Pharmacological and
Parenteral Therapies
Dena Evans, MPH, BSN, RN
Assistant Professor
Department of Nursing
The University of North Carolina at Pembroke
Aminoglycosides
 What are they?
 Give examples
 What do they treat specifically?
 Toxicity
 Labs associated
 Routes of administration
Answers
 They are bacteriocidal antibiotics
 Amikacin; gentamicin; neomycin;
streptomycin
 Gram negative bacteria like pseudomonas,
enterobacter and TB
Toxicity
 Dose related
 Given based on client’s weight
 Can cause ototoxicity and nephrotoxicity
 Why: ½ life in renal cortex is 100 hours so-----
-
Labs
 What labs should we monitor and why?
Normal Creatinine
 0.6 to 1.3 mg/dL
Drug Interactions
 Cephalosporins (Keflex; Ceclor) increase the
risk of nephrotoxicity
 Loop diuretics (Lasix) increase the risk of
ototoxicity
Questions
 The nurse is reviewing the client’s record and
notes that the physician has documented that
the client has a renal disorder. On review of
the laboratory results, the nurse would most
likely expect to see which of the following:
a.
Decreased hgb
b.
Elevated creatinine
c.
Decreased RBCs
d.
Decreased WBCs
Dosage Calculation Based on Weight
 The MD orders Gentamycin 50mg/kg/day and
the recommended dosage is 200-500
mg/kg/day. Your patient weighs 10 kg.
 Question 1: How many mg has the MD
ordered?
 Question 2: Is the dosage safe:
 Question 3: How do you know if it is safe?
Dosage Calculation Tobramycin
 The physician order tobramycin 15mg IV q 6h
for a child with a severe systemic infection
who weighs 10kg. You have on hand
20mg/2mL. Recommended pediatric
parameters are 6-7.5 mg/kg/day in four
divided doses.
 Question 1: How many mL will you give?
 Question 2: Is the order safe?
 Question 3: How do you know?
Drug Question-Kidney

Following kidney transplantation,
cyclosporine is prescribed for a patient.
Which lab result would indicate an adverse
effect from the use of this medication?
a.
b.
c.
d.
Decreased creatinine level
Decreased hemoglobin level
Elevated blood urea nitrogen level
Decreased white blood cell count
Drug Question-Kidney

Following kidney transplantation,
cyclosporine is prescribed for a patient.
Which lab result would indicate an adverse
effect from the use of this medication?
a.
b.
c.
d.
Decreased creatinine level
Decreased hemoglobin level
Elevated blood urea nitrogen level
Decreased white blood cell count
Indicates nephrotoxicity
Drug Therapy-Kidney
 A client with chronic renal failure is receiving
epoetin alfa (Epogen, Procrit). Which lab
result would indicate a therapeutic effect of
the medication?
a.
Hematocrit of 32%
b.
Platelet count of 400,000
cells/mm3
c.
BUN of 15mg/dL
d.
WBC of 6,000 cells/mm3
Drug Therapy-Kidney
 A client with chronic renal failure is receiving epoetin
alfa (Epogen, Procrit). Which lab result would indicate
a therapeutic effect of the medication?
a.
Hematocrit of 32%
b.
Platelet count of 400,000
cells/mm3
c.
BUN of 15mg/dL
d.
WBC of 6,000 cells/mm3
This is the intended effect of the drug
Drug Therapy-Steroids
 Prednisone is prescribed for a client with diabetes
mellitus who is taking daily NPH insulin. Which of the
following medication changes would the nurse
anticipate during therapy with prednisone:
a.
An additional daily prednisone
dose
b.
A decreased amount of daily NPH
c.
An increased amount of daily NPH
d.
The addition of an oral hypoglycemic
agent
Drug Therapy-Steroids
 Prednisone is prescribed for a client with diabetes
mellitus who is taking daily NPH insulin. Which of the
following medication changes would the nurse
anticipate during therapy with prednisone:
a.
An additional daily prednisone
dose
b.
A decreased amount of daily NPH
c.
An increased amount of daily NPH
d.
The addition of an oral hypoglycemic
agent
Steroids can trigger diabetes and worsen in existing
cases
TPN
Total Parenteral Nutrition
What is it?
 Mixture
 Specifically designed—
individualized
 Sugar, carbs, protein,
lipids, electrolytes, trace
elements
 Should be clear—no
sediment
Why would someone need it?
 Can’t eat
 Needs nutritional support
 Cancer patient; transplant patient;
stabilization of electrolytes in the elderly
How is it administered? Pay attention
Electrolytes--revisited
 Sodium
 Potassium
 Chloride
 Phosphate
 Calcium
 Magnesium
Question
 Does having too much or too little of any
electrolyte have the potential to cause health
problems?
 Give me an example
So…
 If you have a patient who is already
nutritionally challenged and you are giving
them a solution of electrolytes via a central
line, what signs and symptoms would you
observe for?
Possibilities
 Could you see an EKG changes? Why? What
specifically?
 Could you see issues with muscle strength?
Why? What specifically?
 Could you see an problems with mental
status? Why? What specifically?
EKG Changes
 Hyperkalemia may cause spiked “T” waves
Muscles
 Hypocalcemia
 Chvostek’s Sign
 Trousseau’s
www.sohnurse.com
Mental Status
 Hypomagnesemia
 Psychotic behavior/sedation/confusion
Side Effects of TPN
 Mouth sores; skin changes; *fever, chills,
stomach pain, *SOB, rapid wt. loss or gain;
muscle weakness or twitching, jumpy
reflexes, swelling of hands or feet
 What type of patient do you think TPN should
be use cautiously with?
Answer
 Renal
 Cardiac Insufficiency
 Diabetics
 Remember: Fluid overload (report SOB/ rapid
wt. gain/swelling of hands and feet).
 Hypokalemia: ESRD and poor nutrition
coupled with extra fluid, sodium, potassium.
 And TPN has a lot of sugar in it
What labs will you monitor?
 Electrolytes
 Kidney specific
 ?Infection at site of central line? WBCs
 Blood sugar due to high amounts of sugar in
the mixture
Storage
 Should be kept in fridge or freezer
 Remove 4-6 hours before giving (why)?
 Do not refreeze
TPN Question

A patient with Chron’s disease is receiving
TPN via a subclavian triple lumen catheter.
The nurse recognizes that a priority is to:
a.
b.
c.
d.
Assess the insertion site for signs of infection
Complete the administration within 8 hours
Discontinue the infusion if the patient
experiences hyperglycemia
Change the IV tubing and dressing every 72
hrs.
Coonan, P.R. (2006). NCLEX for dummies.
TPN Question

A patient with Chron’s disease is receiving
TPN via a subclavian triple lumen catheter.
The nurse recognizes that a priority is to:
a.
b.
c.
d.
Assess the insertion site for signs of infection
Complete the administration within 8 hours
Discontinue the infusion if the patient
experiences hyperglycemia
Change the IV tubing and dressing every 72
hrs.
Coonan, P.R. (2006). NCLEX for dummies.
Rationale
 Infection is a major concern for clients
receiving TPN
 Usually given continuous drip
 Never stop abruptly (hyPOglycemia
 Change bag each time and dsg. Per policy
TPN Question
 When caring for a patient who is receiving
TPN, what should the nurse do to prevent
infection in the patient?
a.
b.
c.
d.
Encourage the patient to take fluids by
mouth each day
Monitor the serum blood urea nitrogen and
blood sugar daily
Maintain strict I&O records
Use strict aseptic technique when caring for
the IV site
TPN Question
 When caring for a patient who is receiving
TPN, what should the nurse do to prevent
infection in the patient?
a.
b.
c.
d.
Encourage the patient to take fluids by
mouth each day
Monitor the serum blood urea nitrogen and
blood sugar daily
Maintain strict I&O records
Use strict aseptic technique when caring for
the IV site
TPN Question
 A patient is started on TPN. Which of the
following lab tests should the nurse monitor
several times a day?
a.
b.
c.
d.
Serum calcium and magnesium
Urine specific gravity
Blood glucose
Serum total protein
TPN Question
 A patient is started on TPN. Which of the
following lab tests should the nurse monitor
several times a day?
a.
b.
c.
d.
Serum calcium and magnesium
Urine specific gravity
Blood glucose
Serum total protein
Rocephin and Clostridium
Difficile
Questions
 What is Clostridium Difficile?
 Where is it found?
 What is Rocephin?
 What is it used for?
Answers
 Clostridium Difficile is a resident flora of your
intestinal tract.
 It is not the most abundant flora
 Rocephin is a broad-spectrum antibiotic.
 What does that mean?
Rocephin and C-Diff
 Give broad spectrum antibiotics—potentially
wipe out good bacteria that keep flora in
check (C-Diff).
 This allows C-Diff, usually a minority bacteria,
to multiply.
 Causes pseudomembranous enter colitis.
What is that?
 Condition marked by diarrhea, abdominal
pain and foul smelling stool.
 AKA: Antibiotic-Associated colitis
Question
 How do you diagnose pseudomembranous
entercolitis?
Stool Sample-Sterile Container
Question
 How do you think you would treat C-Diff?
Treatment
 Stop the broad spectrum antibiotics
 Give Flagyl or Vancomycin
Long term use of Steroids
Side Effects
Questions
 What are steroids commonly used to treat?
 What hormone do they mimic?
 Where does this hormone come from?
 What does this hormone do?
Answers
 Anti-inflammatory
 COPD; Asthma; Infections
 Mimic cortisol
 Comes from the adrenal cortex
 Cortisol helps body cope during times of
stress: illness/surgery/infection
 Also triggers insulin release
Pathway
 Stressor – Pituitary – “Send down some
ACTH” – Adrenal cortex = Cortisol
Problem with LT Use of Steroids
 They mimic body’s natural production of
cortisol
 Pituitary can’t tell the difference
 Taken LT potential that the body will
essentially stop or decrease natural
production—bad thing.
 Short-term: Usually taper off so the adrenals
can adjust and resume work
Side Effects of Steroids
 Mimic Cushings disease (Over production of
cortisol).
 Moon-face and buffalo hump
 Increased appetite; diabetes; wt. gain; fat
deposits on face and back; Na and H2O
retention; HTN, slow healing
Question
 A patient is receiving methylprednisone (Solu-Medrol)
to treat a spinal cord injury at L-1. What action should
the nurse take to monitor one of the adverse effects
of this medication:
a.
Monitor LOC every hour
b.
Conduct a 24-hour creatinine
clearance
c.
Take blood glucose readings every 4
hours
d.
Check skin turgor every two hours
Question
 A patient is receiving methylprednisone (Solu-Medrol)
to treat a spinal cord injury at L-1. What action should
the nurse take to monitor one of the adverse effects
of this medication:
a.
Monitor LOC every hour
b.
Conduct a 24-hour creatinine
clearance
c.
Take blood glucose readings every 4
hours
d.
Check skin turgor every two hours
Question
 A nursing instructor asks a student to describe the
pathophysiology of Cushing’s disease. Which
statement by the student indicates an accurate
understanding of the disorder?
a.
“Cushing’s disease results from an
undersecretion of corticotropic hormones.”
b.
“Cushing’s disease results from an
oversecretion of insulin.”
c.
“Cushing’s disease results from an
undersecretion of mineralocorticoids.”
d.
“Cushing’s disease results from an
increased pituitary secretion of
adrenocorticotropic hormone.”
Question
 A nursing instructor asks a student to describe the
pathophysiology of Cushing’s disease. Which
statement by the student indicates an accurate
understanding of the disorder?
a.
“Cushing’s disease results from an
undersecretion of corticotropic hormones.”
b.
“Cushing’s disease results from an
oversecretion of insulin.”
c.
“Cushing’s disease results from an
undersecretion of mineralocorticoids.”
d.
“Cushing’s disease results from an
increased pituitary secretion of
adrenocorticotropic hormone.”
Question
 The nurse is teaching a patient with chronic
COPD about the side effects of long-term
corticosteroid therapy. The nurse realizes that
the patient will need further teaching when he
states:
a.
b.
c.
d.
I may experience some facial swelling
I will need to take the drug every day to
avoid serious side effects
My doctor will be checking my blood
sugar regularly
I will heal faster if I get injured
Question
 The nurse is teaching a patient with chronic
COPD about the side effects of long-term
corticosteroid therapy. The nurse realizes that
the patient will need further teaching when he
states:
a.
b.
c.
d.
I may experience some facial swelling
I will need to take the drug every day to
avoid serious side effects
My doctor will be checking my blood
sugar regularly
I will heal faster if I get injured
Side Effects of Tricyclic
Antidepressants
Question
 What is a tricyclic antidepressant?
 Give examples
 How do they work?
Answers
 Called tricyclic because of their structural
makeup (3 atoms)
 Inhibit the reuptake of serotonin,
norepinephrine and dopamine
 Also increase histamine which is why they
have more sedative effects
 Elavil, Anafranil, Tofranil
 Can be used to treat OCD
Side Effects
 Drowsiness, dry mouth, constipation,
impaired sexual function, low BP,
photophobia, tachycardia
 These are old school antidepressants
Keep in Mind
 May reduce effectiveness of HTN meds
 Don’t use with ETOH or Benadryl
(antihistamines)
 Using with MAOIs = HTN crisis
 Takes several weeks for therapeutic effects
 Monitor for suicidal ideations
 Long term: Renal and liver function-monitor
 Taper off
Question

The home health nurse visits a client who
takes Anafranil. The nurse notices that the
client has not taken the medication in 2
months. What behavior observed in this
client would validate his noncompliance:
a.
b.
c.
d.
Complaints of insomnia
Complaints of hunger and fatigue
Pulse rate less than 60 beats per minute
Frequent hand washing with hot soapy water
Question

The home health nurse visits a client who
takes Anafranil. The nurse notices that the
client has not taken the medication in 2
months. What behavior observed in this
client would validate his noncompliance:
a.
b.
c.
d.
Complaints of insomnia
Complaints of hunger and fatigue
Pulse rate less than 60 beats per minute
Frequent hand washing with hot soapy water
Question
 The nurse is teaching a client who is being started on
imipramine hydrochloride (Tofranil) about the
medication. The nurse informs the client that the
maximum desired effects may:
a.
b.
c.
d.
Start during the first week of
administration
Not occur for 2-3 weeks of administration
Start during the second week of
administration
Not occur until after 2 months of
administration
Question
 The nurse is teaching a client who is being started on
imipramine hydrochloride (Tofranil) about the
medication. The nurse informs the client that the
maximum desired effects may:
a.
b.
c.
d.
Start during the first week of
administration
Not occur for 2-3 weeks of administration
Start during the second week of
administration
Not occur until after 2 months of
administration
Question
 The client receiving tricyclic antidepressants arrives
at the mental health clinic. Which observation would
indicate that the client is following the medication
plan correctly:
a.
b.
c.
d.
Client reports not going to work for this past
week
Client arrives at the clinic neat and
appropriate in appearance
Client complains of not being able to do
anything anymore
Client reports sleeping 12 hours per night and
3-4 hours during the day
Question
 The client receiving tricyclic antidepressants arrives
at the mental health clinic. Which observation would
indicate that the client is following the medication
plan correctly:
a.
b.
c.
d.
Client reports not going to work for this past
week
Client arrives at the clinic neat and
appropriate in appearance
Client complains of not being able to do
anything anymore
Client reports sleeping 12 hours per night and
3-4 hours during the day
Identifying the need for
Additional Pain Medication
Pain (The 5th vital sign)
 Believe the patient
 Assess the patient
 Use a combination of drug and nondrug
therapies
 Don’t wait until severe pain strikes
 Be aware of side effects
 Teach your patient
Assessing your Client
 Use a pain scale
 Be aware of nonverbal indicators
 Reassess after administration
 Narcotics: Respiratory rate
Questions
 A client with metastatic breast cancer and bone
metastasis has continuous, poorly localized pain. The
nurse teaches the patient to use pain medications:
a.
As often as needed to keep pain under
control
b.
On an around the clock basis
c.
By alternating two different types to
avoid addiction
d.
When the pain cannot be controlled
with complementary therapies
Questions
 A client with metastatic breast cancer and bone
metastasis has continuous, poorly localized pain. The
nurse teaches the patient to use pain medications:
a.
As often as needed to keep pain under
control
b.
On an around the clock basis
c.
By alternating two different types to
avoid addiction
d.
When the pain cannot be controlled
with complementary therapies
Questions

A postoperative patient is receiving IV
morphine via a PCA pump for severe
incisional pain. Nursing assessment will
include what parameters. Select all that
apply:
a.
b.
c.
d.
e.
f.
Respiratory rate and depth
Level of sedation
Pain level and quality
Frequency of bowel movements
Urine output
Serum glucose level
Questions

A postoperative patient is receiving IV
morphine via a PCA pump for severe
incisional pain. Nursing assessment will
include what parameters. Select all that
apply:
a.
b.
c.
d.
e.
f.
Respiratory rate and depth
Level of sedation
Pain level and quality
Frequency of bowel movements
Urine output
Serum glucose level
Pharmacological
Interactions
Lasix
TB Meds and Dilantin
Lasix (Not all inclusive)
 Lasix and aminoglycosides (ototoxicity)
 Lasix and salicylates (rheumatoid patients)
drugs compete with excretory sites in kidney
= salicylate toxicity
 Lasix and Lithium can lead to Lithium toxicity
 Carafate and Lasix may reduce
antihypertensive effect of Lasix
TB Medications and Dilantin
(Phenytoin)
 Clients receiving TB medications and dilantin
may be at risk for Dilantin toxicity because the
TB medication (Isoniazid) increases serum
Dilantin levels.
 Theophylline also increases the risk of
Dilantin toxicity
Signs and Symptoms of Dilantin
Toxicity
 Rapid eye movements
 Difficulty speaking or slurred speech
 Lethargy
 Problems with coordination or balance
 Dizziness
 Drowsiness
 Unusual body movements or shakiness
 And seizures!
Pudendal Blocks
Perforating the
sacrospinous ligament and
injecting 1% Lidocaine.
www.brooksidepress.com
Why are they used?
 Less painful delivery
 Painless episiotomy repair
 Lasts for 30 minutes
 Has no impact on contractions
 Usually given at 2nd stage of labor
Risks
 Infection
 Hematoma
 Anesthetic toxicity
Medication Dosage
Adjustments Based on Age
Questions
 Can everyone take the same dosage of
medication?
 Should adjustments be based entirely on
age?
 What are the formulas used for determining
dosages for children?
Answers
 No
 Actually the least accurate
 Weight is actually better mg/kg
 However---
Clark’s Rule
 An old rule for an approximate child's dose,
obtained by dividing the child's weight in
pounds by 150 and multiplying the result by
the adult dose.
 example a child weighs 14 lbs. the adult dose
is 100 mg. Using clarks rule 14/150 = .09 x
adult dose = .09x100 =9.3 mg
www.wikianswers.com
Young’s Rule
 It is a way of calculating pediatric doses for
children over the age of 2 based on the adult
dose.
Take the age of the child in years and divide
that by their age plus 12. Multiply this number
times the adult dose.
Pediatric dose = [age/(age + 12)] x adult dose
Body Surface Area—The Best
 Order: Gantrisn 2g/m2 daily in 4 divided
doses. The client weighs 110 lbs and is 60
inches tall. How many mg will the client
receive per dose?
 Need Nomogram
 1.5m2 x 2g = 3g/day or 3000 mg/day divided
by 4 is 750 mg per dose.
Cardiac Glycosides
Client Education to Reduce Risk
What are they?
 Used to tx. CHF and arrhythmias
 Inhibit the Na/K ATPase which balances cell
membrane potential (ionic concentration)
 Improves contraction
 Increases cardiac output
 Reduces heart distention
Example
 Digoxin (Lanoxin)
 Inhibit the Na/K ATPase which balances cell
membrane potential (ionic concentration)
 Moves sodium out of the cell and pulls
potassium in
 Digoxin competes with K for binding sites on
Na/K ATPase. If a client has low K this frees
up more binding sites for Digoxin and can
cause Digoxin toxicity
Biggest Threat
 Overdose/Toxicity
 Digoxin—classic sign-yellow/green halos
around objects
 Apathy, blurred vision, slow, irregular heart
beat, weakness, confusion.
Question

A patient with a history of atrial fibrillation is
currently receiving digoxin (Lanoxin) 0.25
mg po daily. Before administering the
medication, the nurse will assess the patient
carefully for which condition that may
precipitate digoxin toxicity:
a.
b.
c.
d.
Hypokalemia
Hypocalcemia
Hyperthyroidism
Hypotension
Question

A patient with a history of atrial fibrillation is
currently receiving digoxin (Lanoxin) 0.25
mg po daily. Before administering the
medication, the nurse will assess the patient
carefully for which condition that may
precipitate digoxin toxicity:
a.
b.
c.
d.
Hypokalemia
Hypocalcemia
Hyperthyroidism
Hypotension
References
 Coonan, P.R. (2006). NCLEX-RN for
dummies. New Jersey: Wiley Publishing
Inc.
 Kee, J.L., & Marshall, S.M. (2004). Clinical
calculations with applications to general
and specialty areas (5th ed.). St. Louis,
MO: Elsevier.
 Silvestri, L.A. (2008). Comprehensive review
for the NCLEX-RN examination (4th ed.).
St. Louis, MO: Elsevier.