT3) basiliximab (Simulect) infliximab (Remicade) iii. uses prevention and treatment of transplant allograft rejection in combination with other immunosuppressants and glucocorticoids Crohns disease, rheumatoid arthritis iv. adverse effects increased susceptibility to infection, heart failure, anaphylaxis, pulmonary edema, hemodynamic instability GI upset, bleeding, gingival hyperplasia fever, chills, headache, insomnia, muscle and joint pain impaired metabolism of uric acid, K+, Ca++, P v. nursing care establish baseline data and monitor o drug levels o RFT, LFT, CBC, CXR, hidden infection o cardiac allograft: cardiac output, blood pressure, EKG, PAP, PCWP o pulmonary allograft: SaO2, PaCO2, PFT o renal allograft: creatinine, creatinine clearance o hepatic allograft: bilirubin, ALT, AST, prothrombin time administration oral route preferred IV: reconstitute by gently inverting 50 ml bag of 5% dextrose or 0.9% NaCl, do not shake client teaching avoid pregnancy promptly report signs of infection need for follow-up care and testing hand-washing and infection control wear tight fitting mask on windy days cook meat, poultry, and fish until well-done

i.

vi.

vii.

avoid sick people, ceiling fans and room fans restrict fresh fruits and vegetables to items that are easily peeled or washed in soap and water such as bananas, oranges, apples, carrots, tomatoes, potatoes avoid digging in dirt, cat litter box, birds and bird cages e. type: glucocorticoids (See also: II.K.1)

used in combination with cyclosporine and other immunosuppressants

5. Therapeutic class: anti-infective agents a. information common to antibiotics

i. ii.

iii.

iv.

action: interferes with the cellular functioning of the pathogen resulting in impaired proliferation and death without injuring host uses surgical prophylaxis treatment of infections from susceptible bacterial pathogens adverse effects hepatotoxic and nephrotoxic especially in older clients diarrhea, secondary infections especially candidiasis GI upset including anorexia, nausea, diarrhea, especially common in children and older clients may render oral contraceptives ineffective contraindications: viral infections

v.

nursing care establish baseline data and monitor hydration, temperature, WBC, signs of the infection, bowel pattern, indications of secondary infection obtain cultures before initiating therapy client teaching o drink fluids, maintain nutrition o take entire course of the medication o continue to take medication when feeling better o barrier contraception may be required during therapy o resistant strains and secondary infections may develop if not taken as directed and for entire length of therapy o report secondary infection: vaginal itching, diarrhea, fever, rash, change in cough or sputum, white plaques in mouth

b. therapeutic class: antibiotics i. type: aminoglycosides action: powerful bactericidal agents associated with many severe adverse effects examples (dosing adjusted according to blood level of drug and renal function) o gentamycin (Garamycin 1 mg/kg IV every 8 hours) o streptomycin (Streptomycin 1 gram IM every 6 hours) uses: against susceptible gram-negative organisms including Pseudomonas, E. coli adverse effects o nephrotoxicity, myelosuppression, irreversible deafness, changes in blood pressure, pseudomembranous colitis o palpitations, diarrhea, weight loss, stomatitis o CNS toxicity: depression, disorientation, paresthesias contraindications o renal or hepatic dysfunction o Myasthenia gravis or parkinsonism o active herpes or mycobacterium infection i. ii. action: interferes with the cellular functioning of the pathogen resulting in impaired proliferation and death without injuring host uses surgical prophylaxis treatment of infections from susceptible bacterial pathogens adverse effects hepatotoxic and nephrotoxic especially in older clients diarrhea, secondary infections especially candidiasis GI upset including anorexia, nausea, diarrhea, especially common in children and older clients may render oral contraceptives ineffective contraindications: viral infections nursing care

iii.

iv. v.

establish baseline data and monitor hydration, temperature, WBC, signs of the infection, bowel pattern, indications of secondary infection obtain cultures before initiating therapy client teaching o drink fluids, maintain nutrition o take entire course of the medication o continue to take medication when feeling better o barrier contraception may be required during therapy o resistant strains and secondary infections may develop if not taken as directed and for entire length of therapy o report secondary infection: vaginal itching, diarrhea, fever, rash, change in cough or sputum, white plaques in mouth

b. therapeutic class: antibiotics i. type: aminoglycosides action: powerful bactericidal agents associated with many severe adverse effects examples (dosing adjusted according to blood level of drug and renal function) o gentamycin (Garamycin 1 mg/kg IV every 8 hours) o streptomycin (Streptomycin 1 gram IM every 6 hours) uses: against susceptible gram-negative organisms including Pseudomonas, E. coli adverse effects o nephrotoxicity, myelosuppression, irreversible deafness, changes in blood pressure, pseudomembranous colitis o palpitations, diarrhea, weight loss, stomatitis o CNS toxicity: depression, disorientation, paresthesias contraindications o renal or hepatic dysfunction o Myasthenia gravis or parkinsonism o active herpes or mycobacterium infection nursing care o monitor for signs of infection o client teaching 1. report severe diarrhea, headache, dyspnea, dizziness 2. avoid alcohol during therapy and for 72 hours after; may cause disulfiram-like reaction: flushing, headache, nausea, chest pain, dyspnea, blurred vision, seizures ii. type: dichloracetic acid derivative example: chloramphenicol (Chloromycetin 12.5 mg/kg by mouth, IV every 6 hours up to 100 mg/kg/day) use: meningitis, septicemia adverse effects o depression, Gray syndrome of newborn, myelosuppression o nausea, vomiting, diarrhea

iii.

iv.

v.

contraindications: severe renal or hepatic disease nursing care o establish baseline data and monitor 1. clinical indicators of infection, secondary infection 2. bowel pattern, bleeding 3. WBC, drug level, platelets, LFTs o screen clients for allergy to other antibiotics type: fluoroquinolones examples o ciprofloxacin (Cipro 500-750 by mouth every 12 hours) o levofloxacin (Levaquin 250-750 mg by mouth, IV every 24 hours) uses: against gram-negative bacteria usually associated with urinary tract, respiratory tract, and skin infections adverse effects o myelosuppression, depression, anaphylaxis o fever, rash, photosensitivity o insomnia, nausea, dry mouth, diarrhea contraindications: renal dysfunction nursing care o establish baseline data and monitor WBC, renal function, skin, neuro status o administer 2 hours before or after meals type: lincosamides example: clindamycin hydrochloride (Cleocin HCl 150-300 mg by mouth or 300-600 mg IV every 6 hours) uses: against Streptococci and Staphylococcus adverse effects: polyarthritis contraindications: allergy to tartrazine dye, ulcerative colitis nursing care o establish baseline data and monitor rash, fever, chills, joint pain, bleeding o avoid with renal insufficiency o keep emergency drugs and equipment at bedside o administration 1. do not crush or chew tablets 2. do not refrigerate oral preparations 3. give deep IM injection, give with 8 oz. of water 4. IV: dilute > 300 mg in at least 50 ml, infuse first dose at 10 mg/minute over 30 minutes, then 0.75 mg/minute type: macrolides examples o clarithromycin (Biaxin 250 mg by mouth every 12 hours) o erythromycin (E-Mycin) o azithromycin (Zithromax 500 mg by mouth on 1st day, then 250 mg by mouth for days 2-5) uses: against Staphylococcus pneumoniae, betahemolytic streptococci, Haemophilus influenzae adverse effects

vi. vii.

myelosuppression, hepatotoxic, pseudomembranous colitis, StevensJohnson syndrome, dysrhythmias o dizziness, increases blood levels of digoxin nursing care: establish baseline data and monitor LFT, Hct type: monobactam aztreonam (Azactam) used in serious infections, rarely used type: oxazolidinone action: prevents bacterial translation example: linezolid (Zyvox 600 mg by mouth, IV every 12 hours) (do not confuse with Vioxx) uses: vancomycin-resistant Enterococcus faecium, pneumonia adverse effects: myelosuppression nursing care o establish baseline data and monitor LFT, allergic reaction o IV: infuse over 30-120 minutes, do not infuse through another IV solution or any other drug client teaching o ask for help before getting up o avoid large amounts of food containing tyramine
o

viii.

store reconstituted oral mixture at room temperature for up to 3 weeks type: penicillins examples o penicillin G (Penicillin G Potassium 1-5 million units IM, IV every 4-6 hours) o penicillin V potassium (1 mg = 1600 units) (Pen-Vee 125-500 mg by mouth every 6-8 hours, 200,000-800,000 units by mouth every 6-8 hours) sub-type: aminopenicillin o amoxicillin (Amoxil 500-875 mg by mouth every 8 hours) o ampicillin (Principen 250 mg by mouth every 8 hours, 500 mg IV every 8-12 hours) sub-type: beta-lactamase inhibitors o amoxicillin with clavulanate (Augmentin 500 mg tab by mouth every 8 hours) uses o meningitis, septicemia, sinusitis o prophylaxis against bacterial endocarditis o infections of skin, respiratory tract, urinary tract adverse effects o glomerulonephritis, seizure, pseudomembranous colitis o myelosuppression, respiratory distress, anaphylaxis, serum sickness contraindication: neonates, hypersensitivity to penicillins, aminopenicillins, or cephalosporins nursing care o establish baseline data and monitor urine output, edema, bleeding o may give with food for GI upset o monitor INR during therapy if administered concurrently with warfarin o oral administration 1. capsules may be opened and taken with fluids 2. shake well before dosing, store in refrigerator up to 14 days 3. give around the clock, must be taken for 10-14 days for effective therapy
o

xii.

IV infusion rate: follow manufacturers instructions o client teaching report bleeding, fever, joint pain drink fluids and maintain nutrition type: streptogramins
o example: quinupristin and dalfopristin (Synercid) use: against vancomycin-resistant enterococci,

xii.

methicillin-resistant Staphylococcus aureus, penicillin-resistant pneumococcus type: sulfonamides action: inhibit folic acid synthesis examples o sulfisoxazole

xiii.

xiv.

cotrimoxazole (Septra, Bactrim: trimethoprim 160 mg with sulfamethoxazole 800 mg by mouth every 12 hours) uses: gram-negative and gram-positive bacteria, UTI, and STDs adverse effects o nephrotic syndrome, myelosuppression, hepatocellular injury, seizures o dizziness, ataxia, crystalluria o photosensitivity, rash, GI upset, stomatitis contraindications o history of renal dysfunction o allergy to sulfa drugs or sulfonamides, thiazide diuretics nursing care o establish baseline data and monitor RFT, UA o client teaching take 1 hour before or 2 hours after meals discontinue drug and report rash, hematuria, ringing in ears avoid driving and hazardous activities until adverse effects of drug are well-established drink 2,000-3,000 ml of fluids daily during therapy type: tetracyclines examples o tetracycline (Tetracyn) o doxycycline (Vibramycin 100 mg by mouth, IV every 12 hours) o minocycline (Minocin) uses: wide range of infections, when penicillin is contraindicated, acne, C. trachomatis adverse effects o hepatotoxic o GI upset, nausea, glossitis, dysphagia o weaken teeth and bones, photosensitivity, rash o decreases effectiveness of oral contraceptives, increases risk of digoxin toxicity contraindications: allergy to tartrazine, children < 8 years-old nursing care o establish baseline data and monitor LFT, RFT, o client teaching take 1 hour before or 2 hours after meals use sunscreen do not take with antacids or salts use barrier protection to avoid pregnancy type: tricyclic glycopeptide example: vancomycin (Vancocin 7.5 mg/kg IV every 6-12 hours) uses: drug resistant staphylococcal infections, pseudomembranous colitis, endocarditis, Clostridium
o

 adverse effects o cardiac arrest, anaphylaxis,

pseudomembranous colitis, nephrotoxicity, myelosuppression o red mans syndrome, ototoxicity nursing care o establish baseline data and monitor hearing, RFT, LFT, urine output, blood pressure, EKG, respiratory rate o establish baseline data and monitor drug peak and trough draw blood specimen 1 hour after a 1-hour infusion draw blood specimen for trough before next dose o subsequent doses dependent on serum concentration o IV infusion: rate not to exceed 500 mg/hour; decrease rate if red mans syndrome occurs o client teaching: take at equal intervals around the clock to maintain even drug levels 2. type: antifungal agents xi. information common to antifungal agents action: alter fungal cell permeability, prevents replication causing cell death adverse effects o hepatotoxicity, renal dysfunction o nausea, dyspepsia, anorexia o rash, headache, dizziness, fever contraindications: renal or hepatic dysfunction nursing care o obtain cultures before initiating therapy o establish baseline data and monitor LFT, RFT, neuro status o client teaching therapy may last for 6 months report unusual bruising or bleeding, jaundice change position slowly, ask for help before getting up take entire course of therapy, do not stop taking when feeling better xii. sub-type: azoles action: fungistatic and fungicidal systemic agent examples o ketoconazole (Nizoral 200-400 mg by mouth daily) o fluconazole (Diflucan 100 mg by mouth, IV daily for at least 2 weeks) uses: Candidiasis, Cryptococcal meningitis, peritonitis adverse effects: hepatotoxic, Stevens-Johnson syndrome nursing care o establish baseline data and monitor INR, LFT o administration do not admix IV administration with inline filter in distal veins; prevent extravasation

o o

do not rely on PT levels if on warfarin: effect on liver may alter PT, use INR results client teaching may take with food shake oral suspension before using use barrier contraception to avoid pregnancy report jaundice, nausea, anorexia, fatigue, dark urine or stool

iii.

iv.

sub-type: amphotericin B, systemic agent examples: amphotericin B deoxycholate (Fungizone 0.5-0.7 mg/kg IV daily) uses: severe, potentially fatal fungal infections adverse effects o hemorrhagic gastroenteritis, acute liver failure o renal tubular necrosis, myelosuppression o headache, fever, chills, neuropathy o myalgia, arthralgia, weakness o anorexia, nausea, low serum electrolytes contraindications: severe myelosuppression nursing care o establish baseline data and monitor Hct, Hgb, RFT, LFT, serum K+, Mg+ +, Na+, weight monitor VS every 15 minutes during initial infusion: check blood pressure and heart rate o administer 2,000-3,000 ml fluid daily o IV administration first dose: run a test dose of 1 mg over 30 minutes and monitor clients reaction o change needle after diluting, shake to mix well, then change needle after mixing in IV bag administer over at least 2 hours monitor closely for extravasation, use in-line filter give acetaminophen and diphenhydrAMINE 30 minutes before initiating infusion o topical administration do not use occlusive dressing clean area before each application rub into lesion, cover lesion completely o client teaching avoid acidophilus, do not itch area avoid OTC topical agents, may stain clothing use glove to apply agent to skin, wash hands thoroughly after application to prevent spread sub-type: nystatin example: nystatin (Mycostatin swish in mouth and swallow) uses: oral and topical treatment of Candida organisms; prevent thrush in immunosuppressed clients

adverse effects: nausea, anorexia, diarrhea, cramps, rash nursing care o eliminate cause of fungal infection o suspension: shake well, swish in mouth, swallow; store in refrigerator o topical: clean area before each application, apply agent to glove or swab for application o vaginal: insert high in vaginal vault, store at room temperature in dry area, protect from light client teaching o avoid getting agent on hands o long-term therapy may be required o avoid commercial mouthwash during oral therapy o avoid occlusive dressings or OTC drugs, ointment, creams, and lotions to affected area

c. type: antiviral agents i. information common to antiviral agents adverse effects: hepatic and renal dysfunction contraindication: infections other than viral nursing care o children and older clients may experience increased sensitivity to antiviral agents ii. sub-type: agents for influenza A and respiratory viruses action: prevents viral replication examples o amantadine (See also: II.C.2.a.ii antiparkinson agents: dopamine agonists) (Symmetrel 200 mg by mouth daily or in 2 doses) o oseltamivir (Tamiflu 75 mg by mouth twice daily for 5 days) o ribavirin (Virazole 600 mg by mouth twice daily for 6 months, may be inhaled for children) uses: prevention and treatment of influenzae, RSV, and respiratory viruses adverse effects o dizziness, insomnia o nausea, orthostatic hypotension contraindications: hepatic or renal dysfunction nursing care o establish baseline data and monitor neuro status, blood pressure, respiratory rate, urine output o initiate therapy as soon as possible after exposure client teaching: complete course of therapy to obtain full therapeutic effect

iii.

sub-type: agents for herpes and cytomegalovirus (CMV) action: inhibit viral replication examples o herpes: acyclovir (Zovirax 200 mg by mouth 5 times daily) o CMV: ganciclovir (Cytovene 5-6 mg/kg IV on 5 out of 7 days/week)

uses herpes: cold sores, encephalitis, shingles, and genital lesions o CMV: infections in eye, respiratory tract, liver adverse effects o myelosuppression, abnormal LFT and RFT, seizures, coma o dizziness, drowsiness o nausea, vomiting, headache, depression o rash, inflammation, and burning at injection site contraindications: ANC < 500/mm3 or platelets <25,000/mm3, renal disease or severe CNS disorders nursing care o establish baseline data and monitor lesions, neuro status, RFT and LFT, CBC with differential, bleeding o maintain hydration o administration oral: may take with food IV: mix with same precautions as antineoplastics; infuse over 1 hours with inline filter, do not bolus o client teaching report swollen lymph nodes, fever, paresthesias, bleeding therapy is not curative wear gloves for topical application avoid sexual intercourse to prevent spread of virus need for follow-up care and testing: ophthalmologist, blood tests complete course of therapy to increase effectiveness and to prevent emergence of resistant strains
o

iv.

agents for HIV and AIDS reverse transcriptase inhibitor o action: bind directly to HIV reverse transcriptase to prevent transfer of information vital to viral replication and survival o examples delavirdine (Rescriptor 9 or 18 mcg/kg/day IV for 5 days, every 21 days) nevirapine (Viramune 200 mg by mouth daily for 14 days, then 200 mg by mouth twice daily in combination with a nucleoside analog antiretroviral agents (See also: II.K.5.c.iv- nucleoside analog antiretroviral agents) o use: in combination with other antiviral agents o adverse effects nephrotoxicity, hepatotoxicity, myelosuppression

fatigue, diarrhea, anorexia, rash, myalgia o nursing care establish baseline data and monitor LFT, RFT, bowel pattern, bleeding, skin, CBC, CD4 and CD8 counts drug levels decrease with concurrent protease inhibitor therapy administration: add 4 tablets (each 100 mg) to 3-4 oz. of water, allow to stand, stir, swallow mixture, rinse glass, swallow contents o client teaching report signs of toxicity: severe nausea, vomiting, maculopapular rash must be taken at equal intervals around the clock missed dose: take up to 1 hour before next dose, do not double dose protease inhibitors o action: block protease activity in the HIV critical for viral maturation o examples amprenavir (Agenerase 1200 mg by mouth twice daily with other antiretrovirals) nelfinavir (Viracept 1250 mg by mouth twice daily) o use: in combination with other retroviral agents against HIV o adverse effects hepatotoxic, hemolytic anemia, Stevens-Johnson syndrome diarrhea, paresthesias, hyperglycemia, nausea, rash o contraindications: renal failure o nursing care avoid administration with antacids capsules and oral solution are not interchangeable establish baseline data and monitor LFT, RFT, CBC, viral load, CD4 count, bowel pattern, skin o client teaching report diarrhea, nausea, vomiting, rash may take with food, but not high-fat food must be taken at equal intervals around the clock avoid pregnancy, OTC drugs and St. Johns wort nucleoside analog antiretroviral agents o action: inhibit cell protein synthesis o examples abacavir (Ziagen 300 mg by mouth twice daily) didanosine (Videx 400 mg by mouth daily with buffered powder packet)

lamivudine (Epivir 150 mg by mouth twice daily) zidovudine (AZT, Retrovir 200 mg by mouth 3 times daily) o uses: in documented AIDS or ARC for clients with deficient T-cell levels and opportunistic infections o adverse effects seizures, myelosuppression fever, headache, malaise, constipation, diarrhea change in taste, hearing loss, photophobia paresthesias, twitching, emotional lability, vertigo, loss of mental acuity o nursing care establish baseline data and monitor neuro status, LFT, pancreatic enzymes, retinal exam, CBC with differential, platelets, viral load, CD4 count, temperature administer on empty stomach o client teaching report fever, flu-like symptoms, faintness, shortness of breath must take on empty stomach avoid OTC and herbal remedies use condom during sexual intercourse combination agents o lamivudine and zidovudine (Combivir) o abacavir, lamivudine, and zidovudine (Trizivir) v. locally active antiviral agents action: interfere with viral replication and metabolic processes examples o penciclovir (Denavir 1% cream every 2 hours for 4 days) uses: CMV retinitis, genital herpes, herpes labialis adverse effects: local burning and discomfort nursing care o agents are injected or implanted in the eye, applied topically o client teaching: these agents are not curative 2. type: antiprotozoal agents iv. sub-type: antimalarial agents action: attack various phases of the red blood cell phase of the Plasmodium malariae life cycle examples o chloroquine (Aralen 300 mg by mouth weekly for 1-2 weeks prior to exposure, post-exposure treatment 5 mg/kg at 6 hours, 24 hours, and 48 hours) o hydroxychloroquine (Plaquenil 200-400 mg by mouth daily) uses: used in combination with other antimalarial agents adverse effects

seizure, heart block, hypotension, asystole, myelosuppression, exfoliative dermatitis o nausea, anorexia, diarrhea, cramps o blurred vision, corneal or retinal changes, vertigo, deafness contraindications: visual field changes, porphyria nursing care o decreased absorption with antacids o IM injection: aspirate before injecting o administer 1 hour before or 2 hours after meals o establish baseline data and monitor vision, stability, LFT o client teaching report anorexia, jaundice, paresthesias avoid alcohol ask for help before getting up need for follow-up care and testing take with meals if GI upset is severe avoid driving and dangerous activities with impaired vision v. other antiprotozoal agents action: inhibit DNA synthesis in susceptible protozoans examples o metronidazole (Flagyl, MetroGel 200-400 mg by mouth every 8 hours) o pentamidine (Pentam 300: 4 mg/kg IV daily for 14-21 days) o atovaquone (Mepron) uses: against Pneumocystis carinii, amebiasis, trichomoniasis, trypanosomiasis, and leishmaniasis; client with Pneumocystis carinii resistant to co-trimoxazole adverse effects o myelosuppression, increased ICP, nephrotoxicity o dysrhythmias, Stevens-Johnson syndrome, acute pancreatitis o pruritus, rash, thrush, sterile abscess at injection site o hyperkalemia, hyponatremia, altered glucose metabolism o anorexia, diarrhea, increased LFT, abdominal pain nursing care o establish baseline data and monitor WBC, serum Na+ and K+, serum glucose, EKG breath sounds, neuro status, bowel pattern o IM administration: use Z-track method, do not mix with normal saline o IV administration over 1 hour o inhalant therapy over 30-45 minutes o client teaching avoid alcohol and aspirin ask for help before getting up take with high-fat foods, maintain hydration 3. therapeutic class: anthelmintics
o

action: impair metabolic pathways present in invading worm that humans do not have v. examples pyrantel (Antiminth, Pin-Rid) thiabendazole (Mintezol) albendazole (Albenza 400 mg by mouth twice daily for 28 days, followed by 14 days off, repeat this cycle two additional times) vi. uses: pinworm, hookworm, roundworm, tapeworm, whipworm vii. adverse effects Stevens-Johnson syndrome, renal failure, severe myelosuppression fever, malaise, dizziness, drowsiness rash, pruritus, alopecia, fever, headache abdominal pain, diarrhea, anorexia viii. contraindications: renal or hepatic disease, severe diarrhea, malnutrition ix. nursing care establish baseline data and monitor reflexes, muscle strength, LFT, RFT, skin client teaching o report worsening symptoms o ask for help before getting up o complete full course of therapy for effectiveness o avoid tub baths; shower at least once daily in AM o sanitize toilet facility; wash bed linens and underwear in hot water o wash hands and scrub under fingernails after voiding or bowel movement 2. Therapeutic class: antineoplastic agents 1. information common to antineoplastic agents iv. action: effects malignant cells in the cell-cycle (active) or non-cell cycle (resting) state; destroys malignant cells and halts their progression without destroying the host v. adverse effects heart failure, pulmonary edema, neurotoxicity, nephrotoxicity, hepatotoxicity, bleeding, often debilitating, severe immunosuppression cytotoxic to malignant and normal cells, attacking the most rapidly dividing cells: hair, GI tract, bone marrow loss of body hair, extreme fatigue, malaise GI: nausea, vomiting, diarrhea, anorexia, stomatitis vi. nursing care establish baseline data and monitor WBC, LFT, RFT, tumor markers maintain nutrition, fluid and electrolyte balance protect client from infection, provide frequent oral care symptom management: nausea, vomiting, stomatitis, fatigue, constipation, diarrhea emotional support and counseling for client and family o provide information o assist with hats, wigs, scarves o collaborate with social services for support groups o provide rest, information, calm, soothing environment

iv.

provide therapeutic communication: offer active listening, reflection, open ended questions, control o offer strategies to ameliorate adverse effects: pre-administration antiemetics, sedation; small frequent meals, trigger avoidance, pain management administration and handling o use Luer-Lok fittings, label antineoplastic drugs with cytotoxic warning o avoid contact with skin, mouth, eyes: wear non-permeable gloves, gown; wear goggles o avoid inhaling aerosols mixing should be performed with laminar airflow hood place equipment and waste in sharps container labeled with cytotoxic waste leak-proof, puncture-proof containers with cytotoxic label empty body waste into toilet without splashing o dispose of waste safely, handle body fluids safely urine for at least 48 hours and stool for 7 days after last dose wear non-permeable gloves, gown, goggles for waste, fluids, and linens o clean work surfaces according to manufacturers directions prevent extravasation o establish baseline data and monitor infusion site avoid using distal or small veins confirm integrity of IV site before infusing o avoid using infusion control device to administer: if extravasation occurs, device pumps drug under pressure into soft tissue, may result in severe tissue damage o stop infusion immediately if extravasation is suspected: keep antidote immediately available (See also: II.K.6.j.i agents to manage extravasation) client teaching o report: unusual bruising and bleeding, fever, chills, sore throat, dyspnea, flank pain, swelling o need for follow-up care and testing o avoid pregnancy: use barrier contraception o take as directed and take entire course of therapy o wash fresh fruits and vegetables in soap and water o avoid sick people, perform thorough, frequent hand washing o try to maintain balanced diet: eat highly nutritious food, drink 10-12 glasses of water daily
o

b. type: alkylating agents i. action: non-cell cycle-specific; effect neoplasm cell DNA, RNA, or protein in resting or active state to disrupt intracellular mechanisms and cause cell death ii. examples mechlorethamine (Nitrogen Mustard 0.4 mg/kg IV as single dose or divided over 2-4 days) do not cross blood-brain-barrier o busulfan (Myleran 0.6-1.2 mg/kg/day by mouth, titrate to maintain WBC at 20,000/mm3) o cyclophosphamide (Cytoxan 1-5 mg/kg/day by mouth 40-50 mg/kg in divided doses over 2-5 days) cross blood-brain-barrier o carboplatin (Paraplatin 300 mg/m2 IV at 4week intervals) o cisplatin (Platinol 20 mg/m2 IV daily for 5 days, repeat at 3-4-week intervals) iii. uses: leukemia, lymphoma, solid organ neoplasms, multiple myeloma iv. adverse effects severe myelosuppression, nephrotoxicity, hepatotoxicity, central neurotoxicity alopecia, fluid and electrolyte imbalance, seizures nausea, vomiting, anorexia, diarrhea, erosion of GI tract hemorrhagic cystitis, bleeding, tissue damage, extreme fatigue v. contraindications: allergy to platinum or mannitol, severe bone marrow depression, bleeding vi. nursing care establish baseline data and monitor o CBC with differential, RFT, LFT, tumor markers, serum electrolytes including calcium and uric acid o temperature, breath sounds, and SaO2 o urine output, neuro status, bowel patterns, bleeding administration: protect from light, avoid IV needles with aluminum

mechlorethamine: antidote is isotonic sodium thiosulfate (See Also: agents to manage extravasation II.K.9.j.i) client teaching o report fever, bleeding, severe nausea, vomiting, diarrhea, edema, ringing in ears o use barrier contraception o ask for help before getting up o encourage clients to obtain head covering early in therapy o take drug as directed and do not stop until directed to do so o avoid OTC drugs and herbal remedies, alcohol, shaving, commercial mouthwash, vaccinations c. type: antimetabolites (See also: II.K.6.b) i. action: replace normal metabolites to inhibit DNA production in malignant cells; S-phase specific and are most effective on rapidly dividing cells ii. examples 5-fluorouracil (5-FU 370 mg/m2 IV preceded by leucovorin 425 mg/m2 IV daily for 5 days, repeat every 4-5 weeks) mercaptopurine (6-MP, Purinethol 2.5 mg/kg by mouth as single or divided dose, after 4 weeks may increase to 5 mg/kg) iii. uses: leukemia, GI and basal cell cancer iv. adverse effects respiratory complications, hyperuricemia bone pain, chest pain, rash, conjunctivitis photosensitivity headache, drowsiness, aphasia d. type: antineoplastic antibiotics (See also: II.K.6.b) i. action: cytotoxic to rapidly dividing cells and interfere with DNA synthesis ii. examples bleomycin (Blenoxane 0.25-0.5 units/kg subcutaneous injection, IM, IV weekly or twice weekly) doxorubicin (Adriamycin 60-75 mg/m2 IV daily, repeat every 21 days) daunorubicin (DaunoXome 45 mg/m2 IV for 1st 3 days, then for 2 days in second course) iii. uses: sarcomas and carcinomas, squamous cell carcinoma, advanced HIV, Kaposi'?s sarcoma, leukemias iv. adverse effects: pulmonary fibrosis, cardiac and pulmonary toxicity, radiation recall v. contraindications: pre-existing diseases, debilitation vi. nursing care extravasation (See also: II.K.9.j.i agents to manage extravasation) o daunorubicin and doxorubicin: antidote is sodium bicarbonate injection o dactinomycin: antidote is ascorbic acid 50 mg injection e. type: cell-protecting agents i. action: binds and detoxifies damaging metabolites ii. example for cisplatin: amifostine (Ethyol 910 mg/m2 IV daily 30 minutes before chemotherapy)

for ifosfamide and cyclophosphamide: mesna (Mesnex: give mesna dose equal to 20% of ifosfamide dose) iii. adverse effects: dizziness, somnolence, hypotension, sneezing, hiccups, nausea, hypocalcemia iv. contraindications: hypotension, dehydration v. nursing care establish baseline data and monitor oral mucosa, fluid and electrolyte balance, Ca++, blood pressure administer within 30 minutes of chemotherapy by IV keep client in supine position during therapy client teaching: report severe nausea, vomiting, fever, chills, somnolence, hiccups, sneezing f. sub-type: folic acid antagonist i. action: prevents toxicity by protecting normal cells ii. example: leucovorin (Wellcovorin 10 mg/m2 by mouth, IM, IV) iii. uses: methotrexate toxicity iv. adverse effects: thrombocytosis, rash, pruritus, erythema, wheezing v. contraindications: anemias other than megaloblastic anemia vi. nursing care establish baseline data and monitor creatinine clearance, RFT, fluid status, skin increase fluid intake protect from heat and light IV administration: may give IVP < 160 mg/minute client teaching: drink 3,000 ml of fluid daily g. type: hormones and hormone modulators i. action: block or interfere with hormone receptor sites with hormone-sensitive tumors ii. examples ACTH-releasing: goserelin (Zoladex 3.6 mg subcutaneous injection every 4 weeks) androgen (See also: II.I.2 androgens): testosterone propionate anti-estrogen: anastrozole (Arimidex 1 mg by mouth daily) corticosteroids: dexamethasone (Decadron) estrogens: diethylstilbestrol (DES) estrogen antagonist: tamoxifen (Nolvadex 10-20 mg by mouth twice daily) iii. uses: breast and prostate cancer iv. adverse effects general: fluid retention, HTN, diabetes mellitus men: gynecomastia women: hirsutism, masculinization, symptoms of menopause h. type: mitotic inhibitors (See also: II.K.6.b) i. action: cell-cycle specific agents that kill cells at the beginning of cell division and interfere with DNA synthesis; work in the M phase of the cell cycle ii. examples paclitaxel (Taxol) vinblastine (Velban 100 mcg/kg IV, increase weekly) vincristine (Oncovin 10-30 mcg/kg IV once or twice weekly) iii. uses: malignant tumors, leukemia, Kaposis sarcoma, lymphoma iv. nursing care

i.

j.

establish baseline data and monitor CBC, LFT, RFT, breath sounds, bowel sounds, bowel pattern, mucous membranes antidotes (See also: II.K.9.j.i agents to manage extravasation) o hyaluronidase (Wydase) 1. administer subcutaneously into affected tissue 2. apply heat to area o antidote for vinblastine, vincristine is sodium bicarbonate injection type: monoclonal antibodies i. action: inhibits proliferation of malignant cells by binding to extracellular aspect of human epidermal growth factor receptor 2 (HER2) ii. example: trastuzumab (Herceptin) iii. use: breast cancer, metastatic breast cancer with HER2 overexpression iv. adverse effects leukopenia, tachycardia, hypotension, heart failure, anaphylaxis, angioedema, potentially fatal infusion reaction nausea, anorexia, diarrhea may mask signs of infection flu-like syndrome, cough, dyspnea, pharyngitis dizziness, confusion, rash, acne, herpes simplex v. contraindications: hypersensitivity to Chinese hamster ovary cell protein vi. nursing care establish baseline data and monitor WBC, neuro status, vital signs, EKG, echocardiogram, multigated angiogram establish baseline data and monitor fatal infusion reaction: fever, chills, nausea, vomiting, pain, dizziness, hypotension o discontinue drug administration o do not administer by IV push or bolus or in dextrose solution o reconstitute with 1.1% benzyl alcohol or sterile water for injection; mixture is good for 28 days o increase daily fluid intake to 2-3 L o client teaching 1. may take acetaminophen for fever or headache 2. avoid dangerous activities 3. ask for help before getting up 4. report signs of infection: fever, chills, sore throat, diarrhea 5. emotional lability is common, report severe condition to provider other agents related to antineoplastics i. agents to manage extravasation type: enzyme o action: disperses other drugs o example: hyaluronidase (Wydase) o use: extravasation of antimitotic chemotherapeutic agents, urography, hypodermoclysis o contraindications: hypersensitivity to bovine products, heart failure, hypoproteinemia,

around infected, inflamed, or cancerous tissue o nursing care: administer subcutaneously into affected tissue, apply heat type: alkalinizer o action: buffers H+ concentration o example: sodium bicarbonate 8.4% o use: extravasation of daunorubicin, doxorubicin, vinblastine, vincristine into soft tissue o nursing care 1. flush area with normal saline 2. apply cold compress 3. may infiltrate area with corticosteroid type: anti-alkylating agent o example: isotonic sodium thiosulfate (1/6 M) o use: extravasation of mechlorethamine (Nitrogen Mustard) o nursing care: infuse 10 ml immediately for extravasation 1. apply ice compress for 6-12 hours type: water-soluble vitamin o example: ascorbic acid, vitamin C o use: extravasation of dactinomycin o nursing care: administer 50 mg injection 1. flush area with normal saline 2. apply cold compresses 3. may also use corticosteroid injection k. adjunct therapy i. therapeutic class: antiemetics (See also: II.F.1 antiemetics) type: serotonin (5HT) receptor blockers (See also: II.F.1.e 5HT receptor blockers) o examples 1. granisetron (Kytril 1 mg by mouth twice daily at least 30 minutes before chemotherapy) 2. ondansetron (Zofran) o nursing care 1. very effective, often combined with corticosteroids 2. granisetron: given two times daily beginning 30 minutes before starting chemotherapy 3. ondansetron: given two times daily beginning 30 minutes before starting chemotherapy type: benzodiazepine (See also: III.D.2.b anxiolytics) o examples 1. alprazolam (Xanax) 2. lorazepam (Ativan) o nursing care: very effective, may give with corticosteroids type: dopaminergic blocker (See also: II.F.1.f antiemetics: dopaminergic blockers) o example: metoclopramide (Reglan) o nursing care 1. especially effective when combined with a corticosteroid, an antihistamine, and a centrally-acting blocker (haloperidol)

ii.

type: combined dopaminergic, a-adrenergic, anticholinergic blocker (See also: III.D.3 antipsychotic agents) o example: haloperidol (Haldol) type: phenothiazines (See also: III.D.3 antipsychotic agents) o example: prochlorperazine (Compazine) type: tetrahydrocannabinol derivative o example: dronabinol (Marinol) o nursing care 1. associated with many side effects 2. usual dose 5 mg/mm2 1-3 hours before chemotherapy, may repeat every 2-4 hours after chemotherapy nursing care: most effective when combined with supportive and comforting measures o oral care, ice chips o environmental control o accepting environment therapeutic class: antihistamines (See also: II.K.2 antihistamines) o use: to manage secretions associated with chemotherapy therapeutic class: anti-inflammatory agents type: steroid (See also: II.K.1.b steroid antiinflammatory agents) o example: corticosteroids o use: decrease inflammation associated with chemotherapy

L. Managing eye conditions 1. Drugs used to manage glaucoma a. therapeutic class: cholinergic agents i. type: miotics

action: constrict the pupil and increase drainage of aqueous humor by stimulating the ciliary muscle to contract example

o o o

pilocarpine hydrochloride (Isopto Carpine 4%-5% solution) (Ocusert Pilo-20 20 mcg/hr for 7 days) homatropine hydrobromide (Isopto Homatropine) cyclopentolate hydrochloride (Cyclogyl) tropicamide (Mydriacyl)

uses
o

glaucoma, xerostomia, compromised lacrimal and salivary function adverse effects o increased risk of toxicity in children o diaphoresis, stimulation of salivation and GI tract without significant CV effects o stimulation of lacrimal, digestive, tracheobronchial glands; transient hypotension contraindications: asthma, hyperthyroidism, coronary insufficiency, PUD client teaching: blurred vision, poor vision at night, periorbital discomfort c. therapeutic class: cholinesterase inhibitors action: increases drainage of aqueous humor, pulls iris away from anterior chamber angle by constricting the ciliary muscle and iris sphincter example: physostigmine (Eserine) client teaching: may experience periorbital discomfort, watery eyes, burred vision c. therapeutic class: beta-adrenergic agents i. action: decrease intraocular pressure (IOP) by decreasing production of aqueous humor and increasing drainage ii. example: timolol maleate (Timoptic) iii. nursing care: establish baseline data and monitor blood pressure, heart rate may cause bronchospasm in clients with reactive airway disease, carefully review medication profile of clients with cardiac history d. therapeutic class: carbonic anhydrase inhibitors i. action: inhibits the enzyme needed to produce aqueous humor leading to decreased production ii. example: acetazolamide (Diamox) iii. nursing care establish baseline data and monitor potassium client teaching: report paresthesias, tinnitus, GI upset, or hearing loss e. therapeutic class: adrenergic agents i. action: decreases production of aqueous humor to decrease IOP ii. example: epinephrine bitartrate (Epitrate) iii. client teaching report tachycardia may experience blurred vision, periorbital discomfort, pigment deposits in cornea, conjunctiva, and lids f. therapeutic class: osmotic agents i. action: decreases IOP by moving water out of intraocular structures ii. example: isosorbide (Ismotic)

nursing care: establish baseline data and monitor serum electrolytes, glucose g. therapeutic class: prostaglandin agonists i. action: increases outflow of aqueous ii. example: latanoprost (Xalatan) iii. nursing care establish baseline data and monitor RFT and LFT client teaching: may experience burning, blurred vision, itching, photophobia h. therapeutic class: antiinfectives i. antibiotics (See also: II.K.5.a antibiotics) ii. antiviral agents (See also: II.K.5.c antiviral agents) i. therapeutic class: glucocorticoids (See also: II.K.1.b antiinflammatory agents: glucocorticoids) M. Managing ear conditions 1. Managing infection: otitis media a. therapeutic class: antibiotics (See also: II.K.5.a) i. action: bactericidal by inhibiting cell wall synthesis ii. type: aminopenicillin 1. example: amoxicillin (Amoxil) iii. client teaching: take drug around the clock at regular intervals, completely finish prescription, do not miss doses b. therapeutic class: decongestants (See also: decongestants II.B.7) i. action: constricts smooth muscle to increase passageways ii. type: sympathomimetic 1. example: pseudoephedrine (Sudafed) iii. nursing care 1. establish baseline data and monitor heart rate and blood pressure 2. client teaching 1. avoid taking right before bedtime 2. withhold medication if restlessness or palpitations or racing heart occur 3. avoid OTC medications and stimulants 2. Managing vertigo a. therapeutic class: anticholinergics (See also: II.C.2.b anticholinergic agents) b. therapeutic class: antiemetics (See also: II.F.1 antiemetics) c. therapeutic class: antihistamines (See also: II.K.2 antihistamines) d. therapeutic class: diuretics (See also: II.A.7 diuretics) e. therapeutic class: vasodilators (See also: II.A.10 vasodilators)

iii.