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Nursing Care for Patients Receiving Medications that Affects Cellular Aberration

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Cebu Normal University

College of Nursing

Pharmacology, Therapeutics and Diagnostics

UNIT III

Nursing Care of Patients Receiving Medication that Affects Cellular Aberration

Antimicrobials – Fighting Infection

-ane – volatile general anesthetics

-caine – local anesthetics (cocaine)

-cillin – penicillins (nafcillin)

-cycline – tetracycline –type antibiotics (doxycycline)

Pharmacology conjures images of the magic pill a prescriber gives you to relieve your runny nose, headache, fever, and other symptoms that make it unbearable to go about daily activities.

A. From your body adjusting to irritants like pollen. B. Caused by malfunctioning parts of your body such as the pancreas in the case of diabetes. C. Invading microbial.

Microbial is a tiny organism—such as bacteria and viruses—that can enter the body and make you

sick.

Immune system produces antibodies that seek out, attack, and kill microbial. However, this natural defense isn’t sufficient for some patients who need to call in the cavalry. The cavalry is medication that kills the invading microbial.

Microorganism – A Small Formidable Opponent

There are millions of microorganisms around us—and in our body. Some are harmless. Others, called flora, help us with digestion. And then there are the harmful ones called pathogens. A pathogen is a microorganism that causes an infection.

Antimicrobials – Stuff Microorganisms Die For

Bacteriostatic - which means they stop the growth of bacteria

Antibiotic - is a bacteriocidal and kills bacteria using lysis, which explodes the bacteria into parts. There are four ways in which these medications work. 1. They inhibit the bacteria from growing a cell wall (cell wall synthesis). 2. They disrupt or alter the permeability of the bacteria’s membrane. The membrane is within the cell wall and is used to let nutrients into the cell and send waste out of the cell. 3. They inhibit the bacteria’s ability to make protein (protein synthesis). Medications that stop the growth of bacteria interrupt steps in protein synthesis. Those that kill bacteria cause the bacteria to form defective proteins. 4. They inhibit the bacteria’s capability to make (synthesize) essential metabolites. A metabolite is a component necessary for bacteria’s metabolism to function properly. Common ones that you probably recognize: • Rash • Fever • Urticaria (hives) with pruritis (itching) • Chills, general erythema (redness)


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• Anaphylaxis (circulatory collapse) These side effects are usually treatable by using other medication such as: • Antihistamines (Benadryl) • Epinephrine (adrenalin) • Steroids for anti-inflammatory response

Superinfections Antibiotics kill bacteria. The normal microbial flora dies along with the bacteria. This flora can be replaced by resistant bacteria and superinfection can occur. Resistance to the antibiotic is another problem that can occur. Culture and sensitivity studies should be performed on all infections in order to determine which antibiotics will work for the microorganism that is causing the infection. Some patients stop taking medication as soon as the symptoms of infection dissipate, however the bacterium is still alive and actively growing. The prescriber may under prescribe an antibiotic by giving the patient a lower-than-effective dose or order the antibiotic for a short period of time. At first this seems like a logical way to prevent the bacterium from becoming resistant to the antibiotic. However, a low dose may not completely kill the bacterium resulting in a recurrence of symptoms that requires additional doses of antibiotics. It is very important to choose the right antibiotic, in the right dose, for the right amount of time.

Preparing to Administer Antimicrobial Medication

Antimicrobial medication requires the nurse to follow the same general administration procedures that are required for any type of medication.

The most critical step is to determine if the patient has allergies to drugs, food, environmental

stimuli, and a family history of allergies to antibiotics. Always display allergies in red and clearly write them on the patient’s record. Even if the

patient’s record indicates that the patient doesn’t have allergies, always ask the patient each time you administer the antimicrobial medication.

Always have emergency medications such as epinephrine, Benadryl, and steroids handy so they

can be given to counteract any adverse side effect of the antimicrobial medication.

Be sure to carefully monitor the patient for a half hour. After the medication is given to determine if the patient experiences an adverse reaction.

It is important to administer antimicrobials at the times described in the prescriber’s order in order to maintain a therapeutic blood level of the medication.

Sometimes a double dose of an antibiotic is administered as the first dose to quickly achieve a

therapeutic level. This is called a loading dose. Intramuscular injections of antibiotics should be given deep into the muscle and sites should be

rotated if more than one injection is prescribed. In severe cases, aggressive treatment is necessary to control the growth and destroy the

microbial quickly. To do this, the medication is administered parenterally in an IV dose that is diluted in a neutral solution (pH 7.0 to 7.2) such as normal saline (N.S.) or isotonic sodium chloride or 5% dextrose and water (D5W). Antibiotics should not be mixed together or administered at the same time.


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They can be administered as a piggyback infusion. The following nursing diagnoses can be used for patients who are taking antibiotics:

Risk of infection related to treatment failure or superinfection. Risk of fever related to treatment failure or superinfection. Risk of fluid volume deficit related to adverse GI reaction such as anorexia,

nausea/vomiting/diarrhea, and complications of allergic reaction.

They are also at risk for having the following collaborative problems: Sepsis Ototoxicity (ears) Blood dyscrasias Nephrotoxicity (kidney)

It is critical that the patient be given information on the management of his or her condition.

These instructions include: Take all the medication even after the symptoms subsides. Do not take medication that is left over from a previous illness. (The medication may not treat

the patient’s condition or may have lost its therapeutic capabilities.) Do not share drinks, food, and utensils with others until the healthcare provider determines that

the patient is no longer infected by the microbial. Sharing may enable the microbial to spread to other people.

Recognize the expected effects, side effects, and adverse reactions that might occur as a result of taking the medication. Also provide the patient with a telephone number to call if the patient has questions about these effects.

Wear a Med-alert bracelet if the patient has allergies to medication. PENICILLIN Introduction

Penicillin (PCN) is derived from molds that you sometimes see on bread and fruit. It was discovered in 1940 and remains the most effective—and least toxic—antimicrobial drug. Drug Name:

amoxicillin (Amoxil)

ampicillin

penicillin G Sodium or Potassium (Pfizerpen)

penicillin V Potassium (Penicillin VK)

amoxicillin and potassium clavulanate (Augmentin) Pharmacodynamics

Penicillin weakens the cell wall of a bacteria resulting in the rupture and destruction of a cell, which is called lysis.

Overuse of penicillin allows bacteria that were initially sensitive to natural penicillin’s to develop a protective enzyme (penicillinase or B-lactamase) and become resistant to therapy.

Other newly developed penicillin’s include broad spectrum penicillin’s (aminopenicillin’s) which have an amino group attached to their penicillin nucleus that enhances their activity against gram-negative bacteria.


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Extended spectrum penicillin’s have a wider spectrum of activity than do other types of penicillin.

Penicillin are bactericidal (inhibits the action of enzymes that are necessary for bacterial cell wall formation)

Pharmacotherapeutics

Penicillin is most active against gram-positive bacteria and some gram negative bacteria.

However, it isn’t active against bacteria that contain enzymes that destroy penicillin. There are four types of penicillin:

1. Basic (natural) 2. Penicillinase-resistant (resistant to beta-lactamase inactivation) 3. Aminopenicillins (broad spectrum) 4. Extended-spectrum

- Treatment for pharyngitis, tonsillitis, otitis media, pneumonia, endocarditis, soft-tissue

infections, meningitis, scarlet fever, rat-bite fever, diphtheria, anthrax, UTI, syphilis, and gonorrhoea.

- Prophylaxis for surgery and dental procedures.

Drug Interactions

Penicillin can produce adverse effects if it is administered in conjunction with other drugs.

This is the situation with giving penicillin with an anti-hypertensive such as Captopril (angiotensin-converting enzyme [ACE] inhibitors), potassium sparing diuretics such as Aldactone, potassium-containing drugs, or potassium supplements such as Kay Ciel. The combination of drugs may increase the patient’s potassium level (hyperkalemia) and therefore require that the patient’s serum potassium levels be carefully monitored while the patient receives penicillin.

There is an increased risk of bleeding when administering high doses of parenteral carbenicillin or ticarcillin as these drugs inhibit platelet aggregation.

In addition to information described for generic antibiotics, female patients should be informed that penicillin can interfere with the effectiveness of birth control pills that contain estrogen

Adverse Effects

- Most common cause of drug allergy - Minor rashes to life-threatening anaphylaxis - Occur within the first 30 minutes. - GI System with glossitis, mouth sores, anorexia, heartburn, gastritis abdominal pain, N/V, and

mild-to-severe diarrhea. - Taste alterations - Neurologic Reactions: lethargy, twitching, confusion, dysphasia, depression, hallucination, and

coma. - Hematologic Toxicity

Nursing Process Assessment

ALLERGY

Impaired renal function (a lower dose may be given in such cases).After penicillin is administered, monitor the patient for:


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o Serum electrolytes for hyperkalemia (elevated potassium) and/or hypernaturemia (elevated sodium)

o Unusual weight loss (especially in the elderly) o Vital signs o WBC o Cultures o Prothrombin Time (PT) (bleeding times)

Diagnosis

Altered protection against infection related to reduction in normal flora (superinfection)

Altered bowel elimination pattern related to antibiotic-associated pseudomembranous colitis

Fluid volume deficit related to nausea, vomiting, and/or diarrhea

Impaired skin integrity related to side effects or allergic reaction

Allergic response

Hepatotoxicity (toxicity affecting the liver)

Leukopenia (A decrease in the number of circulating white cells in the blood)

Neutropenia (abnormal decrease in the number of neutrophils, which are the most common type of white blood cells in the blood)

Thrombocytopenia (decreased number of platelets in the blood)

Mental disturbances

Seizures

Cross-sensitivity to cephalosporins, cephamycins, griseofulvin, or penicillamine

Abdominal cramps

Diarrhea

Darkened or discolored tongue

Sore mouth Planning

Infection will resolve

Maintain adequate hydration

Deficient knowledge

Implementation

If penicillin is given PO, avoid giving this medication an hour before and an hour after the patient has eaten.

Give penicillin with a full glass of water and not with acidic fruit juices.

If penicillin is administered IV, give it slowly because penicillin contains a large amount of potassium that can cause heart failure in patients with renal insufficiency.

Before penicillin is administered, the patient must be assessed for a number of conditions. (allergies) An allergic reaction to penicillin can be anywhere from a mild rash to anaphylactic shock and death.

Don’t administer penicillin to patients who have: o A tendency to bleed. o Ulcerative colitis and other GI diseases. o Mononucleosis (a skin rash may develop with use of ampicillin or bacampicillin). o A low-salt diet (parenteral carbenicillin and ticarcillin have high sodium content

Impaired renal function (a lower dose may be given in such cases).After penicillin is administered, monitor the patient for:

o Serum electrolytes for hyperkalemia (elevated potassium) and/or hypernaturemia (elevated sodium)

o Unusual weight loss (especially in the elderly) o Vital signs o WBC o Cultures o Prothrombin Time (PT) (bleeding times)

Evaluation


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Free from infection

Maintains adequate hydration

Demonstrate understanding of drug therapy CEPHALOSPORINS Introduction

First Generation: Effective against gram-positive bacteria Pregnancy Category: B

Cefadroxil (Duricef) Protein-Binding: 20%

Cefazolin (Ancef, Kefzol) Protein-Binding: 75%–85%

Cephalexin (Keflex) Protein-Binding: 65%–80%

Cephalothin (Keflin) Protein-Binding: 10%–15%

Cephapirin (Cefadyl) Protein-Binding 40%–50%

Cephradine (Velosef, Anspor) Protein-Binding: 20%

Second Generation: Increased activity against gram (−) microorganisms Pregnancy Category: B

Cefaclor (Ceclor) Protein-Binding: 25%

Cefamandole (Mandol) Protein-Binding: 60%–75%

Cefmetazole (Zefazone) Protein-Binding: 68%

Cefonicid (Monocid) Protein-Binding: 98%

Cefotetan (Cefotan) Protein-Binding: 85%

Cefoxitin (Mefoxin) Protein-Binding: 70%

Cefprozil (Cefzil) Protein-Binding: 99%

Cefurozine (Ceftin, Zinacef) Protein-Binding: 50%

Loracarbef (Lorabid) Protein-Binding: Unknown

Third Generation: More active against gram (−); ceftazidime and cefoperazone are also effective against Pseudomonas aeruginosa (gram −) and b-lactamaseproducing microbial strains; less effective against gram (+) cocci Pregnancy Category: B

Cefixime (Suprax) Protein-Binding: 65%

Cefoperazone (Cefobid) Protein-Binding: 70%–80%

Cefotaxime (claforan) Protein-Binding: 30%–40%

Cefpodoxime (Vantin, Proxetil)


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Protein-Binding: 20%–40%

Ceftazidime (Fortaz) Protein-Binding: 10%–17%

Ceftibuten (Cedax) Protein-Binding: Unknown

Ceftriaxone (Recephin) Protein-Binding: 85–95%

Ceftizoxime (Cefizox) Protein-Binding: 30%–60%

Cefdinir (Omnicef) Protein-Binding: Unknown

Fourth Generation: Cefipime same as third generation + more resistant to b-lactamases Pregnancy Category: B

Cefepine (Maxipime) Protein-Binding: Unknown

Pharmakokinetics

Administered parenterally because they aren’t absorbed from the GIT tract.

Some can be administered orally.

Pharmacodynamics

The cephalosporin family of medications is a chemically modified version of penicillin that stops growth and kills a broad spectrum of bacteria by making it impossible for bacteria to create a cell wall.


Cephalosporin can be prescribed for patients who are allergic to penicillin.

Prescribers use cephalosporins to combat a wide variety of infections and typically use it as a prophylaxis to prevent a bacterial infection to occur during or after surgery.

Sinusitis, pharyngitis, laryngitis, tonsillitis, bronchitis, otitis media, skin infections, UTI,

abdominal infections, PID, septicaemia, meningitis, and osteomyelitis.

Drug Interactions

Alcohol. should be avoided when taking certain cephalosporins (cefamandole, cefoperazone, or moxalactam) because patients might experience adverse side effects that include:

Stomach pain

Nausea

Vomiting

Headaches

Hypotension

Tachycardia (fast heart rate)

Difficulty breathing

Sweating

Flushed face

Besides alcohol, some cephalosporins (cefamandole, cefmetazole, cefoperazone, or cefotetan) expose the patient to an increased risk of hemorrhaging if administered with anticoagulants such as coumarin or indanedione, heparin, and with clot-busting drugs such as thrombolytics.

The same adverse reaction might occur if the patient takes NSAIDs, especially aspirin, or sulfinpyrazone (Anturane) while on cephalosporins

Adverse Effects

Cephalosporins also have side effects which include diarrhea, abdominal cramps or distress, oral and/or vaginal candidiasis, rash, pruritis, redness, or edema. There is also an increase of


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bleeding and bruising with four commonly prescribed cephalosporins: cefamandole, cefmetazole, cefoperazone, and cefotetan.

A patient who is undergoing treatment with cephalosporins might experience other problems. These are a fever and rash brought about by hypersensivity, an allergic reaction such as anaphylaxis, Stevens-Johnson syndrome, renal dysfunction, serum sickness-like reaction, or seizures. Nursing Process

Assessment

The patient assessment for cephalosporins is the same as for penicillin.

pay particular attention to any previous bleeding disorder reported by the patient because cephalosporins can exacerbate this condition.

Before administering cephalosporins, assess for allergies, vital signs, and urine output.

Check laboratory results, especially those that indicate renal and liver function such as BUN, serum creatinine, AST, ALT, ALP, and bilirubin. Also monitor bleeding time (PT and PTT) and white blood cell count.

Diagnosis

Here are the common nursing diagnoses that are related to a patient who is receiving cephalosporins.

Altered bowel elimination pattern related to antibiotic-associated pseudomembranous colitis

Risk for superinfection

Altered protection related to hypoprothrombinemia and superinfection

Planning

the same

Intervention

Do not administer cephalosporins to patients who have had a serious reaction to penicillin such as anaphylaxis.

Administer cephalosporins using the same methods as used for penicillin.

If given IM, it should be injected deeply into a large muscle mass. This decreases pain, induration (becoming hard), and a sterile abscess.

The patient should be provided with the same instructions as is given to a patient who is receiving penicillin

Take a small meal or snack to decrease GI effects.

Adequate hydration

Avoid taking alcohol until 72 hour after drug discontinuation to avoid the disulfiram like reaction.

Report if difficulty in breathing, severe H/A, severe diarrhea, dizziness, weakness, and superinfections.

Evaluation

same

Sulfonamide

Introduction

Pregnancy Category: C

Synthetic derivatives that are Bacteriostatic, which means they have the ability to inhibit the formation

of new bacteria but have no effect on bacteria that are already formed.


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Because of the emergence of resistant bacteria and development of newer antibiotics, sulphonamides

are no longer widely used. However, sulphonamides remains inexpensive.

sulfadiazine (Sulfadiazine)

sulfamethizole (Thiosulfil Forte)

sulfasalazine (Azulfidine)

sulfisoxazole (Sulfisoxazole)

co-trimoxazole (Bactrim, Septra)

erythromycin – sulfisoxazole (Pedizole, Enyzole)

Pharmakokinetics

Most sulphonamides are well absorbed and widely distributed in the body.

Oral or IV

Peak plasma levels generally reached within 4 hours.

Peak in IV reached in 1 hour.

Pharmacodynamics

Sulfonamides compete with para-aminobenzoic acid (PABA) and prevent PABA from uniting with folic

acid to form new bacteria, thereby preventing the growth of bacteria.

The sulphonamides, rather than the PABA, enter the reaction, competing for the enzyme involved and

causing the formation of non functional derivatives of folic acid.

Because bacteria require PABA to unite with folic acid- an agent that is required for the synthesis of

DNA, RNA and proteins – bacterial cell replication is halted.


Otitis media, bronchitis, UTI, ulcerative colitis, Chlamydia, gonorhea and other STD’s.

Drug Interactions

If given with alcohol may increase blood urate levels.

If taken with warfarin may increase bleeding tendencies.

Hypoglycemia may occur of taken with sulfonyl ureas.

Adverse Effects

Rash, headache, fever, anorexia, N/V, abdominal pain and diarrhea.

Nursing Process

Assessment

CBC(bone marrow depression and blood dyscrassias)

Monitor renal and liver function test before and throughout administration.

Check glucose levels to those who are taking sulfonyl ureas

Signs and Symptoms of infection

Diagnosis

The same

Planning

The same

Intervention


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Administered orally on an empty stomach, 1 hour before or 2 hours after meals and with a full

glass of water. (Maybe taken with small frequent meals or snacks to prevent GI distress)

Teach patient IOF

Store in tight, light resistant container in room temperature

Frequent oral intake and sucking on ice chips or sugarless candy (stomatitis)

Use sunscreen to prevent sunburns

Patients who are prescribed sulfonamides should avoid coffee, tea, and juices. These are high

in citric acid. They also should abstain from cola, alcohol, chocolate and spices which irritate

the bladder.

Adhere to full length of treatment

Sulfonamides should not be administered to neonates.

Patients need at least 3000 mL of fluid each day in order to flush the urinary tract and follow

good hygiene to reduce the likelihood of acquiring the infection again.

If S/S persist consult your doctor

Evaluation

The same

Aminoglycoside

Introduction

amikacin (Amikin)

gentamicin (Garamycin)

kanamycin (Kantrex)

neomycin (Mycifradin)

streptomycin (Streptomycin)

tobramycin (Nebcin)

Pharmakokinetics

Negligible GI absorption

IV admin (Rapid and Complete)

Cross the placenta (not the blood brain barrier)

Not metabolized, excreted in the kidney

Pharmacodynamics

bactericidal

They bind irreversibly to both the 30S and 50S ribosomes to prevent bacterial protein synthesis.

When ribosomes stop functioning, protein synthesis is disrupted and the bacterial cell

eventually dies.


Potent

Reserved for more serious life threatening infections.

Treat serious nosocomial infections (gram-negative bacteremia, peritonitis, pneumonia)

For greater effectiveness combine with cephalosporins, penicillins or vancomycins.

Drug Interactions

Co-administering aminoglycosides and a neuromuscular blocking agents. can lead to peripheral

nerve toxicity and paralysis.

Use with oral anticoagulants increase bleeding (Vit. K loss)


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Adverse Effects

N/V, stomatitis, diarrhea, weight loss, headache, paresthesia, neuromuscular blockade,

dizziness, vertigo, skin rash fever, and superinfections.

Cardiovascular effects also occur.

Capable of producing potentially serious toxicities (nephro and ototoxicity Cranial nerve 8)

Nursing Process

Assessment

Allergy

Culture and Sensitive

V/S

Baseline renal Function

Diagnosis

Sensory-perceptual alterations: auditory ototoxicity (loss of hearing and tinnitus), vestibular ototoxicity (dizziness and loss of balance) and peripheral neuritis (tingling of the fingers and toes)

Intervention

IV should be refrigerated after use.

2 hours apart in aminoglycoside and penicillin administration

Monitor renal function test every other day.

CBC for bone marrow depression

Monitor S/S of infection

Adequate fluid intake

Take in full course of treatment

Teach patient safety precaution

Report any difficulty in breathing, severe H/A, loss of hearing, decreased urine output.

Report bleeding

Tetracycline Introduction

Tetracyclines are the first broad-spectrum antibiotic that was used to halt the growth of many gram-positive and gram-negative bacteria.

demeclocycline (Declomycin)

doxycycline (Vibramycin)

minocycline (Minocin)

oxytetracycline (Terramycin)

tetracycline(Panmycin, Tetracyn, Sumycin)

Pharmakokinetics

absorption is enhanced on an empty stomach.

Pharmacodynamics

Bacteriostatic

Compete for binding of the 30S subunit site of the RNA ribosome to decrease bacterial growth,

repair and multiplication, thereby obstructing protein cell wall synthesis in susceptible bacteria.

Bactericidal in high concentrations.



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Infections (uncommon)

o First line of defense for Rocky Mountain spotted fever (DOC) (Choramphenico DOC) and

other rickettsial infections as well as pneumonia, typhus, peptic ulcer, cholera etc.

Acne, Anthrax

Prophylactic against ophthalmic neonatorum

Plague

STD, urinary and respiratory infections and meningitis

Drug Interactions

Compromised with dairy products (except doxycycline and minocycline)

Don’t take with penicillin

Adverse Effects

N/V, abdominal cramping and distension, diarrhea and superinfections.

Discolour primary teeth if taken by mother during pregnancy

Glossitis

Phototoxic reaction

High dose IV tetracycline that exceeds 2g/day has been associated with liver failure and death.

Nursing Process

Assessment

Allergy

Obtain specimen for culture and sensitivity

Diagnosis

Altered comfort (heartburn and abdominal cramping)

Fluid volume deficit related to anorexia, nausea, and vomiting

Altered bowel elimination (diarrhea)

Altered protection related to loss of normal florae (fungal overgrowth)

Intervention

May discolour teeth (yellow grayish)

Give all oral tetracyclines (except doxycyline and minocycline) 1 hour before or 2 hours after

meals for maximum absorption (may give small meal if GI upset occurs)

Give with water

Don’t give the drug within 1 hour of bedtime to prevent esophageal reflux.

Provide adequate hydration

Monitor s/s

Not taken during pregnancy and lactation

Wear sunscreen (should not contain PABA)

Report difficulty in breathing, rash, itching, cramps etc.

Macrolide Introduction

Macrolide antibiotics are used to combat gram-positive and gram-negative bacteria.

As you’ll recall from microbiology, the gram stain is used as a method to identify a bacteria. If after staining, the bacteria it appears purple, then the bacteria are said to be gram positive. If it is pink, then the bacteria are gramnegative. There is one exception:

If the bacteria are either purple or pink, then a macrobide antibiotic is effective against the bacteria


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azithromycin (Zithromax)

clarithromycin (Biaxin)

erythromycin (Eryc, Illosone, E-mycin)

Pharmakokinetics

Acid sensitive: it must be buffered or enteric coated to prevent destruction by gastric acid.

Pharmacodynamics

Inhibits RNA- dependent protein synthesis by acting on a small portion of the ribosome, much

like clindamycin.


Mild to moderate infections (and respiratory tract) URTI

DOC pertussis. Diphtheria, legionnaires’ disease, atypical viral pneumonia, syphilis and

Chlamydia.

Treat Anthrax infection

Prophylaxis for dental procedures in patients with valvular heart disease.

Drug Interactions

Decreased absorption if taken with antacid)

May increase serum levels of Digoxin.

Aminoglycosides and tetracyclines competes with each other.

Adverse Effects

Considered to have low toxicity and have few adverse effects.

Dose related anorexia, abnormal taste, heartburn, N/V, abdominal cramping, stomatitis,

flatulence, diarrhea, pruritus ani, confusion, reversible hearing loss, allergic reactions and mild

acute pancreatitis.

Nursing Process

Assessment

Assess infection

Obtain C/S, CBC

Diagnosis

Altered bowel elimination pattern

Impaired tissue integrity related to inflammation or phlebitis at the injection site

Fluid volume deficit related to nausea and vomiting

Alteration in comfort related to abdominal cramping

Sensory-perceptual disturbance related to hearing loss

Altered protection related to loss of normal flora

Intervention

Maybe taken with a small snack.

Erythromycin is not given IM because of painful injections and formation of sterile abscess.

Safety precautions

Monitor liver and function tests

Watch for phlebitis during IV infusion.

Monitor for infection

Drink adequate amount of fluids and maintain nutrition


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Report changes in hearing and allergic reactions

Fluoroquinolone Introduction

Fluoroquinolones are a broad spectrum, synthetic antibiotic

New addition

Ciprofloxacin – most widely used can be administered Oral, injectables and topical. Infused over

60 minutes (if rapid seizure may occur)

enoxacin

gatifloxacin

levofloxacin

lomefloxacin

moxifloxacin

ofloxacin

sparfloxacin

Pharmakokinetics

Not highly protein bound

Minimally metabolized in the liver

Pharmacodynamics

Bactericidal

Interfere with DNA gyrase, which is an enzyme that is required to synthesize bacterial DNA and

for growth and reproduction.


e-coli, pseudomonas, staph infections

infections (anthrax infections)

Gonorrhea

pnuemonia

Drug Interactions

Predispose seizures if taken with theophylinne and caffeine.

Dairy products and other food reduce absorption of ciprofloxacin

Adverse Effects (disappear if drug is discontinued)

nausea, vomiting, diarrhea (interferes with normal flora), discomfort, dizziness, confusion,

depression, light headedness

Decrease WBC and Hct

Alter liver enzyme

Nursing Process

Assessment

Assess for infection

Obtain C/S

Knowledge

Diagnosis

Fluid volume deficit related to anorexia, nausea and vomiting

Altered comfort related to arthralgia (joint discomfort and stiffness)

Impaired tissue integrity related to phlebitis (IV cipro and ofloxacin only)


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Altered bowel elimination (diarrhea)

Altered thought processes related to CNS stimulation (confusion, hallucinations)

Intervention

Complete full course of treatment

Check renal and liver function

Maintain an adequate fluid intake

Avoid milk products, antacids, iron, sucralfate

Use protective clothing against sunlight

Report difficulty breathing etc. M ay prolong QT interval.

Monitor for seizures

Monitor V/S

Miscellaneous Antibiotic Introduction

The following shows other antibiotics that are likely to be prescribed to treat microbial infections.

chloramphenicol (Chlomycetin)- Chloramphenicol is a broad-spectrum antibiotic that slows the growth of a wide variety of gram-positive and gram-negative bacteria. In high doses, chloramphenicol can kill bacteria. Chloramphenicol is given for treatment of meningitis (H influenzae, S pneumoniae, and N meningitides), parathyroid fever, Q fever, Rocky Mountain spotted fever, typhoid fever, typhus infections, brain abscesses, and bacterial septicemia.

spectinomycin (Trobicin)

vancomycin (Vancocin)- treatment of various infections (life threatening) (DOC for antibiotic-associated pseudomembranous colitis.

aztreonam (Azactam)- septicaemia, skin, intraabdominal, UTI and gynaecologic infections.

Clindamycin (Cleocin)- severe anaerobic infections outside the CNS.DOC for abdominal and pelvic infections.

imipenem-cilastatin (Primaxin)- used to treat serious infections in the respiratory tract, urinary tract, bones, joints, skin etc.

telithromycin (Ketek)- mild to moderate respiratory tract infections.

Adverse Effects

Pain and thrombophlebitis at injection site.

Nursing Process

Intervention

Ascertain C/S

Monitor hepatic and renal function test

Dilute drug appropriately and frequently changing the infusion site.

Instruct the patient to report more than five watery stools per day for the early detection of

pseudomembranous colitis.

Antivirals

Viruses are intracellular parasites with no metabolic machinery of their own

Lacks cell wall and a cell membrane and do not carry out metabolic processes.

To replicate, viruses must attach to and enter a living host cell – animal, plant and bacterium - and use its metabolic processes.


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Viral replication requires DNA and RNA synthesis and synthesis of viral proteins and glycosylation.

All viruses require cells to replicate.

Antiviral drugs penetrate cells that are already infected to produce a therapeutic antiviral response.

Few drugs are sufficiently selective to prevent viral infection without injury to the host.

Virustatic: inhibit single steps in the viral; temporarily halt viral replication cycle.

Optimal antiviral effectiveness requires a competent host immune system that can eliminate or effectively halt virus replication.

Protease Inhibitor Introduction

o Not curative o Antiretroviral o saquinavir (Invarase)

o nelfinavir (Viracept)

Pharmakokinetics

Pharmacodynamics

Blocks protease activity of the human immunodeficiency virus (HIV)

Aspartate proteinase – essential for the final step of viral proliferation and is encoded with the

HIV genome.

Protease inhibitors interfere with HIV protease enzyme, thereby impeding the viral replication

of retroviruses, including HIV type I (HIV) and type II (HIV-2)

The active enzyme generates proteins, which are necessary to the virus.

The HIV protease inhibitirs interfere in this process and lead to the assembly of non-functional

varions.

In summary, protease inhibitors interfere with the multiplication of the virus and slow the

progression of the disease, which may prolong survival.


Treat HIV infection in adults

Drug Interactions

Rifampin reduces plasma concentration and action of protease inhibitors.

Anticonvulsants decrease nelfinavir levels.

Adverse Effects

Well tolerated

H/A

Alopecia

Dizziness

Rash, dry skin, fatigue, cough, taste alteration, nausea, vomiting, diarrhea, back pain,

hyperglycemia, and paresthesias around the mouth.

More serious: nephrolithiasis, anaphylaxis, hepatic failure, Stevens-Johnson syndrome.

Nursing Process

Assessment

Diagnosis

Planning


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Intervention

Take with water or milk 1 hour before meals and 2 hours after meals. (To prevent GI irritation:

take with a light snack ex. Toast with Jelly)

Don’t mix nelfinavir with acidic juice or food because of the bitter taste.

Watch renal, hepatic and blood glucose test.

Monitor nutritional status

Encourage IOF 1500 ml in 24 hours to prevent nephrolithiasis

Take medication as ordered. Cessation of treatment results in re-emergence of the virus.

If a dose is missed, take dose should be disregarded and the next dose should be taken at usual

time.

Evaluation

Nucleoside Reverse Transcriptase Inhibitor Antiretroviral Introduction

zidovudine (AKA azidothymidine) (Retrovir)

didanosine (Videx)

Pharmakokinetics

IV or Oral administration

Pharmacodynamics

Interefere with viral RNA-directed DNA polymerase (transverse transcriptase), thereby impeding

the replication of retroviruses, including HIV.

NRTI’s exert a virustatic effect.

HIV is constantly moving target; thus the therapeutic response decreases with long term usage,

particularly in the later stage of the disease

Viral load – another factor that contributes to drug efficacy.


Treat HIV infections in adults and children over 3 months of age.

Retroviral therapy should be started before immunodeficiency becomes evident.

The aim is to reduce plasma viral concentration as much as possible and for as long as possible.

Drug Interactions

If didanosine is taken with aluminium and magnesium antacids, the adverse effects are

increased.

If zidovudine is taken with acetaminophen bone marrow depression may occur.

Adverse Effects

Anemia, neutropenia, particularly with long term administration.

Other: dizziness, headache, fever, insomnia, confusion, nervousness, anxiety, depression, dry

mouth, seizures, liver dysnfunction etc.

Nursing Process

Assessment

Diagnosis

Planning

Intervention


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Administer in empty stomach, before or after meals

Ensure adequate intake if GI distress is severe.

Take with water, not with juice or other acidic fluids.

Watch for patients plasma viral load, CD4 count, CBC, and renal and liver function test.

Tell the patient to avoid double doses. When a dose is missed, the patient should take the

missed doses only if it is more than 4 hours before the next dose.

Report rash, particularly when blisters and fever are present.

Evaluation

Nonnucleoside Reverse Transcriptase Inhibitor Antiretoviral Introduction

Nevirapine (Viramune)

Delavirdine (Rescriptor)

Pharmakokinetics

Pharmacodynamics

Bind to the active center of reverse transcriptase to block RNA and DNA polymerase activities.

This action causes a disruption of the enzymes catalytic site and prevents replication of HIV-1

virus.


Treatment of HIV infection

Drug Interactions

Antacids and didanosine decrease absorption of delavirdine.

Adverse Effects

Rash most common benign or life threatening

Rash is associated with fever, conjunctivitis, oral lesions, muscle or joint pain, Steven-Johnson’s

syndrome,

Other: N/V, fatigue, H/A, diarrhea

Nursing Process

Assessment

Diagnosis

Planning

Intervention

Given with or without food

Delavirdine should be mixed with at least 3 ounces of water before administration.

Can be given with acidic juice to increase absorbability (orange and cranberry juice)

Check liver and renal function

Watch CBC reports

Adequate fluid intake

Safety precaution

If rash occur withhold the drug

Nucleoside Analog Antiviral

Introduction


Page 19 of 23

acyclovir (Zovirax)

famciclovir (Famvir)

Pharmakokinetics

Oral or IV but not SC, IM, IV bolus, or opthamically

Absorption unaffected with food

Pharmacodynamics

acts by being converted by the viral cell into its active form of triphosphate and inhibits viral

DNA polymerase

Preferentially interferes with DNA synthesis of herpes simplex types 1 and 2 and varicella-zoster

virus.


Used to inhibit viral replication of herpes, types 1 and 2 herpea simplex and varicella (chicken

pox) viruses.

Drug Interactions

Adverse Effects

Hypotension, headache, dizziness, confusion, insomnia, tremors, rash, N/V, and diarrhea.

Serious: haalucinations, depression, hematuria, seizures and coma

Nursing Process

Assessment

Diagnosis

Planning

Intervention

Oral acyclovir may be taken without food

Check IV site during administration (inflammation, phlebitis, extravasation, sloughing of tissues

in the injection site

Ascertain patient Well hydrated

Monitor creatinie and BUN

Manage only the diaease and not cure it.

Instruct patient to avoid sexual intercourse

Report any unexplained redness or pain in the eye.

Take the full course of treatment

Evaluation

Antifungals

Fungal infections may be superficial or systemic (occur mostly in the immunocompromised:HIV or those who are taking corticosteroids or anticancer drugs.

Two main groups of fungi that can cause disease in humans

Molds: filamentous fungi – dermatophytes (infection in the skin, nails and hair) and Aspergillus Fumigatus (pulmonary and disseminated aspergillosis)

True Yeast is either a unicellular round or oval fungus. Cryptococcus neoformans – cryptococcal meningitis or pulmonary infections.

Aantifungal drugs are few and are highly toxic.


Page 20 of 23

Polyene Antifungal Introduction

amphotericin B (Amphotec, Fungizone)

nystatin (Mycostatin)

Pharmakokinetics

poorly absorbed orally and is given IV infusion

Pharmacodynamics

Binds to sterols, such as ergosterol, in the fungal cell membrane.

The fungal membrane is then no longer able to function as a selective barrier.

As a result, cell membrane permeability is changed, allowing leakage of intracellular

components and causing cell death.

TOXIC


DOC for fungal infection amphotericin B.

For Aspergillus, Candida or Cryptococcus

nystatin is for Candida Albicans

Drug Interactions

Interacts with corticosteroids and digitalis to increase risk for hypokalemia.

Adverse Effects

Paresthesia, flushing, fever, chills, anorexia, nausea, vomiting, dyspepsia, and abdominal

cramping.

Long Term: renal damage

Local irritation, burning and thrombophlebitis at teh IV site

Nursing Process

Assessment

Diagnosis

Planning

Intervention

Protect drugs from light exposures

Administer nystatin oral suspension by rinsing the mouth or by using a “swish swallow”

technique. The solution should be kept in the mouth as long as possible (2 minutes)

Instruct the patient to avoid food or drink 30 minutes after oral administration of nystatin

Remove dentures before oral administration because oral infections may likely to occur

Insert vaginal suppositories and creams high into the vagina

Continue suppository-cream therapy during menses

When sensitivity or rash occur discontinue drugs

Wathc intake and output daily

Monitor electrolytes, hepatic and renal function and blood studies

When BUN exceeds 40mg/dL or serum creatinine above 3 mg/dL withhold and report

Monitor vital signs

Inspect skin for rashes

Report tinnitus, vertigo, unsteady gait or hearing loss

Evaluation


Page 21 of 23

Azole Antifungal Introduction

fluconazole (Diflucan) – Treatment of candidal infections nad cryptococcal meningitis

ketoconazole (Nizoral) – Treatment of systemic and cutaenous fungal infections

itraconazole (Sporanox_ - treatment of tinea pedis

clotrimazole (Lotrimin) – treatment of skin, oropharyngeal and vulvovaginal candidiasis

oxiconazole (Oxistat) –treatment of tinea pedis, tinea cruris and tinea corporis

Pharmakokinetics

Pharmacodynamics

These agents binds to sterols in the fungal cell membrane, which changes cell membrane

permeability.

Azoles can be fungustatic or fungicidal depending on types of organism.


Fluconazole is used for cryptococcal meningitis, pneumonia, peritonitis, UTI, oropharyngial and

vaginal candidiasis, systemic fungal infections

Prophylaxis to decrease the incidence of candidiasis in bone marrow transplant recepients.

Drug Interactions

Ketoconazole and itraconazole decrease the efficacy of oral contraceptive and increase the

effects of warfarin etc.

Antacids, anticholinergics, H2 blockers, didanosine and sucral fate decrease the absorption and

action of ketoconazole.

Adverse Effects

Mild to moderate

Hypersensitivity, headache, drowsiness, dizziness, confusion, depression, nausea, vomiting,

abdominal pain and diarrhe.

Phopobia, impotence, menstrual disorders, gynecomastia, suicidal tendencies,

Nursing Process

Assessment

Diagnosis

Planning

Intervention

Itraconazole capsules and oral solution cannot be used interchangeably.

Maximum rate of Fluconazole via IV is 200mg/hr.

IV mixtures with other drugs are not recommended

Administer itraconazole capsules after a fullmeals (oral solutions should be taken without food)

Report evidence liver dysfunction

Apply topical administration sparingly and protect hands with latex gloves when applying the

drug.


Page 22 of 23

Occlusive dressing should be avoided.

Monitor hepatic studies, BUN, and serum creatinine periodically for 1 month.

Obtain fungal culture specimens before initiating therapy

Allow clotrimazole oral lozenge to dissolve slowly in the mouth over 15 to 30 minutes for

maximal effectiveness

If missed dose occur do not double dose. Rather, take the missed dose only if the next

scheduled dose is more than 4 hours.

Evaluation

CELLS EAT PATHOGEN

ENGULF

REMOVE

KILL in many ways

ANTIMICROBIALS

SIGNS & SYMPTOMS

PROSTAGLANDIN INHIBITORS


Page 23 of 23

PATHOGENS

ENTER

BODY

CUT FOOD

INFLAMMATORY RESPONSE STARTS

REDNESS

SWELLING

PAIN

VASODILATION

VASCULAR

PERMEABILITY

WBC INFILTRATE THE

AFFECTED AREA

STIMULATION OF

NERVE ENDINGS

BRAIN DETECTS

SOMETHING IS WRONG

PATCH OF TISSUE ORGAN / ENTIRE SYSTEM MULTIPLE ORGAN & SYSTEMS

LOCAL INFECTION SEPTECEMIA SEPSIS

Documents

Cebu Normal University - idomino2013.weebly.comidomino2013.weebly.com/uploads/5/3/4/8/5348182/nursing_care_for... · Nursing Care for Patients Receiving Medications that Affects Cellular