Pharm Test 2
Module 2.1- Respiratory
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Pharmacology Chapter 35 & 36
o Compare antihistamine, decongestant, antitussive, and expectorant drug groups.
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Antihistamine
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Action:
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Competes with histamine (H1) for receptors
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Prevents a histamine response
Decreased:
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Nasopharyngeal secretions
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Itching decrease
First- generations antihistamines:
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Usually cause drowsiness, dry mouth
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Dizziness, fatigue, blurred vision
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Disturbed coordination, urine retention
Second-generation antihistamines:
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Usually have less drowsiness
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Usually have less anticholinergic symptoms
Type: Diphenhydramine
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Indications
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Acute and allergic rhinitis, pruritus, urticaria
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Common cold, sneezing, cough
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Motion sickness
Contraindications
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Cautions
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Narrow angle glaucoma, urinary retention
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Severe liver disease
Interactions
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ETOH
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Other CNS depressants
Anticholinergic, drowsiness, confusion, restlessness
Adverse reactions
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Increases CNS depression with:
Side effects
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Acute asthmatic attack, severe liver disease
Hypotension, palpitations, psychosis
Decongestant
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Nasal Congestions
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Dilation of nasal blood vessels
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Due to infection, inflammation, allergy
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Transudation of fluid into tissue spaces
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Leads to swelling nasal cavity
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Stimulate alpha adrenergic receptors
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Produces nasal mucous constriction
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Shrinks nasal mucous membranes
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Reduces nasal secretion
Decongestant indicators
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Local administration & effects
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Allergic rhinitis, hay fever, acute coryza
Nasal spray, nasal drops
Side effects/ adverse reaction
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Nasal irritation, nervous, restless
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***Rebound Nasal Congestion if use is prolonged
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Abrupt withdrawal can stop the cycle of rebound congestion
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Intranasal glucocorticoid transition
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Beginning 1 week before discontinuing decongestant,
while withdrawing decongestant is recommended
Systemic Decongestants
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Tablet, capsule, and liquid form
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Ephedrine and pseudoephedrine
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Frequently combined with:
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Antihistamines, analgesic, antitussives
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Relieve congestion for a longer period than nasal route
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More side effects than nasal decongestants
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Interactions:
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Decreases effect of beta blockers
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MAOIs increase risk of HTN or dysrhythmias
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Large amounts of caffeine- may increase restlessness and
palpitations
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Adverse effects:
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Contraindicated used with extreme caution:
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BP and blood glucose levels can increase
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Hypertension
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Cardiac disease
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Hyperthyroidism
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Diabetes mellitus
Pseudoephedrine National regulatory measures:
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Individual limits
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3.6g/day & 9 g within 30 days
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Identifications are scanned with each purchase
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Database linked nationally and keeps a 2 year tally
Intranasal glucocorticoids
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Administration:
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Spray should be directed away from nasal spectrum
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•
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Patient should sniff gently
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With continuous use, dryness of nasal mucosa may
occur
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Most allergic rhinitis is seasonal; therefore short term
use
Common side effects:
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Nasal irritation, epistaxis
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Pharyngitis
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Fatigue, insomnia, nervousness
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Candidiasis
Benefits:
§ With local administration, a smaller dose is required
§ No risk of adrenal suppression if taken as
instructed
§ Therefore no tapering needed
§ Most are available over the counter
Most effective drugs for preventing and treating seasonal and
allergic rhinitis
Antihistamine is only one several medicators of allergic
rhinitis
Considerations:
§ Maximal effects may require 1-3 weeks to develop
§ Initial response can be seen within hours
§ After symptoms are under control, reduce
dose or discontinue
§ May be used alone or in combo with H1
antihistamine
§ If nasal congestion is present
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Antitussive
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Types:
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Nonopioid: dextromethorphan, benzonatate
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Opioid: Codeine, hydrocodone
Effective against
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Chronic nonproductive cough
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Experimentally induced cough
Antitussives- Opioid
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Action
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Acts on cough control center in medulla
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Suppresses cough reflex
Codeine
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Most effective cough suppressant available
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Doses are low, about 1/10 needed to relieve pain
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Risk for physical dependence is small
Hydrocodone
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Nasal decongestant (if ordered) before
glucocorticoid administration
Concomitant corticosteroid pulmonary inhalers
§ May warrant active screening for subclinical
adrenal suppression
More potent than codeine and carries a greater liability for abuse
Antitussives- Non Opioid
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Dextromethorphan
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Acts on cough- control center in medulla- suppresses cough reflex
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Most effective and common OTC cough medication
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Active ingredients in > 140 OTC cough medicines
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Expectorant drug groups.
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Action:
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loosens secretions by reducing surface tension
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Allows elimination by coughing-> easier
Indications:
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SE(rare): drowsiness, dizziness, irritability, nausea
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Common cold
Nausea-> GI upset
Guafenesin= most common expectorant
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Found in many OTC cold remedies along with it(lumped together but
dose is lower than typical recommendations)
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Analgesics
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Antihistamines
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Decongestants
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Antitusives
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Hydration is the best natural expectorant
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Either way-> fluid increse is needed to ensure it works
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o
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Increase fluid intake-> at least 8 glasses/day to help loosen
mucous
Describe the side effects of nasal decongestants and how they can be avoided.
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o
Data skeptical-> supposedly hydration is the health aide, not
drug
SE & Adverse reactions:
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Nasal irritation, nervousness, restless
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REBOUND NASAL CONGESTION if use prolonged-> >3 days, meant to be
short term
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Abrupt withdrawal can stop the cycle of rebound
congestion=uncomfortable
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Intranasal glucocorticoid transition-> beginning 1 week before
discontinuing decongestant, while withdrawing decongestant is
recommended
Contrast the therapeutic effects of antihistamines, and mucolytics.
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Antihistamines: decrease nasopharyngeal secretions and itching
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Mucolytics: Agents that act as detergents to liquefy and loosen thick mucus secretions so
they can be expectorated
Differentiate the drug groups used to treat COPD and asthma and the desired effects of
each.
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Albuterol: Asthma and COPD, promotes bronchodilation
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Muscarinic Antagonists: antagonizes acetylcholine, relaxing smooth muscle of bronchi;
dilates bronchi, used for COPD and chronic asthma
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Ipratropium (SAMA):
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Asthma- not recommended for routine treatment of acute bronchospasm (unless
cannot tolerate SABA), beneficial when used with SABA during acute
exacerbations
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COPD- monotherapy for those with low risk, less symptoms
Tiotropium (LAMA):
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Not used for asthma
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COPD- used alone or in combination with LABA), maintenance treatment
Short Acting sympathomimetics (SABA):
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Asthma- 1st line of defense for acute asthmatic attack
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COPD- prevent or reduce symptoms, scheduled not just PRN- improves FEV
and symptoms
Long acting sympathomimetics (LABA):
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Used for maintenance- not rescue
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Asthma- not the first line of defense, must be combined with ICS (adjunctive
therapy)
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COPD- 1st line (unless pt is low risk/less symptoms), used to improve lung
volumes, dyspnea, and exacerbation #’s
Methylxanthines- theophylline
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Asthma exacerbations (alternative to 1st line)
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Montelukast
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Glucocorticoids (inhaled glucocorticoids)
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Asthma- drug of choice for long term control with persistent asthma, to be
effective in controlling inflammation (ICS must be used regularly)
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COPD- ICS+ LABA or LAMA (group C, D), improve symptoms, lung function
and quality of life, associated with an increased risk of pneumonia
Chromones- Cromolyn
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Safest of all antiasthma medications
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Asthma- suppresses inflammation (does not cause bronchodilation), prevents
asthmatic attacks by inhibiting histamine release
Compare the side effects of beta2-adrenergic agonists and methylxanthines.
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Asthma- Binds with leukotriene receptors to inhibit smooth muscle contraction
and bronchoconstriction, Contraindications (Severe attack, status asthmaticus)
Albuterol: Beta 2- adrenergic receptor
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Adverse reaction- palpitations, tachycardia, HTN, hyperglycemia, hypokalemia
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Life threatening- dysrhythmia, angioedema, bronchospasm, steven-Johnson
Methylxanthines- Theophylline
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Side Effects: restlessness, headache, insomnia, dizziness, N/V/D
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Adverse Effects: tremor/palpitations, tachycardia, dysrhythmia, convulsions,
death
Describe the therapeutic serum or plasma theophylline level and the toxic level.
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Therapeutic range 5-15 mcg/L
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Toxicity is related to theophylline levels
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Serum drug level should be obtained
Nutrition Chapter 4
•
Discuss the functions of carbohydrates as a source of energy and dietary fiber.
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Energy Source
o What does the body do when there are not enough carbohydrates available?
§ If enough carbohydrates is provided to meet the energy needs of the body, protein
can be spared or saved to use for specific protein functions. (protein-sparing effect)
§ When there are not enough carbohydrates available, fat is metabolized, resulting in
the formation of ketones, intermediate products of fat metabolism.
§ If carbohydrate levels continue to be insufficient to meet energy demands, increased
levels of ketones overwhelm the physiologic system and ketoacidosis affects the pH
balance of the body, which can be lethal if uncontrolled.
o What is a dangerous condition that may occur if carbohydrate levels continue to be
insufficient to meet energy demands?
§ Ketoacidosis
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Lactose intolerance
o What nutrients usually consumed in lactose-containing dairy products are important for
the patient to consume, and what are some diet changes they can make?
§ Vitamin D, helps your body absorb and use calcium
§ Lactase enzyme is available to maybe added to milk in order to tolerate 24 hours in
advance
§
•
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For diet: limit lactose containing foods, yogurt, chocolate milk, cheese maybe
consumed in moderation
Other Sweeteners
o What are some considerations when selecting products with “sugar free” on the label?
§ Products containing these sweeteners may be labeled as “sugar free,” but this label
does not mean “calorie free.”
§ Consumers still need to be aware of calories per serving as well as trans fat and
saturated fat contents. Sometimes when “sugar” is removed, fats are added to
improve the taste and texture of the product.
§ This may be problematic for individuals with diabetes who monitor their
carbohydrate and dietary fat intake.
o What are some advantages/ disadvantages of sugar alcohols?
§ Sugar alcohol is a nutritive sweetener related to carbohydrates that provides 2 to 3
kcal/g ; sorbitol, mannitol, xylitol are sugar alcohols, also called sugar replacers
§ Sugar alcohols, also called sugar replacers to avoid confusion with
noncarbohydrate alcohol, fewer than the 4 kcal/g of carbohydrates.
§ They occur naturally in fruits and berries.
§ Advantages:
• Less cariogenic than sucrose
• Do not reencourage the growth of bacteria in the mouth that leads to tooth
decay
• Absorbed more slowly and incompletely than carbohydrates
• Longer absorption time= a slower rise in blood glucose levels or reduced
glycemic response
• Diabetics can consume moderate amounts of these sweeteners and still
control their glucose
§ Disadvantages:
• If larger quantities are consumed, they may ferment in the intestinal tract
because of their slower absorption rate
o May cause gas and diarrhea
• Incomplete absorption results in a lower caloric value per gram, so less
energy is available
o Therefore sugar alcohols are called reduced- energy or low energy
sweeteners
o What is the relationship between aspartame and phenylketonuria (PKU)?
§ Aspartame: a nonnutritive sweetener formed by the bonding of the amino acids
phenylalanine and aspartic acid
§ Phenylketonuria: a genetic disorder in which the body cannot breakdown excess
phenylalanine
Describe the differences and health benefits of soluble and insoluble fiber.
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o
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Insoluble fiber: dietary fibers that do not dissolve in fluids
Soluble Fiber: dietary fibers that dissolve in fluid
Soluble dietary fibers dissolve in fluids, include pectin, mucilage, psyllium seed husk, guar
gum, and other related gums. Soluble fiber thickens substances.
o Insoluble dietary fibers do not dissolve in fluids and therefore provide structure and
protection for plants.
§ Some insoluble dietary fibers are cellulose and hemicellulose.
§ Lignin, considered a dietary fiber, is composed of chains of alcohol rather than
carbohydrate.
o Benefits: improve the physical functioning of the human body, allow the body to function at a
more efficient level
• What are some sources of dietary fiber?
o Dietary fiber has several beneficial effects on the digestive and absorptive systems of the
body.
o These effects range from preventing constipation to possibly reducing the risk of colon cancer
and heart disease.
• Compare the nutrient content of refined versus unrefined grains.
o Refined grains: grains that contain only some edible kernel
§ Examples: white flour, de-germed cornmeal, white bread, white rice
o Unrefined grains: grains prepared for consumption containing all edible portions of kernels;
also known as whole grains
•
What affect do these refined grains have on health?
o Refined grains have been milled, a process that removes the bran and germ.
o Milling is done to give grains a finer texture and improve their shelf life, but it also removes
dietary fiber, iron, and many B vitamins.
o Most refined grains are enriched.
o This means that certain B vitamins (thiamin, riboflavin, niacin, folic acid) and iron are added
back after processing.
o Fiber is not added back to enriched grains.
o Check the ingredient list on refined grain products to make sure that the word “enriched” is
included in the grain name.
o Some food products are made from mixtures of whole grains and refined grains.
Nutrition Chapter 5
• Discuss the function and sources of the linolenic and linoleic essential fatty acids.
o Linoleic acids: an essential polyunsaturated fatty acid with the first double bond located at
the sixth carbon atom from the omega end
o Linolenic acids: an essential polyunsaturated fatty acid with the first double bond located at
the third carbon atom from the omega end
o What is fat’s effect on satiety and satiation?
§ Within a controlled environment, yes, fats do have an effect on satiety and appear
to regulate appetite through several mechanisms including the release of appetite
hormones and inhibition of gastric emptying and intestinal transit.
§ Certain types of fats are more satiating than others.
o What are some of the health benefits of essential fatty acids (EFAs) such as Omega-3?
§ Lower BP
§ reduce triglycerides
§ slow the development of plaque in the arteries
§ reduce the chance of abnormal heart rhythm
§ Reduce likelihood of heart attack and stroke
§ Lessen the chance of sudden cardiac death in people with heart disease
o What are some food sources of essential fatty acids (EFAs)?
§ Food sources of omega-3:
• Fish sources: salmon, mackerel, herring, tuna, rainbow trout, sardines
• Plant sources: canola oil, walnuts and walnut oil, soy bean and soybean oil,
flaxseed ground and oil, wheat germ and oat germ, green leafy vegetables
o What is fat’s role is the transportation and absorption of nutrients?
o
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Digestion of lipids occurs mainly in the small intestines; absorption depends on the
transportation of lipids through lymph and blood circulatory system.
§ Lipids travel through the body in lipoprotein packages containing triglycerides,
protein, phospholipids, and cholesterol.
Describe the potential health concerns and benefits related to dietary fat intake.
o Specific saturated fatty acids raise blood cholesterol levels and, thereby, increase the risk of
atherosclerosis.
o Greater fat, intake is a major cause of obesity and hypertension, diabetes, and gallbladder
disease.
o What are the main differences between the health effects of saturated vs. unsaturated
fats?
§ The difference between saturated and unsaturated fat lies in the number of double
bonds in the fatty acid chain.
§ Saturated fatty acids lack double bonds between the individual carbon atoms, while
in unsaturated fatty acids there is at least one double bond in the fatty acid chain.
o What fat has the greatest influence on blood cholesterol?
§ Saturated fats: Because saturated fat also increases high-density lipoprotein (HDL)
cholesterol, the total cholesterol (TC) to HDL cholesterol ratio (a risk marker for
CVD) is not altered
Module 2.2- Antimicrobial Medications
LEARNING OBJECTIVES CHAPTER 27-29
•
Pharmacology
o
Explain the mechanisms of action of antibacterial drugs.
o
Differentiate between bacteria that are naturally resistant and those that have acquired
resistance to an antibiotic.
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Definition: pathogen continues to grow after antibacterial administration
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§
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An acquired resistance is caused by prior exposure to the antibacterial.
§ Although S. aureus was once sensitive to penicillin G, repeated exposures have
caused this organism to evolve and become resistant to that drug.
§ Penicillinase, an enzyme produced by the microorganism, is responsible for
causing its penicillin resistance.
§ Penicillinase metabolizes penicillin G, causing the drug to be ineffective;
however, penicillinase-resistant penicillins that are effective against S. aureus
are now available.
Bacterial resistance can result naturally, called inherent resistance, or it may be
acquired.
§ A natural, or inherent, resistance occurs without previous exposure to the
antibacterial drug. For example, the gram-negative bacterium Pseudomonas
aeruginosa is inherently resistant to penicillin G.
Teach Patient about antibiotic resistance
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Check if patient can be treated without antibiotics.
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Encourage patient to complete antibiotics as prescribed.
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Teach patient to:
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Use antibiotics correctly
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Not to skip doses
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Not to self-medicate with someone else’s medication.
Reinforce self-management skills in personal hygiene
RESISTANCE TO ANTIBACTERIAL
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Antibiotic misuse
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Taken for viral infections
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Taken when no bacterial infection present
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Taking antibiotics incorrectly (skipping doses)
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Misuse increases antibiotic resistance
Cross-resistance
§
o
Summarize the three general adverse effects associated with antibacterial drugs.
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Three major adverse reactions associated with the administration of antibacterial drugs
are (1) allergic (hypersensitivity, anaphylaxis) reactions, (2) superinfection, and (3) organ
toxicity.
Type
Allergy or hypersensitivity
Superinfection
Can occur between antibacterial drugs with similar actions
Considerations
Allergic reactions to drugs may be mild or severe.
Examples of mild reactions are rash, pruritus, and hives.
An example of a severe response is anaphylactic shock,
which results in vascular collapse, laryngeal edema,
bronchospasm, and cardiac arrest. Severe allergic reaction
generally occurs within 20 minutes, and shortness of
breath is often the first symptom of anaphylaxis. Mild
allergic reaction is treated with an antihistamine, whereas
anaphylaxis requires treatment with epinephrine,
bronchodilators, and antihistamines.
Superinfection is a secondary infection that occurs when
the normal microbial flora of the body are disturbed
during antibiotic therapy. Superinfections can occur in the
mouth, respiratory tract, intestine, genitourinary tract, and
skin. Fungal infections frequently result in
superinfections, although bacterial organisms (e.g.,
Proteus, Pseudomonas, Staphylococcus) may be the
offending microorganisms. Superinfections rarely develop
when drug is administered for less than 1 week, and they
occur more commonly with the use of broad-spectrum
antibiotics. For fungal infection of the mouth, nystatin is
frequently used.
The liver and kidneys are involved in drug metabolism
and excretion, and antibacterials may result in damage to
these organs. For example, aminoglycosides can be
nephrotoxic and ototoxic.
Organ toxicity
o
Apply the nursing process for patients receiving penicillins and cephalosporins.
o
Nursing Process: Penicillin
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Concept
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§
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Assessment
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Assess for allergy to penicillin or cephalosporins.
§
Evaluate lab results, especially hepatic enzymes.
Patient problems
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§
§
o
Tissue injury, nausea, vomiting
Planning
§
§
Infection
The patient’s WBC will be within normal limits.
Nursing interventions
§
Obtain a sample for lab culture and antibiotic sensitivity testing to discern the
infective organism before antibiotic therapy is started.
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Monitor for evidence of superinfection, especially in patients taking high doses
of an antibiotic for a prolonged time.
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Examine the patient for an allergic reaction, especially after the first and second
doses.
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Teach patient to take entire prescribed antibiotic.
Evaluation
Nursing Process: cephalosporin
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Concept
§
§
§
Assessment
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Assess for allergy to cephalosporins or penicillins.
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Evaluate lab results, especially renal/liver function.
Patient problems
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§
Tissue injury, nausea, vomiting
Planning
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§
Infection
The patient’s WBCs will be within normal limits.
Nursing interventions
§
Culture the infected area before cephalosporin therapy is started.
§
o
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Tell patient to report signs of superinfection.
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Instruct patient to take complete course of treatment.
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Observe for hypersensitivity reactions.
§
Advise patient to take medication with food if gastric irritation occurs.
Evaluation
Describe the pharmacokinetics and pharmacodynamics of erythromycin.
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§
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Erythromycin is the drug frequently prescribed if the patient has a hypersensitivity to
penicillin.
Narrow-spectrum antibiotics: For example, penicillin and erythromycin are used to
treat infections caused by gram-positive bacteria.
Erythromycin levels increase with fluconazole, ketoconazole, itraconazole, verapamil,
diltiazem, and clarithromycin.
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Risk of sudden cardiac death.
§
Erythromycin should not be given with other macrolides
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Pharmacokinetics: Erythromycin are readily absorbed from the GI tract, mainly by the
duodenum.
§
Pharmacodynamics: The onset of action of oral preparations of erythromycin is 1 hour,
peak concentration time is 4 hours, and duration of action is 6 hours.
o
Apply the nursing process for tetracyclines, including patient teaching.
o
NURSING PROCESS: TETRACYCLINES
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Concept
§
§
Infection
Assessment
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Assess vital signs and urine output.
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Check lab results, especially renal and liver function.
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Patient problems
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Planning
§
§
§
§
Tissue injury, nausea, vomiting
The patient’s WBCs will be within normal limits.
Nursing interventions
§
Obtain a sample for culture from infected area and send to lab for C&S before
antibiotic is begun.
§
Monitor lab values for renal and hepatic function.
§
Record vital signs and urine output.
§
Inform female patients who are contemplating pregnancy to avoid taking
tetracycline because it can cause discoloration of permanent teeth.
§
Encourage patient to take entire course of antibiotic.
Evaluation
o
Summarize the nurse’s role in detecting ototoxicity and nephrotoxicity associated with the
administration of aminoglycosides.
o
Nursing interventions
§
Send a sample from the infected area to the laboratory for culture to determine the
organism and its antibiotic sensitivity before the aminoglycoside is started.
§
o
Monitor intake and output. Urine output should be at least 600 mL/day.
Immediately report any decrease in urine output. Urinalysis may be ordered daily,
and results should be checked for proteinuria, casts, blood cells, and appearance.
§ Check for hearing loss. Aminoglycosides can cause ototoxicity.
§ Evaluate laboratory results and compare with baseline values. Report abnormal
results.
§ Monitor vital signs. Note whether body temperature has decreased.
§ Dilute gentamicin in 50 to 200 mL of normal saline (NS) or 5% dextrose in water (D5W)
solution and administer intravenously (IV) over 30 to 60 minutes.
§ Check that therapeutic drug monitoring (TDM) has been ordered for peak and
trough drug levels. Blood should be drawn 45 to 60 minutes after drug has been
administered for peak levels and minutes before next drug dosing for trough levels.
Gentamicin peak values should be 5 to 8 mcg/mL, and trough values should be less
than 1 to 2 mcg/mL.
§ Monitor for signs and symptoms of superinfection; these include stomatitis (mouth
ulcers), genital discharge (vaginitis), and anal or genital itching.
Explain the importance for ordering peak and trough concentration levels for
aminoglycosides.
§
Most drugs only require trough concentration levels to be drawn (the exception is
aminoglycoside antibiotics, which require both peak and trough levels).
§
The trough drug level is the lowest plasma concentration of a drug, and it measures the
rate at which the drug is eliminated.
§
Trough levels are drawn just before the next dose of drug regardless of route of
administration.
o
Contrast the nursing interventions for each of the drug categories: macrolides, tetracyclines,
aminoglycosides, and fluoroquinolones.
o
Macrolides Nursing interventions
§
o
o
o
Obtain a sample from infected area and send it to the lab for C&S testing before starting
antibiotic. • Monitor vital signs, urine output, and lab values. • Monitor the patient for
liver damage. • Administer antacids either 2 hours before or 2 hours after azithromycin. •
Instruct patient to take the full course of antibiotic. • Encourage patient to report side
effects. • Tell patient to report onset of loose stools/diarrhea.
Tetracyclines Nursing interventions
§
Obtain a sample for culture from infected area and send to lab for C&S before antibiotic
is begun.
§
Monitor lab values for renal and hepatic function.
§
Record vital signs and urine output.
§
Inform female patients who are contemplating pregnancy to avoid taking tetracycline
because it can cause discoloration of permanent teeth.
§
Encourage patient to take entire course of antibiotic.
Aminoglycosides Nursing interventions
§
Send a sample from the infected area to the lab for C&S to determine organism and its
sensitivity.
§
Check for hearing loss and renal function.
§
Check that therapeutic drug monitoring has been ordered for peak and trough drug levels.
§
Monitor for signs and symptoms of superinfection.
§
Encourage patient to increase fluids unless fluids are restricted.
Fluoroquinolones Nursing interventions
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Obtain a specimen from the infected site for C&S.
§
Monitor intake and output.
§
Check lab values for renal function.
§
Check for signs and symptoms of superinfection.
§
Encourage patient to report side effects.
§
Advise patient to wear sunglasses, sun block, and protective clothing when in the sun.
o
Explain the pharmacokinetics of the sulfonamides and apply the nursing process to the
patient taking trimethoprim-sulfamethoxazole and metronidazole.
o
Drug Class- Sulfonamides: trimethoprim- sulfamethoxazole
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Action Inhibit bacterial synthesis of folic acid
§
Bacteriostatic
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Effective against gram-negative bacteria
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Proteus, Klebsiella, E. coli, Toxoplasma gondii, and Chlamydia species
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Use
§
§
§
Treats otitis media, meningitis, malaria, and respiratory and urinary tract
infections
§
Treats prostatitis and gonorrhea
Side effects/adverse reactions
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Anaphylaxis
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Photosensitivity
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GI distress, stomatitis
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Insomnia, rash
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Crystalluria, hematuria
Nursing Process
§
Concept
§
§
Assessment
§
§
o
The patient’s WBC’s will be within normal limits.
Nursing interventions
§
§
Tissue injury, nausea, vomiting
Planning
§
§
Assess the patient’s renal function. • Determine whether the patient is
hypersensitive to sulfonamides. • Assess baseline lab results, especially
CBC.
Patient problems
§
§
Infection
Administer sulfonamides with a full glass of water. • Record vital signs
and intake and output. • Observe the patient for hematologic reactions.
• Check for signs and symptoms of superinfection. • Counsel patient
not to take antacids with sulfonamides. • Warn patient to wear
sunglasses, avoid direct sunlight, use sun block, and wear protective
clothing in the sun.
Evaluation
Drug Class- Nitroimidazoles: Metronidazole
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Action
§
§
§
§
Disrupts DNA and protein syntheses in bacteria and protozoa
§
Effective against H. pylori, Clostridium, Giardia, Gardnerella, Prevotella,
Peptococcus bacteria species, and Trichomonas vaginalis protozoa
§
Treats Clostridium difficile-associated diarrhea
§
Treats amebiasis, giardiasis, trichomoniasis
§
Treats gynecologic, skin, intraabdominal, bone/joint, and respiratory infections
§
Treats endocarditis, meningitis
§
Treats H. pylori, acne
§
Treats bacterial vaginosis, septicemia
Use
Side effects/ Adverse effects:
§
Anaphylaxis, superinfection
§
Headache, dizziness, insomnia, weakness
§
Dry mouth, dysgeusia, GI distress
§
Tongue/tooth discoloration
§
Peripheral neuropathy, seizures
§
Disulfiram-like reaction
§
Urine discoloration
Patient Safety: To avoid antibiotic resistance, use health care provider-patient/family
collaboration to counsel patients in antibiotic management by:
§
§
§
§
Checking if patient can be treated without antibiotics.
Completing antibiotics as prescribed.
Teaching patient correct use of the antibiotic, including not skipping doses or
self-medicating with someone else’s medication.
§ Reinforcing self-management skills in personal hygiene.
Assessment
• Obtain a health history listing all prescribed and over-the-counter (OTC)
medications, medications, and medication allergies.
• Assess the patient’s prior use of antibiotics, use of a multidrug regimen, and
presence of untreated infections.
• Assess the patient’s level of consciousness.
• Assess renal function and urinary output.
• Assess skin integrity and evaluate for skin rash and pruritus.
•
Patient Problems
o Allergic skin rash
o Need for health teaching
o Decreased functional ability: dizziness
o Sensory-perceptual impairment: decreased hearing, decreased vision
o Nausea and vomiting
o Disrupted fluid and electrolyte balance: nephrotoxicity
•
Planning
o The patient will show liver and kidney laboratory values at baseline
level by assessing urine output, blood urea nitrogen (BUN), and hepatic
enzymes.
o The patient’s skin will be intact without pruritus, swelling, or rash.
o The patient will be able to identify dose and explain how to properly
take the prescribed drug.
The patient will describe the side effects and adverse reactions that
require notification of a health care provider.
Nursing Interventions
o Monitor laboratory values, including liver function tests (aspartate
aminotransferase [AST], alanine aminotransferase [ALT]) and
evaluation of renal function (BUN, creatinine clearance [CrCl]) and
blood serum (platelet count, hemoglobin, hematocrit).
o Check urinary function by monitoring intake and output.
o Monitor the patient for an altered level of consciousness.
Patient Teaching
• Teach patients to read all instructions before taking medications.
• Inform patients to take all prescribed medication.
• Discuss possible side effects that can occur as a reaction to the drug.
o
•
•
•
•
•
•
•
•
•
Instruct patients to check for signs of superinfection, such as white patches
on the tongue.
Advise patients to report all adverse reactions to a health care provider,
including fever, diarrhea, trouble breathing, and decreased urination.
Describe urinary signs that indicate impairment, such as decreased urinary
flow.
Caution patient to not replace an herbal supplement for a prescribed
medication.
Use safety measures during activities of mobility.
Encourage self-management skills, reporting all side effects and adverse
reactions.
Evaluation
o Evaluate effectiveness of treatment by absence of manifestations.
§ Evaluate patient understanding of the medication regimen by
encouraging patient feedback and questions.
o
Discuss the adverse reactions of antitubercular, antifungal, and antiviral drugs.
o
Antitubercular
§
§
Side effects
§
Headaches
§
GI distress
Adverse reactions
§
Ocular toxicity, ototoxicity, hepatotoxicity
§
Paresthesia
§
Hyperglycemia
§
Hypocalcemia
§
Thrombocytopenia
§
Rifampin: turns body fluids orange
§
o
Soft contact lens may be permanently discolored
Antifungals
§
Patient safety
§
To avoid antibiotic resistance, use health care provider-patient/family
collaboration to counsel patients in antibiotic management by:
•
Checking if patient can be treated without antibiotics.
•
•
Completing antibiotics as prescribed.
Teaching patient correct use of the antibiotic, including not skipping doses
or self-medicating with someone else’s medication.
• Reinforcing self-management skills in personal hygiene.
Contraindications:
Drug-lab-food- Interactions
Hypersensitivity to drug components, first trimester of Drug: Alcohol may cause disulfiram-type reaction.
pregnancy; breastfeeding should be withheld,
Disulfiram may increase risk of toxicity. May increase
hematological disease
effects of oral anticoagulants
Use of disulfiram within 2 wk, use of alcohol during
Herbal: None significant
therapy or within 3 days of discontinuing
Food: None known
metronidazole
Lab: May increase serum LDH, ALT, AST
Caution: Liver impairment, cardiac and neoplastic
disease
Side Effects
Adverse Reactions
Anorexia, nausea, dry mouth, metallic taste, headache, Seizures, aseptic meningitis, pseudomembranous colitis,
dizziness, vomiting, diarrhea, abdominal cramps
pancreatitis leukopenia, bone marrow suppression,
aplasia, thrombocytopenia, Stevens-Johnson syndrome,
toxic epidermal necrolysis
o
Hepatitis Antivirals
§
o
Side effects—Mild to life-threatening
§
Fatigue, flu-like symptoms, depression, alopecia
§
Photosensitivity, anorexia, dysgeusia, arthralgia, myalgia
§
Thyroid and ophthalmic dysfunction
§
Hepatotoxicity, renal impairment
§
Lactic acidosis, pancytopenia
Cytomegalovirus Antivirals
§
Side effects:
§
Headache, dizziness, GI distress
§
Rash, pruritus, hematuria
§
Local irritation, renal dysfunction
§
Leukopenia, thrombocytopenia, granulocytopenia
o
Apply the nursing process for patients taking antitubercular, antifungal, and antiviral
drugs.
o
Antitubercular
§
Concept
§
§
Assessment
§
§
Pulmonary infection
Planning
§
§
Assess for hearing changes if drug regimen includes streptomycin.
Patient problems
§
§
Drug adherence
The patient’s sputum test for acid-fast bacilli will be negative 2-3 months after
prescribed antitubercular therapy.
Nursing interventions
§
o
§
Administer INH 1 hour before or 2 hours after meals.
§
Give pyridoxine (vitamin B6) as prescribed with INH to prevent peripheral
neuropathy.
§
Monitor hepatic function tests.
§
Emphasize importance of complying with drug regimen.
§
Encourage eye exams for patient taking INH and ethambutol.
Evaluation
Antifungals
§
Concept
§
§
Assessment
§
§
o
The patient will list potential complications and when to call the medical
provider.
Nursing interventions
§
Advise the patient to take drugs as prescribed.
§
Advise the patient not to consume alcohol.
§
Encourage the patient to report side effects.
§
Monitor patient’s urinary output. Evaluation
Antivirals
§
Concept
§
§
§
§
Decreased immunity
Planning
§
§
Obtain patient’s medical history including hepatic and renal disease.
Patient problems
§
§
Infection
Assessment
§
o
Decreased tissue integrity
Planning
§
§
Assess patient’s hepatic and renal function tests.
Patient problems
§
§
Drug adherence
The patient’s signs and symptoms of the viral infection will be diminished or
eliminated
Nursing Interventions
§
Observe the patient for evidence of side effects.
§
Check the patient for superinfections.
§
Monitor the patient’s CBC for evidence of leukopenia, thrombocytopenia, low
hemoglobin, and hematocrit.
§
Record the patient’s urinary output.
§
Dilute the antiviral drug in appropriate amount of solution.
Evaluation
Identify side effects and adverse reactions of people responding to antimalarial and antihelminthic drugs.
§
§
Antimalarial
§
Visual disturbances, dizziness
§
GI distress, hypokalemia
§
Eighth cranial nerve and retinal damage
§
Ototoxicity, cardiovascular effects
§
Nystagmus, wheezing
§
Renal and hepatic impairment
§
Hemolytic anemia
Anti-helminthic
§
Dizziness
§
Drowsiness
§
Headache
§
Weakness
§
GI distress
o
Apply the nursing process, including patient teaching of route, and side effects for people
receiving antimalarial and anti-helminthic drugs
o
Antimalarial
§
Treatment regimen
§
§
Prophylactic measures
§
§
§
Combinations used for drug-resistant malaria
Chloroquine, primaquine
Malaria eradication methods
§
Prophylaxis
§
Treatment for acute attack
§
Prevention of relapse
Side effects/adverse reactions
§
Visual disturbances, dizziness
§
GI distress, hypokalemia
§
Eighth cranial nerve and retinal damage
§
Ototoxicity, cardiovascular effects
§
Nystagmus, wheezing
§
Renal and hepatic impairment
§
Hemolytic anemia
§
Concept Infection, nutrition, immunity
§
Assessment
§
§
Assess whether the patient has traveled out of the country to a malariaendemic
area.
§
Obtain a patient history of malaria and antimalarial drugs.
Patient problems
§
§
Decreased immunity, decreased visual acuity
Planning
§
The patient will take antimalarial drugs at the times and dosages prescribed.
o
Anti-helminthic drugs
§
Action
§
Destroy parasitic worms
§
Drugs
§
Administration
§
§
§
§
§
Usually given 1 to 3 days
Side effects/adverse reactions
§
Dizziness
§
Drowsiness
§
Headache
§
Weakness
§
GI distress
Concept
§
§
Ivermectin
Infection, nutrition
Assessment
§
Assess patient for anal itching/abdominal discomfort.
§
Assess whether the patient has traveled to other countries.
§
Obtain a history of foods the patient has eaten and how the food was prepared.
Patient Problems
§
Coping, decreased immunity
§
Planning
§
§
§
The patient will demonstrate handwashing before eating.
§
The patient will explain how to prepare foods properly to avoid
recurrence.
Nursing interventions
§
Monitor the patient for adverse effects.
§
Explain to the patient the importance of handwashing before eating and
after working in soil or with animals.
Evaluation
o
Summarize the side effects and adverse reactions of peptides used as microbials including
colistimethate, polymyxins, bacitracin, and metronidazole.
o
Colistimethate
§
o
Polymyxins
§
o
Treats most gram-positive and some gram-negative bacteria
Metronidazole
§
o
Treats Pseudomonas aeruginosa, Escherichia coli, Klebsiella, Shigella
Bacitracin
§
o
Treats Pseudomonas aeruginosa, CRE, Klebsiella, Shigella
Treats Trichomonas vaginalis, amebiasis, giardiasis, Helicobacter pylori, rosacea
Side Effects/Adverse effects:
§
Hypersensitivity, anaphylaxis
§
Dizziness, headache, slurred speech
§
GI distress, respiratory distress Pruritus, rash, fever, skin redness
§
Neuromuscular blockage, paresthesia
§
Peripheral neuropathy, neurotoxicity, seizures
§
Ototoxicity, nephrotoxicity
§
Superinfection
§
Clostridium difficile associated diarrhea
o
Apply the nursing process for people taking antimicrobial peptides.
o
Concept:
o
o
o
o
§
Immunity
§
Infection
Assessment:
§
Health history
§
Prior use of antibiotics
§
Renal function Patient problems
§
N/V
§
Fluid and electrolyte imbalance
§
Skin integrity
Planning
§
The patient’s skin will be intact without pruritus, swelling, or rash.
§
The patient will be able to identify dose and explain how to properly take the prescribed
drug.
§
The patient will describe the side effects and adverse reactions that require notification of
a health care provider.
Interventions
§
Monitor Fluid and Electrolytes
§
Monitor I/O’s
§
Teach the patient to read all the instructions before taking medication
§
Discuss possible side effects and adverse reactions
Evaluation
Nutrition chapter 6 & 7
o
Distinguish between complete proteins and incomplete proteins.
§
Complete Proteins: contain all EAAs in sufficient quantities that best support growth
and maintenance of our bodies
§
§
o
EX: animal-derived foods, including meat, poultry, fish, eggs, and most dairy
products, and soybeans
Incomplete Proteins: lacks one or more of the nine EAAS
§
Will not provide a sufficient supply of amino acids and will not support life
§
Many plant foods contain considerable amount of incomplete proteins
§
EX: grains and legumes
What types of food would represent complete and incomplete proteins?
§
§
Complete Protein
§ Animal- derived foods, including meat, poultry, fish, eggs, and most dairy
products, contain complete protein. (A notable exception is gelatin, which is
incomplete.)
§ Soybeans are the only plant source that provide all nine essential amino acids.
§ Foods that contribute the best balance of EAAs and the best assortment of
NEAAs for protein synthesis and are easily digestible are high-quality protein
foods.
§ The two highest-quality protein foods are eggs and human milk.
§ The egg is of high quality because it contains all the necessary nutrients to
support life.
§ Human breast milk is the perfect food; its nutrient profile is ideal for human
growth.
Incomplete Protein
§ Incomplete proteins will not provide a sufficient supply of amino acids and will
not support life .
§ Many plant foods contain considerable amounts of incomplete proteins. Some of
the better sources are grains and legumes.
o
What are complementary proteins, and what are their function?
§ If different kinds of plant foods are eaten throughout the day, the total protein intake will
equal that of complete proteins found in animal-related products.
§ The advantages to complementary proteins are that plant foods cost less and tend to
contain less fat; consuming less dietary fat is a prevention strategy for several chronic
diet-related diseases.
§ A balance of amino acids is required throughout the day for protein synthesis.
§ A sufficient assortment of EAAs is provided without planning if both animal and plant
protein foods are eaten.
§ If animal foods are not eaten, more care is required to ensure that limiting amino acids
are consumed.
§ Combinations of plant foods that provide all the EAAs are grains (e.g., wheat or rice)
with legumes (e.g., kidney beans or chickpeas) and grains or legumes with small amounts
of animal protein from dairy, meat, poultry, or fish
Food Combinations That Provide Complete Proteins
Grains + Legumes = Complete Protein
Peanut butter sandwich
Tacos with refried beans
Rice and beans
Split pea soup with croutons
Falafel (chickpea balls) on pita bread Lentil soup with rye bread
Baked beans with bread
Grains or Legumes + Animal Protein (Small Amount) = Complete Protein
Chili with beans and cornbread Ready-to-eat cereal with skim milk Cheese sandwich
Pasta with cheese
Rice pudding
French toast
Pancakes (made with milk and/or eggs) Tuna casserole
o
What are limiting amino acids, and how does a diet avoid this effect?
§ The EAAs that those incomplete proteins lack are called limiting amino acids.
§ The limiting amino acid reduces the value of the protein contained in the food.
§ Unless the limiting amino acid is consumed in other foods, the amino acid pools inside
the cells would be missing some of the EAAs.
§ Protein production within the cell would be affected, and fewer proteins could be formed.
§ Consequently, limiting amino acids reduces the number of proteins our bodies can make.
§ Generally, we consume a sufficient mix of complete and incomplete proteins; therefore,
this is not a health problem.
§ Only those who adopt a dietary pattern restricting certain types of protein foods are at
risk for an imbalanced intake.
o Discuss how protein is digested, is absorbed as amino acids, and becomes available to
cells.
§ Because of the complex structure of proteins, a number of protein enzymes, or proteases,
produced by the stomach and pancreas are required to hydrolyze proteins into smaller and
smaller peptides until individual amino acids are ready for absorption.
§ Only mechanical digestion of protein occurs in the mouth.
• Mastication breaks protein-containing food into smaller pieces that mix with
saliva passing through to the stomach.
§ Pepsin becomes activated when it mixes with hydrochloric acid (HCl), also produced by
stomach secretions. Pepsin then begins the process of protein hydrolysis, breaking the
bonds linking the amino acids of the protein peptide.
o What is Nitrogen Balance, and what populations may be in a positive nitrogen balance?
• Nitrogen-balance studies are used to determine the protein requirements of the
body throughout the life cycle and to assign value to the protein quality of foods
to determine their biologic value.
• Because nitrogen (N) is a primary component of protein, the body's use of
protein can be determined by nitrogen-balance studies that compare the amount
o
of nitrogen entering the body in food protein with the nitrogen lost from the
body in feces and urine.
• Positive nitrogen balance occurs when more nitrogen is retained in the body than
excreted.
•
The nitrogen is used to form new cells for growth or healing.
• This state occurs in growing children and in pregnant women who require
additional nitrogen (and protein) for the growth of the fetus.
• Individuals recovering from illness or injury may be in positive nitrogen balance
as the body heals.
Differentiate the processes of anabolism, catabolism, deamination, and
hypermetabolism.
• Anabolism is enhanced by the effect of growth hormone (from the pituitary
gland) and the male hormone testosterone.
• Hormones affecting the catabolism (breakdown) of proteins are the
glucocorticoids that are enhanced by adrenocorticotropic hormone (ACTH);
these hormones are secreted from the adrenal cortex.
o This process releases proteins in the cells to break down to amino
acids, and then the amino acids travel in the bloodstream, contributing
to an available pool of amino acids
• Deamination results in the breaking off of an amino acid (NH2) group from an
amino acid molecule, resulting in one molecule each of ammonia (NH3) and a
o
keto acid.
• Hypermetabolism: an elevated resting energy expenditure > 110% of predicted
REE.
What are the benefits and drawbacks of vegetarianism?
• Benefits:
o Vegetarian dietary patterns may be followed to achieve health,
spiritual, economic, and/or environmental benefits.
o When well planned, vegetarian dietary patterns result in health benefits
that are similar to those of a low-fat, high-fiber diet and consist of
reduced risks for obesity, CVD, type 2 diabetes mellitus, hypertension,
gastrointestinal disorders, and certain cancers such as lung and
colorectal cancers
o The economic approach addresses the belief that animal-related
products cost more than plant protein foods, not only financially but in
terms of costs to our natural environment as well.
• Drawbacks:
o The vegetarian dietary pattern has several drawbacks. Most may affect
vegans.
o The vegan dietary pattern can provide all the essential nutrients except
vitamins D and B12, calcium, and omega-3 fatty acids.
o
o
o
o
These will need to be consumed through carefully selected fortified
foods or consumption of supplements as needed.
Most dietary vitamin D is consumed through milk fortified with the
vitamin. Because vegans do not consume any dairy products, this
source of vitamin D is unavailable.
Vitamin D is also available through synthesis during exposure of the
skin to direct sunlight
§ however, many individuals (even those consuming a
traditional animal-derived intake) have inadequate levels of
vitamin D and should rely on vitamin D–fortified foods or
supplements.
Factors such as regional limitation to sun exposure, darker skin
pigmentation, elderly, cultural clothing customs that conceal the body,
o
o
and regular use of sunscreen increase the risk of vitamin D deficiency
for child and adult vegans.
Another drawback pertains to the dimension of social health.
§ Social health is the ability to interact with people in an
acceptable manner and to sustain relationships with family
members, friends, and colleagues.
§ People following a vegetarian dietary pattern often find
themselves rationalizing their behaviors to others.
§ It can sometimes be tricky to do so without alienating others—
especially while seated at a steak dinner.
§ Perhaps the simplest approach is to emphasize the health
benefits gained by adopting a vegetarian dietary pattern.
What are strategies that vegetarians can take to maintain essential nutrient intake?
• Reliable sources of vitamin B12 are all animal related. Excluding animalderived foods, including milk, means that sources of B12 are simply not
•
•
•
available.
Even ovo-lacto-vegetarians may have low levels of vitamin B12.
Symptoms of vitamin B12 deficiency take years to appear and may cause
permanent damage to the central nervous system.
Individuals who restrict their intake of or exclude animal foods should take B12
supplements or consume foods fortified with vitamin B12 such as fortified soy
milk to ensure adequate intake.
Other nutrients that could be deficient in vegans are iron and zinc, minerals
usually consumed in meat, fish, and poultry.
• Calcium levels may also be low if dairy products are excluded; few plants are
good sources of calcium.
• These nutrients are available in a well-planned vegan diet of whole foods.
• Nonetheless, care must be taken to consume sufficient amounts of calcium
during pregnancy and growth periods; supplements will be necessary.
• If the vegan dietary pattern is poorly implemented and depends on refined and
processed foods, nutrients may be lacking.
• Ensuring that a vegetarian dietary pattern is healthful necessitates learning about
protein complementing and new ways of preparing meatless dishes.
• Simply replacing meat with a lot of cheese won't have any health benefits.
• In fact, the fat content of a cheese dish is probably higher than that of a lean
meat dish.
• The most helpful approach is to read vegetarian cookbooks that not only provide
recipes but also include vegetarian nutrition information.
List the functions of protein.
§ Growth and maintenance
§ Creation of communicators and catalysts
§ Immune system response
§ Fluid and electrolyte regulation
§ Acid-base balance
§ Transportation
•
o
o
What is an appropriate portion size of grains, vegetables, fruit, dairy, and protein based
on MyPlate?
§ Spreading protein intake throughout the food groups allows the objectives of MyPlate to
be met. The first plate provides the following:
• 1-oz (whole) grains
o
o
• 3-cups vegetables
• 0-cups fruit
• 1-cup milk (low-fat or fat-free)
• 6-oz meat and beans
§ The second plate provides the following:
• 2-oz (whole) grains
• 4-cups vegetables
• -cup fruit
• 1-cup milk (low-fat or fat-free)
• 3-oz meat and beans
§ The new plate provides more complex carbohydrates from grains, fruits, and vegetables
while still providing sufficient amounts of protein.
o What is meant as Chaining?
§ Chaining refers to the linking of two behaviors.
§ If two actions consistently occur together, they often become linked or tied to each other.
They become one behavior and a habit.
What are the dangers of chaining (ex. Eating wings and watching football)?
§ Many of us already practice chaining; unfortunately, the results often have a negative
impact on our dietary intake patterns.
• Frequently eating potato chips while studying can link these two actions—eating
chips and studying
What are some ways that chaining can be used to improve eating habits?
o When you eat a sandwich, eat a fruit, too.
§ Instead of linking chips and a sandwich (or hoagie, grinder, or sub), this practice links a
sandwich to a fruit.
o Have a glass of skim milk with the midday meal regularly to increase calcium intake.
§ Skim milk becomes chained to lunch.
o At home, weigh portions of meat, fish, and poultry.
§ Compare the size of an appropriate portion to the size of a deck of cards.
§ Are they similar? Weigh portions regularly, and consciously compare sizes.
§ Animal protein portion sizes will be linked to the deck of cards, and portion control can
be achieved without weighing.
o These are just a few chains related to protein consumption.
o Chaining can be applied to other nutrition and wellness situations of our clients as well.
o
How does protein relate to these functions or substances?
§ Collagen
• needed for growth and maintenance is the protein collagen, found throughout the
body.
• Collagen forms connective tissues such as ligaments and tendons and acts as a
glue to keep the walls of the arteries intact.
• In addition, collagen has a role in bone and tooth formation by forming the
framework structure, which is then filled with minerals such as calcium and
phosphorus.
• Synthesis of scar tissue also depends on collagen
§ Wound Healing
• Wound healing depends on an adequate intake of protein.
§ Insulin
• Insulin, a hormone that directs cells to take in glucose, is a protein.
• Enzymes are also proteins.
• Enzymes are catalysts that enable chemical reactions or biologic changes to
occur within the body.
• Each enzyme has a specific target; consequently, numerous enzymes are
continually formed.
§ Blood Clotting
•
•
o
Blood clotting depends on protein substances as well.
Twelve blood clotting factors must be in place for blood to clot when injury has
occurred; several of the factors, such as fibrogen, are composed of protein.
§ Fluid Balance
• Water is balanced among three compartments in the body:
o intravascular (within veins and arteries), intracellular (inside cells), and
interstitial (between cells). Proteins and minerals attract water, creating
osmotic pressure.
• As proteins circulate through our bodies, they maintain body fluid and
electrolyte balance by keeping water appropriately divided among the three
compartments.
§ Buffering
• The ability of protein to regulate the balance between the acidic and base
characteristics of fluids is called the buffering effect of protein.
• Because the chemical structure of amino acids combines an acid (the carboxyl
group [COOH]) and base (amine), an amino acid can function as either an acid
or a base, depending on the pH of its medium.
• This is why the buffering effect of blood proteins is possible.
o This function is crucial to protect all proteins in the body.
o If fluids become either too acidic or too basic, the shapes of proteins
are altered or denatured.
o Denatured proteins are not able to perform their usual functions.
§ Transportation of vital substances
• proteins are able to transport nutrients and other vital substances.
• For individual cells, proteins act as pumps, assisting the movement of nutrients
in and out of cells.
• Many nutrients, including lipids, minerals, vitamins, and electrolytes, are carried
in the blood by proteins such as lipoproteins.
• This allows the nutrients to be available to all parts of the body.
• Hemoglobin, a special carrier composed of protein, transports oxygen in the
blood.
• Oxygen is stored in our muscles in another protein carrier, myoglobin.
• These protein carriers, hemoglobin and myoglobin, are essential for a wellfunctioning body.
o Describe the differences between water-soluble and fat-soluble vitamins.
§ Most are water-soluble, meaning they dissolve in water.
§ In contrast, the fat-soluble vitamins are similar to oil and do not dissolve in water.
§ Fat-soluble vitamins are most abundant in high fat foods and are much better absorbed
into your bloodstream when you eat them with fat.
§ Water-soluble vitamins types:
• Thiamin, riboflavin, niacin, pantothenic acid, biotin, B6 (pyridoxine), B12
(cobalamin), folate, C (ascorbic acid)
§ Fat-soluble vitamins types:
• A (retinol), D (cholecalciferol), E (tocopherol)
List the main functions, recommended intake/sources, and consequences/causes of
deficiency/excess
• Water Soluble Vitamins
o Thiamin (B1)
§ Function:
• is to serve as a coenzyme, a substance that activates
an enzyme, in energy metabolism; it also has a role in
nerve functioning related to muscle actions.
§
Recommended intake/sources:
o
o
• 1.2 mg for men
• 1.1 mg for women
§ Consequences/causes of deficiency/excess:
• Thiamin deficiency alters the nervous, muscular,
gastrointestinal (GI), and cardiovascular systems.
• In beriberi, a severe, chronic deficiency results,
characterized by ataxia (muscle weakness and loss of
coordination), pain, anorexia, mental disorientation,
and tachycardia (rapid beating of the heart).
• Wet beriberi manifests as edema, affecting cardiac
function by weakening the heart muscle and vascular
system.
• Dry beriberi affects the nervous system, producing
paralysis and extreme muscle wasting.
• Marginal deficiencies may occur, producing
psychologic disturbances, recurrent headaches,
extreme tiredness, and irritability
§ Toxicity:
• Excess thiamin is excreted in urine.
• Although thiamin is nontoxic, there is no rationale for
supplementation in healthy people.
• In acute care settings, supplemental thiamin and other
B vitamins may be recommended for individuals with
chronic excessive alcohol consumption.
• In general, the best advice is to take a daily
multivitamin containing B vitamins.
Riboflavin (B2)
§ Function:
• the main function of riboflavin is as a coenzyme in
the release of energy from nutrients in every cell of
the body.
§ Recommended intake/sources:
• 1.3 mg for men
• 1.1 mg for women
• Good plant sources are broccoli, asparagus, dark
leafy greens, whole grains, and enriched breads and
cereals.
• Rich sources of animal origin include dairy products,
meats, fish, poultry, and eggs.
§ Consequences/causes of deficiency/excess:
• Ariboflavinosis is the name for a group of symptoms
associated with riboflavin deficiency.
• The lips become swollen, and cracks develop in the
corners of the mouth (cheilosis).
• The tongue becomes inflamed, swollen, and purplish
red (glossitis), a common symptom of riboflavin and
other B vitamins.
• Seborrheic dermatitis, a skin condition characterized
by greasy scales, may occur in the regions of the ears,
nose, and mouth.
• Riboflavin deficiency may also affect the availability
and use of pyridoxine and niacin.
Niacin (B3)
§ Function:
•
§
§
§
o
involved as a coenzyme for many enzymes,
especially those involved in energy metabolism; it is
critical for glycolysis and the tricarboxylic acid
(TCA) cycle.
Recommended intake/sources:
• Niacin requirements are measured in niacin
equivalents (NEs), reflecting the body's ability to
convert tryptophan to niacin.
• To form 1 mg of niacin, 60 mg of tryptophan is
needed, both of which equal 1 mg NE.
• The RDA recommends that men and women
consume 16-mg NE and 14-mg NE per day,
respectively.
• The DRI for niacin includes a UL of 35-mg NE per
day because of the adverse reactions experienced
when excess amounts are taken in
• is available in foods as the active vitamin or as its
precursor, the amino acid tryptophan.
• That is, tryptophan can be converted to niacin, and
some niacin can be provided this way.
• Diets adequate in protein tend to be adequate in
niacin.
Consequences/causes of deficiency/excess:
• Pellagra, the niacin deficiency disorder, is
characterized by the three D's:
o Dermatitis
o Dementia
o Diarrhea
Toxicity:
• The UL for niacin is 35-mg NE per day.
• When preformed niacin and nicotinic acid (but not
niacinamide) are consumed in levels greater than the
UL, the vascular system is affected, producing a
flushing effect throughout the body.
Folate
§ Function:
• acts as a coenzyme in reactions involving the transfer
of one- carbon units during metabolism.
• As such, it is required for the synthesis of amino
acids, which are the building blocks of protein, and
for the synthesis of deoxyribonucleic acid (DNA) and
ribonucleic acid (RNA)
§
Recommended intake/sources:
• reflects that some folate is stored in the liver, but
generally, daily supplies are needed.
• 400 μg for men and women
• Folate is widely available in foods, particularly in
leafy green vegetables, legumes, ready-to-eat cereals,
and some fruits and juices.
• Folate is affected by heat, oxidation, and ultraviolet
light; processing and cooking of fresh foods reduce
the amount of folate available.
• Folate is found in many foods that contain ascorbic
acid (vitamin C), such as oranges and orange juice.
•
•
o
Ascorbic acid protects folate from oxidation.
Diets deficient in folate often are deficient in vitamin
C, and vice versa.
§ Consequences/causes of deficiency/excess:
• Folate deficiency results in megaloblastic anemia.
• This is a form of anemia characterized by large red
blood cells that cannot carry oxygen properly.
• Other deficiency symptoms are glossitis, diarrhea,
irritability, absent-mindedness, depression, and
anxiety
• Numerous medications may affect folate absorption
or may be antagonistic to folate.
• These drugs include anticonvulsants, oral
contraceptives, aspirin, cancer chemotherapy agents,
sulfasalazine, nonsteroidal anti-inflammatory drugs,
and antacids.
• Long-term use of any medication may affect the
body's use of nutrients; folate is one that is
particularly vulnerable.
§ Toxicity:
• Excess folate or folic acid intake is not recommended
or warranted.
• Consuming amounts beyond the UL of 1000-μg folic
acid (for men and women) has not been studied.
o Such high levels may mask the presence of
pernicious anemia
Cobalamin (B12)
§ Function:
• Two cobalamins function as vitamin B12 coenzymes
•
•
•
§
in humans.
Vitamin B12 plays a role in folate metabolism by
modifying folate coenzymes to active forms to
support metabolic functions, including the synthesis
of DNA and RNA.
The metabolism of fatty acids and amino acids also
requires vitamin B12.
In addition, this vitamin develops and maintains the
myelin sheaths that surround and protect nerve fibers.
Recommended intake/sources:
• Recommended vitamin B12 levels take into account
•
•
•
•
that some of the vitamin is stored in the liver
Young adults is 2.4 μg.
Foods of animal origin are the only reliable sources
of vitamin B12; meat, fish, poultry, eggs, and dairy
products are all good sources.
o For example, one glass of skim milk
provides 0.93 μg of vitamin B12.
The vitamin has been reported to be found in legumes
(nodules on roots) because of bacteria formation in
soil, but they are not a reliable source.
Vegans must supplement their intake with vitamin
B12 supplements or use fortified products.
§
Consequences/causes of deficiency/excess:
• Deficiencies of B12 are usually secondary.
Pernicious anemia (from lack of intrinsic factor for
vitamin B12 absorption) or megaloblastic anemia
•
•
•
o
(from related folate dysfunction) occurs.
Additional neurologic effects develop because of
damage to the spinal cord as the breakdown of
myelin sheath synthesis affects brain, optic, and
peripheral nerves
Older adults are more at risk for deficiency because
of a naturally occurring reduction in production of
the intrinsic factor by the stomach mucosa.
Most older adults, however, maintain vitamin B12
levels within normal range.
Vitamin C
§ Function:
• perform different functions in various situations.
• Collagen formation for bone matrix, teeth, cartilage,
and connective tissue depends on ascorbic acid.
• Vitamin C provides the cement that holds structures
together.
• Wound healing, which necessitates the formation of
new tissue, also requires vitamin C.
• enhances the absorption of nonheme iron
• may have a role in reducing the risk of cancer
development
§ Recommended intake/sources:
• 45 mg to 60 mg for adults
• 90 mg for men
• 75 mg for women
• Many foods are excellent sources;
o citrus fruits, red and green peppers,
strawberries, tomatoes, potatoes, broccoli,
and other green leafy vegetables.
o Apple and grape juice
§ Consequences/causes of deficiency/excess:
• Older adults may have marginal intake because of
difficulty in obtaining and preparing fresh foods.
• These at-risk groups may experience other vitamin
and mineral deficiencies as well.
• Scurvy represents the extreme result of vitamin C
deficiency.
• Marginal deficiency may manifest as gingivitis with
soreness and ulcerations of the mouth, poor wound
healing, inadequate tooth and bone growth or
maintenance, and increased risk of infection as the
integrity of tissues throughout the body becomes
compromised.
§ Toxicity:
• Toxicity from foods high in vitamin C does not occur
even if we consume cups of fresh strawberries
washed down with a quart of orange juice.
•
•
•
Long-term supplement intakes of megadoses from 1
to 15 g may result in cramps, diarrhea, nausea,
kidney stone formation, and gout.
The effects of anticlotting medication may also be
affected
Fat-Soluble Vitamins
o Vitamin A
§ Function:
• function to maintain skin and mucous membranes
throughout the body.
o vision, bone growth, functioning of the
immune system, and normal reproduction
§ Recommended intake/sources:
• measured as retinol activity equivalents (RAE)
• stored in the liver
• 900-μg RAE for men
• 700-μg RAE for women
•
Natural preformed vitamin A is found only in the fat
of animal- related foods
§ these include whole milk, butter,
liver, egg yolks, and fatty fish.
• Carotenoids are found in deep green, yellow, and
orange fruits and vegetables.
• The best sources are broccoli, cantaloupe, sweet
potatoes, carrots, tomatoes, and spinach
• High consumption of carotenoids, particularly beta
carotene, has been associated with decreased risk of
certain cancers and other chronic diseases.
• This may be due to their action as anti-oxidants.
§ Consequences/causes of deficiency/excess:
• Caused by lack of dietary intake, or secondary, the
result of chronic fat malabsorption.
• As liver storage becomes depleted, symptoms
develop.
• The effects are closely tied to vitamin A functions.
• Ocularly, xerophthalmia incorporates a range of
problems, from night blindness (the inability of the
eyes to readjust from bright to dim light) progressing
to a hard, dry cornea (keratinization) or
keratomalacia, resulting in complete blindness
• Compromised epithelial tissues also result in the
development of hard white lumps of keratin on hair
follicles (hyperkeratosis), respiratory infections,
diarrhea, and other GI disturbances.
o Vitamin D
§ Function:
• Intestinal absorption of calcium and phosphorus
depends on the action of vitamin D.
• This vitamin also affects bone mineralization and
mineral homeostasis by helping to regulate blood
calcium levels.
• Vitamin D also has potential effects on growth and
regulation, cardiovascular function and
immunological performance.
§
o
Recommended intake/sources:
• 15 μg (600 international units [IU])
• people ages 70 and older jumps to 20 μg (800 IU
§ This level reflects the lesser
efficiency of older adults to
synthesize vitamin D from sun
exposure.
o The few sources of natural preformed
vitamin D are the fat of the animal-related
foods butter, egg yolks, fatty fish, and liver.
o Milk, although containing fat, is not a good
source; it is, however, a good vehicle for
vitamin D fortification because it contains
calcium and phosphorus, which need
vitamin D for absorption.
o Because vegans consume no animal foods,
they may require supplements or regular
sunlight exposure to ensure formation of
cholecalciferol.
§ Consequences/causes of deficiency/excess:
• Can lead to rickets and osteomalacia
• older adults who may have a diminished ability to
produce vitamin D, osteomalacia may develop when
marginal intakes of vitamin D or calcium exist for a
number of years.
• Calcium absorption may also be affected by the aging
process and may contribute to osteomalacia risk.
• Older women are more at risk than older men
because of the effects of repeated pregnancies and
lactation on bone density.
• Symptoms of osteomalacia include weakness,
rheumatic-like pain, and an awkward gait.
• Because bones are weakened, fractures of the spine,
hips, and limbs may occur.
• Osteoporosis is a condition in which bone density is
reduced and the remaining bone is brittle and breaks
easily.
• Vitamin D deficiency is associated with increased
risk of CVD, rheumatoid arthritis, cancers, type 1
diabetes mellitus, and multiple sclerosis.
Vitamin E
§ Function:
• acts as an antioxidant, protecting polyunsaturated
fatty acids and vitamin A in cell membranes from
oxidative damage by being oxidized itself.
• This function is particularly important in protecting
the integrity of lung and red blood cell membranes,
which are exposed to large amounts of oxygen.
• Other antioxidative functions of vitamin E are
performed as part of a system in conjunction with
selenium and ascorbic acid (vitamin C).
§ Recommended intake/sources:
• Vitamin E requirement is met by a particular
tocopherol, alpha-tocopherol, which is the most
widely occurring form and the most active.
•
•
o
15 mg for men and women
The best sources of vitamin E are vegetable oils (e.g.,
corn, soy, safflower, canola, and cottonseed) and
margarine.
o Whole grains, seeds, nuts, wheat germ, and
green leafy vegetables also provide adequate
amounts of vitamin E.
o Processing of these foods may decrease the
final vitamin E content.
§ Consequences/causes of deficiency/excess:
• A primary deficiency of vitamin E is rare.
• Secondary deficiencies occur in premature infants
and in other people who are unable to absorb fat
normally.
• Some chronic fat absorption disorders in which
deficiencies may occur are cystic fibrosis, biliary
atresia (blocked bile duct), other disorders of the
hepatobiliary system, and liver transport problems.
• Symptoms of vitamin E deficiency are neurologic
disorders resulting from cell damage and anemia
caused by hemolysis of red blood cells (hemolytic
anemia)
o Vitamin K
§ Function:
• a cofactor in the synthesis of blood- clotting factors,
including prothrombin.
• Protein formation in bone, kidney, and plasma also
depends on the actions of vitamin K.
§ Recommended intake/sources:
• 120 μg per day for men and 90 μg for women
• Stored vitamin K
• Primary food sources for vitamin K are dark green
leafy vegetables.
• Lesser amounts are found in dairy products, cereals,
meats, and fruits.
§ Consequences/causes of deficiency/excess:
• Deficiency of vitamin K inhibits blood coagulation.
• Deficiencies may be observed in clinical settings
related to malabsorption disorders or medication
interactions.
• Long-term intensive antibiotic therapy destroys the
intestinal microflora that produce vitamin K.
• As with the other fat-soluble vitamins, any barrier to
absorption affects the quantity of fat-soluble vitamin
absorbed.
What are some of the benefits of phytochemicals?
§ Phytochemicals are nonnutritive substances in plant-based foods that appear to have
disease- fighting properties.
§ Sulforaphane appears to block the growth of tumors in animals.
§ Broccoli, along with onions and grapes, also contains flavonols, which seems to reduce
the risk of cardiovascular disease (CVD) and cancer while having an anti-inflammatory
effect
Module 2.3 Immune & Cancer
Learning Objectives
•
Pharmacology
o
Ch. 29 HIV/ AIDS
§
Describe the six classifications of antiretroviral therapy and give an example of a
medication in each group.
§
Nucleoside reverse transcriptase inhibitors (NRTIs)
§
Action:
§
§
§
§
Side effects/adverse effects:
§
Nausea, diarrhea, rash, abdominal pain
§
Peripheral neuropathy, pancreatitis, lipoatrophy, myopathy
Nursing considerations:
§
Can take NRTIs without regard to food
§
Didanosine should be taken 30 minutes before a meal or 2
hours after a meal
Nonnucleoside reverse transcriptase inhibitors (NNRTIs)
§
Action:
§
§
§
Binds directly to reverse transverse transcriptase enzymes
blocking DNA polymerization
Side effects/adverse effects:
§
Dizziness, sedation, loss of concentration
§
Rash, nightmares, euphoria
§
Hepatotoxicity, Stevens-Johnson syndrome
Protease inhibitors (PIs)
§
Action:
§
§
§
Inhibit viral replication by interfering with HIV viral RNAdependent DNA polymerase
Inhibits protease activity causing formation and release of
immature, defective, and noninfectious virus particles
Side effects/adverse effects:
§
Rash, nausea, vomiting, diarrhea
§
Dyslipidemia, insulin resistance
§
Hemolytic anemia, StevensJohnson syndrome
§
EKG changes, MI
Fusion (entry) inhibitors
§
Action:
§
§
Prevents HIV entry into healthy cells- > inhibiting fusion of
the virus to healthy cell membranes
Side effects, allergic reactions:
§
Rash, diarrhea
§
Injection site reactions
§
§
CCR5 antagonists
§
Action:
§
§
§
Prevents viral replication by blocking CCR5 coreceptor
needed for CCR5 -tropic HIV entry into immune cells
Side effects/adverse effects:
§
Upper respiratory infection, cough, pyrexia
§
Rash, dizziness
§
Abdominal pain
§
Hepatotoxicity
Integrase strand transfer inhibitors (INSTIs)
§
Action:
§
§
§
Anaphylaxis, fever, hypotension
Limits ability of virus to replicate and infect new cells by
interfering with integrase (enzyme needed for HIV to multiply
and divide)
Side effects:
§
Nausea, diarrhea
§
Rash, insomnia, headache, pyrexia
§
Myopathy, hepatic damage
§
Rhabdomyolysis
Discuss the nurse’s role in medication management and issues of adherence.
§
§
§
Provide information on the necessity of adhering to the drug regimen and
regular health care.
Provide opportunities for the patient and/or support persons to verbalize
feelings.
Encourage strategies to cope with drug side effects.
Patient Adherence
§
Suggestions to promote patient adherence:
§
§
Drug organizers
§
Mobile devices alarm
§
Drug map with pictures
§
Drug diary
§
Support system
§
Patient education
Apply the nursing process, including teaching, to the care of patients with HIV infection.
•
•
Antiretroviral Therapy
o Concept: Drug Adherence
§ The ability or lack of the ability to take drugs as prescribed
Assessment
o Obtain an in-depth patient history and assess physiologic and psychosocial needs.
o Assess for signs and symptoms related to clinical progression of human immunodeficiency virus
(HIV), and refer to medical care and psychological support as indicated.
Perform a drug reconciliation that includes all prescription, over-the-counter (OTC), and herbal
products. Assess for use of illegal and other nonprescription drugs. Report potential drug-drug or
drug-herb interactions.
o Obtain a nutritional history to assess for nutritional deficits and for potential drug-food
interactions. Assess for the potential need for therapeutic lifestyle change.
o Assess readiness to learn and discern the preferred method of instruction (written, verbal,
pictorial).
o With each patient visit, conduct a pill count to determine treatment adherence.
Patient Problems
o Nonadherence, risk for
o Need for health teaching
o Coping
o Decreased immunity
Planning
o The patient will adhere to the drug regimen and will report any difficulties related to adherence.
o The patient will participate in medical treatment and in the spiritual and psychological support that
best fits the patient’s needs and belief system; the patient will verbalize fears.
o The patient will verbalize ways of maintaining self-health management such as a daily calendar
and reminders.
o The patient will verbalize ways to cope with side effects of the drug regimen.
o The patient will verbalize signs and symptoms of potential infection and can reiterate when to
notify the health care provider.
o The patient will have undetectable viral load at end of therapy.
o The patient will not experience secondary or opportunistic infections (OIs).
Nursing Interventions
o Provide information on the necessity of adhering to the drug regimen and regular health care.
Inconsistent dosing can promote drug resistance. Effectiveness and side effects of antiretroviral
therapy (ART) need to be monitored and/or treated.
o Provide information on various methods of remembering to take drugs. Inconsistent dosing can
increase the risk of drug resistance.
o Refer the patient for health care maintenance and appropriate health screening examinations,
including Pap tests, ophthalmologic and dental examinations, and age- or risk-related
colonoscopies. Side effects and adverse reactions are common in patients receiving ART.
o Refer the patient for spiritual support and for mental health or substance use counseling as needed.
o Provide opportunities for the patient and/or support persons to verbalize feelings.
o Encourage strategies to cope with the side effects of medications.
o Monitor laboratory reports for indications of decreasing CD4+ counts and/or rising viral load;
inform the HIV health care provider.
o Refer the patient for nutritional counseling as needed.
Patient Teaching
o General
§ Educate patients about adherence to the therapeutic regimen by providing information on
drugs and a timetable of dosing in patients’ preferred method of learning.
§ Explain common emotional responses.
§ For patients of childbearing age, explain how HIV transmission to the unborn baby can
occur.
§ Teach about safe sex practices and other ways to prevent transmission of HIV.
§ Inform patients that certain drugs—including OTC medications—and foods and herbal
products may interact with antiretrovirals.
§ Assist patients in developing a system for taking the correct dose of the correct drugs at
the correct time.
§ Counsel patients about the importance of having an adequate supply of drugs to avoid
interruption in the dosing schedule. Omission of drugs may result in deterioration of the
patient’s condition.
Side Effects
o Explain how HIV can damage the immune system and promote infection.
o
•
•
•
•
•
To decrease risk for exposure to infection, emphasize protective precautions as necessary, such as
frequent handwashing, avoiding crowds, and receiving influenza vaccines.
o Inform the patient to report unmanageable side effects, such as nausea and diarrhea.
Evaluation
o The patient will have at least a 95% drug adherence.
o Viral load will decrease or become undetectable.
o The patient and/or the significant other will openly discuss any fears or concerns related to HIV
and ART.
o The patient will verbalize safe sex practices and methods to reduce HIV transmission.
o
•
o
Ch. 30 Transplant drugs
§
Differentiate the three drugs used in the treatment of transplant rejection.
§
Drug Class: Transplant induction medication
§
Drug Class: Calcineurin Inhibitors
§
§
§
§
o
Drug: Cyclosporine
Drug Class: Monoclonal anti-CD-3
§
§
Drug: Basiliximab
Drug: Muromonab
Overall Drugs for transplant rejection – no specific drug here
Describe the nurse’s role in promoting adherence to the therapeutic drug regimen.
Ch. 31 Vaccines
§
Apply the nursing process to include teaching for patients receiving vaccines and
reporting adverse effects of the vaccines.
§
Concept
§
§
§
Assessment
§
Obtain a medical history.
§
Determine history of pregnancy or possible pregnancy with the next
month.
§
Determine complete allergy history.
Patient problems
§
§
§
Need for health teaching
Planning
§
§
Safety
The patient will adhere to recommended immunization schedule
Nursing Intervention
Evaluation
§
Document the vaccination date, route, and site of administration;
vaccine type, manufacturer, lot number, and expiration date; and name,
business address, and title of person administering vaccine in patient’s
record.
§
Observe patient for signs and symptoms of adverse reaction to
vaccines.
§
Keep epinephrine available for immediate use in case of anaphylactic
reaction.
§
Vaccine Safety
§
Reporting diseases and adverse reactions:
§
Mild reactions
§
§
§
Contraindications for vaccines
§
Moderate or severe illness
§
Anaphylaxis
Health care providers
§
§
§
o
Injection site swelling, low -grade fever
Responsible for reporting vaccine -preventable diseases and adverse
reactions following immunizations
Report adverse reactions to VAERS
Side Effects/ adverse reactions: Varicella Vaccine
§
Injection site reaction, fever, rash, anaphylaxis
§
Thrombocytopenia, encephalitis, Stevens -Johnson syndrome
Ch. 32 Anticancer
§
§
Define chemotherapy as an anticancer drug.
§
Affects both cancer and normal cells
§
Handle the drug with care during preparation and avoid direct skin contact with
the drug.
§
Most common route for medication administration: IV
Discuss ways the nurse can avoid exposure to anticancer drugs.
§
§
Handle the drug with care during preparation and avoid direct skin contact with
the drug. (Doxorubicin)
Differentiate between cell cycle-specific and cell cycle–nonspecific anticancer drugs.
§
Cell cycle–nonspecific (CCNS) drugs act during any phase of the cell cycle,
including the G0 phase.
§
§
Cell cycle–specific (CCS) drugs exert their influence during a specific phase of
the cell cycle and are most effective against rapidly growing cancer cells.
§
§
CCNS drugs include most alkylating drugs, antitumor antibiotics, and
hormones.
The CCS drugs include antimetabolites, some alkylating agents, and
vinca alkaloids.
Prioritize appropriate nursing interventions to use while patients receive anticancer
drugs.
§
Antitumor antibiotic: Doxorubicin
§
Nursing interventions
§
Maintain strict medical asepsis during dressing changes and
invasive procedures.
§
Assess cardiac status and check for any ECG abnormalities
before and during treatment.
§
Monitor IV site frequently and stop infusion immediately if
signs of extravasation are apparent.
§
Handle the drug with care during preparation and avoid direct
skin contact with the drug.
§
Plant Alkaloids: Vincristine
§
§
Assess for signs of respiratory distress during and
after drug administration.
§
Monitor for signs of peripheral neuropathy.
§
Assess patient’s IV site frequently.
§
Administer stool softener or laxative as prescribed.
§
Advise patient to promptly report signs of infection.
§
Teach patient the signs of drug extravasation into
tissue.
Nursing interventions
§
Monitor patient’s IV site frequently.
§
Maintain strict medical asepsis during dressing
changes and invasive procedures.
§
Administer an antiemetic 30 to 60 min before drug
administration.
§
Monitor fluid intake and output and nutritional status.
§
Advise patient to promptly report signs of infection.
Alkylating drug: Cyclophosphamide
§
o
§
Antimetabolite drug: fluorouracil
§
§
Nursing interventions
Nursing interventions
§
Monitor lab results.
§
Monitor patient’s IV site frequently for irritation and
phlebitis.
§
Maintain strict medical asepsis during dressing
changes and invasive procedures.
§
Encourage small, frequent meals high in calories and
protein.
§
Maintain hydration before and during chemotherapy
Ch. 33 Targeted Therapies to Treat Cancer
§
Identify the different forms of targeted therapy for cancers.
§
Targeted therapy as drugs or other substances that block the growth and spread
of cancer by interfering with specific molecules involved in tumor growth,
progression, and spread.
§
Targeted therapies include angiogenesis inhibitors, epidermal growth factor
receptor (EGFR)–TK inhibitors, BCR-ABL1 TK inhibitors, MAbs, and
proteasome inhibitors.
§
All targeted therapies are categorized as high-alert medications.
§
Targeted therapies differ from standard chemotherapy in several ways.
§
Targeted therapies (1) act on specific molecular targets associated with
cancer, (2) are deliberately designed to interact with a specific target,
and (3) often are cytostatic by blocking tumor cell proliferation.
§
§
Compare the mechanisms of action of targeted therapies for cancer
§
Angiogenesis inhibitors- Prevent new blood vessels from forming
§
Epidermal growth factor receptor inhibitors-blocks the activity of a protein
called epidermal growth factor receptor
§
Tyrosine kinase inhibitors-TKIs come as pills, taken orally.
§
o
A targeted therapy identifies and attacks specific types of cancer cells
while causing less damage to normal cells.
§
Monoclonal antibodies-inhibit or stop specific behaviors in cancer cells that
help them grow and thrive.
§
Proteasome inhibitors-inhibit the action of HIV-1 protease
Ch. 34 Biologic Response Modifiers
§
Distinguish among the different types of biologic response modifiers with regard to
indications, common side effects and adverse effects, route of administration, and
nursing responsibilities.
§
Drug: Interferon Alfa-2b
§
Produced endogenously in response to viral infection and other
exogenous inducers
§
Action
§
§
§
Bind to cell receptors for biologic activities
§
Activate tyrosine kinases
§
Affect cellular differentiation, regulation of antigen
expression, and cytokine induction
§
Antiviral, antiproliferative, immunomodulatory effects
§
Hairy -cell leukemia, malignant melanoma
§
AIDS -related Kaposi sarcoma
§
Hepatitis B and C viruses, non -Hodgkin lymphoma
§
Human papillomavirus infection
Use
Route
§
IV
§
IM
§
§
Side effects
§
Neuropsychiatric disorders
§
Autoimmune disorders
§
Ischemic disorders
§
Infectious disorders
Drug: Erythropoietin-Stimulating Agents—Epoetin Alfa
§
Erythropoietin
§
Glycoprotein produced by kidney
§
Stimulates RBC production in bone marrow
§
Action
§
§
§
§
Side effects/adverse reactions
§
Anaphylaxis
§
Hypertension
Route
§
IV
§
SC
Drug: Granulocyte Colony-Stimulation Factor—Filgrastim
§
Produced by macrophages, endothelium and other immune cells
§
Action
§
§
§
Stimulates red blood cell production
§
Regulates production of neutrophils (WBCs)
§
Chronic neutropenia
§
Patients receiving myelosuppressive cancer chemotherapyneutropenia
§
Induction or consolidation chemotherapy for AML
§
Bone marrow transplantation for cancer
Use
Route
§
IV
§
SC
Incorporate the nursing process related to the needs of patients receiving biologic
response modifiers.
§
§
§
§
§
Concept
§ Immunity
Assessment
§ Conduct detailed current medication history.
§ Obtain baseline lab values.
§ Obtain list of patient’s drug and food allergies.
Patient problems
§ Decreased immunity, need for teaching
Planning
§ The patient will verbalize understanding of immunotherapy.
Nursing interventions
§ Monitor appropriate labs.
§ Monitor renal and hepatic function.
§
§ Monitor patient for any adverse effects.
§ Report symptoms of bleeding immediately.
§ Report unmanageable nausea and vomiting.
§ Teach patient to avoid crowds and people with infection
Evaluation
§ Free from infection
Nutrition
o
Nutrition Assessment in HIV/AIDS
§
§
Lean body mass
§
Shifts in lean body mass may occur even though weight may be initially
maintained.
§
Bioelectrical impedance analysis or upper arm muscle area may be used to
monitor over time.
Visceral protein stores
§
Depletion associated with lowered CD4+ or increased viral load
§
Measured by C-reactive protein, albumin, and prealbumin levels
§
o
o
Dietary assessment
§ May be evaluated by 24-hour recall, food frequency, or food diary
§ Calculation of body mass index (BMI)
§
BMI of less than 18 suggests malnutrition.
§ Body weight in comparison with the client’s usual body weight
§ Any unexplained weight loss should be noted.
§
Weight loss of more than 10% in 6 months places the client at risk
§ Careful attention to gut function/GI complaints
§
ex: N&V, diarrhea
§ Referral to registered dietitian for more thorough assessment as indicated
Describe common characteristics of cancer and HIV/AIDS in terms of their effects on the GI
tract, on which nutrition therapy focuses.
§
Present challenges to nutritional status
§
Characterized by wasting and malnutrition
§
Attributable to the disease or secondary to treatment
List local or systemic effects of cancer that increase the risk of malnutrition or cancer
cachexia.
§
§
§
§
§
Endocrine & Metabolic Disorders:
Hypogonadism
§
Associated with fatigue, decreased libido, loss of muscle mass, muscle
weakness, and loss of body hair
Fatigue
§ Can contribute to decrease in appetite and impairment of ability to prepare and
consume meals
Fat redistribution syndrome or lipodystrophy
§
Abdominal obesity; increased levels of serum triglycerides, cholesterol, and
glucose; and insulin resistance
Malabsorption
§ Causes: opportunistic infections that damage GI tract; malnutrition, which
decreases villus height and enterocyte function; disease itself
§ Steatorrhea possible in patients without GI infections
§ Treat underlying cause
§ Fat and lactose restrictions may help
§
o
Lactose-free supplements and supplements with mediumchain triglycerides
§
Probiotics and prebiotics
§ Glutamine and arginine
§ Attention to energy, protein, and fluid adequacy
§ Weight Loss/Body Composition Changes
§ Loss of fat stores and lean body mass
§ Lipodystrophy or fat redistribution syndrome
§ Mediterranean-style diet and omega-3 polyunsaturated fatty acid
supplementation may be useful.
§ Anorexia
§ Frequent symptom
§ Causes may be many; identify contributing factors
§ Critical to begin interventions early
§ Begin with education about role of nutrition • Small, frequent
meals
§ Encourage nutrient-dense foods
§ Medications may help
§ Physical Impairment
§ Frequent problems result from opportunistic infections
§ Nausea, vomiting, mouth and esophageal lesions, and impaired dentition
Summarize the multiple factors that lead to malnutrition in HIV/AIDS.
§
o
Malnutrition documented in all stages of HIV infections
§ ART has shifted nutritional problems to include hyperlipidemia, insulin
resistance, and diabetes mellitus
§ Wasting syndrome is still common when ART is not accessible or not used
§ Centers for Disease Control and Prevention (CDC) definition:
§
Involuntary weight loss of more than 10% in 1 month with presence of
chronic diarrhea, weakness, or fever for more than 30 days in the absence of a
concurrent illness or condition
§
Important predictor of morbidity and mortality
Explain the basis of interventions to achieve the goals of HIV nutrition therapy.
§
§
§
§
§
§
o
Overall goals of nutrition management
§ Preserving lean body mass and gut function
§ Preventing development of malnutrition
§ Providing adequate levels of all nutrients
§ Minimizing symptoms of malabsorption
§
Preventing nutrition-related immunosuppression
§ Improving quality of life
Effects of ART on focus of nutrition therapy
Individualized care plan
Determining energy and protein needs
§ Harris-Benedict formula (resting energy expenditure [REE] × 1.3 to 1.5) meets
most clients’ needs
§ Protein: 1.2 to 1.5 g of protein/kg actual body weight
Closely monitor vitamin and mineral status.
Antiretroviral therapy necessitates specific nutrition recommendations.
Identify indicators that are key to effective nutrition support and related medical therapies
for cancer and HIV/AIDS.
§
Prevention of Foodborne Illness
§ Crucial component of medical nutrition therapy and nutrition education
§ Focus on safe methods for food purchasing, preparation, and storage
§ Low-microbial diet may be prescribed
§
§
§
Cryptosporidium infections: can be life-threatening and lead to chronic,
debilitating diarrhea
Exercise Recommendations
§ Regular aerobic exercise and resistance training assist with the following:
§ Lipid abnormalities
§ Fat redistribution syndrome
§ Other body composition changes
§ Individualize and initiate slowly with health care provider approval
Multidisciplinary Approach
§ Collaboration of all health care team members, including nurse and dietitian, is
crucial.
§ Nutrition assessment, counseling, and support are critical components of
medical care.
§ Early recognition and intervention for nutritional risk factors are key to effective
nutrition support and related medical therapies
Module 2.4 Gastrointestinal
Learning Objectives
•
Pharmacology
o Compare the pharmacologic treatment of vomiting, diarrhea and constipation.
§
Vomiting- Antiemetic
§
§
Diarrhea-Antidiarrheals
§
§
diphenoxylate with atropine
Constipation- Laxatives
§
o
Metaclopramide, promethazine Vomiting HCL, meclizine
bisacodyl (simulant), psyllium (bulk Constipation forming), polyethylene glycol
(osmotic: saline)
Differentiate the actions and side effects of antiemetics, emetics, antidiarrheals and laxatives.
§
Nonprescription Antiemetic: Antihistamines
§
Action
§
§
Side Effects (similar to anticholinergics):
§
§
Inhibit vestibular stimulation in the middle ear
Drowsiness, dry mouth, constipation
Prescription Antiemetic
§
Anticholinergics
§
Drug: Scopolamine (Trans-derm Scop) • Patch
§
Action:
§
§
Side Effects:
§
§
Act primarily on the vomiting center • Decrease stimulation of
CTZ and vestibular pathways
Caution
• Drowsiness, dry mouth • Blurred vision, tachycardia, urinary
retention, constipation
§
These drugs should not be used in patients with glaucoma
o
Apply the nursing process for patients taking antiemetics, emetics, antidiarrheals and
laxatives.
o
NURSING PROCESS: ANTIEMETICS
§
Assessment
§
Nursing diagnoses
§
§
Planning
§
Nursing interventions
§
o
§
Provide mouth care after vomiting.
§
Warn patient not to consume alcohol while taking antiemetics.
§
Alert patient to avoid driving a motor vehicle or engage in dangerous activities.
§
Monitor bowel sounds for hypoactivity or hyperactivity.
§
Check vital signs.
Evaluation
NURSING PROCESS: ANTIDIARRHEALS
§
§
§
Assessment
§
Obtain a history of any viral or bacterial infection, drugs taken, and foods
ingested.
§
Determine frequency and consistency of bowel movements.
Nursing diagnoses
§
Diarrhea related to laxative abuse
§
Fluid volume, risk for imbalanced
Planning
§
§
§
o
Fluid volume, risk for deficient
The patient will have bowel movements that are formed.
Nursing interventions
§
Monitor frequency of bowel movements and bowel sounds.
§
Check for evidence of dehydration.
§
Administer antidiarrheals cautiously to pregnant patients, and those with
glaucoma, liver disorders, or ulcerative colitis.
§
Encourage patients to drink clear liquids.
§
Advise patients to avoid fried foods or milk products.
Evaluation
NURSING PROCESS: LAXATIVES
§
§
Assessment
§
Obtain a history of constipation and possible causes, frequency and consistency
of stools.
§
Assess electrolyte balance of patients who frequently use laxatives.
Nursing diagnosis
§
§
Constipation related to ignoring urge to defecate
Planning
§
The patient will have a normal bowel elimination pattern.
§
o
Nursing interventions
§
Monitor fluid intake and output.
§
Note evidence of fluid and electrolyte imbalance resulting from watery stools.
§
Encourage patient to increase water intake.
§
Advise patient to avoid overuse of laxatives.
§
Warn patient that the drug is not for longterm use.
§
Inform patient to consume foods high in fiber.
within 1 hour of any other drug.
§
Evaluation
Explain predisposing factors for peptic ulcers.
§
§
Predisposing factors
§
Helicobacter pylori (H. pylori)
§
Mechanical disturbances
§
Genetic influences
§
Environmental influences
§
Drugs
§
Stress ulcer following a critical situation
Symptoms
§
o
Gnawing, aching pain
Compare the actions of several of the classes of drugs used to treat Peptic Ulcer Disease
(PUD). Need to write about actions for each*****
§
Histamine 2 blockers
§
§
§
o
Teach patient not to take the drug
famotidine
Antacids
§
Aluminum hydroxide
§
Calcium carbonate
§
Magnesium hydroxide
Proton Pump Inhibitors
§
Pantoprazole
§
Esomeprazole
Apply the nursing process, including teaching, to antiulcer drugs.
§
§
Antacid: Assessment
§
Evaluate patient’s pain.
§
Check renal function.
§
Assess for fluid and electrolyte imbalances.
Nursing diagnoses
§
§
Pain, acute related to repeated spicy food and alcohol ingestion
Planning
§
The patient’s abdominal pain will decrease after 1 to 2 weeks of antiulcer
treatment.
§
Nursing interventions
§
Avoid administering antacids with oral drugs because antacids can delay their
absorption.
§
Monitor electrolytes, urinary pH, calcium and phosphate levels.
§
Encourage patient to drink 2-4 oz of water after taking an antacid to ensure drug
reaches stomach.
§
Evaluation
§
Histamine 2 Blockers: Assessment
§
§
Determine the patient’s pain, including type, duration, severity, frequency, and
location.
§
Assess fluid and electrolyte imbalances, including intake and output.
Nursing diagnoses
§
§
Planning
§
§
Pain, acute related to excess gastric secretion
The patient’s abdominal pain will decrease after 1 to 2 weeks of drug therapy.
Nursing interventions
§
Administer drug just before meals or at bedtime to decrease food-induced acid
secretion.
§
Advise patient to avoid smoking.
§
Tell patient that drug-induced impotence and gynecomastia are reversible.
§
Alert patient to avoid foods and liquids that cause gastric irritation.
§
Evaluation
§
Pepsin Inhibitors: Assessment
§
§
Evaluate patient’s pain including severity, type, duration, and frequency.
§
Determine patient’s renal function.
§
Assess for fluid and electrolyte imbalances.
Nursing diagnoses
§
§
Planning
§
§
§
Pain, acute related to excess gastric secretion
The patient will have relief of abdominal pain after 1 to 2 weeks of antiulcer
therapy
Nursing interventions
§
Administer drug on an empty stomach.
§
Increase fluids, dietary bulk, and exercise to relieve constipation.
§
Monitor patient for severe constipation.
§
Emphasize cessation of smoking.
§
Teach patient to avoid liquids and foods that can cause gastric irritation.
Evaluation
Nutrition Chapter 13 &14
•
•
•
•
•
Anti-Inflammatory Diets
o What are some common anti-inflammatory diets?
§ Protects against depression, whereas a diet rich in highlight processed, refined foods may
promote it
§ A mixed diet containing magnesium, calcium, selenium, zinc, omega-3 polyunsaturated
fatty acids (omega-3 PUFAs), and antioxidants (coenzyme Q10, glutathione peroxidase,
or zinc) will improve the functions of brain receptors
§ Examples: almonds, walnuts, fatty fish (salmon), green leafy vegetables
(spiniach, kale, and collards)
Nutritional Concerns and Therapies for Esophageal, Stomach, and Intestinal Disorders:
Dysphagia
o What issues are related to swallowing difficulties?
§ Signs of dysphagia include drooling, pocketing of food, choking, gagging, and taking
longer than 2 to 10 seconds to swallow food.
§ The most restrictive diet (pureed, often with thinned or thickened liquids)
§ Level 1 is the Dysphagia Pureed diet; no coarse textures are allowed and 757
foods are totally blended without lumps. Liquids are ordered separately, usually
at pudding consistency.
§ Level 2 is Dysphagia Mechanically Altered; foods are to be moist, softened, and
easily chewed. Meats are ground and served with a gravy or sauce, or soft salads
may be used (tuna or chicken salad, for example).
§ Level 3 is Dysphagia Advanced; hard, dry, sticky and crunchy foods are
omitted. Level 4 is a return to the general diet
o What approaches do nurses use to maintain nutrition and hydration?
§ Nurses should check with their institution's diet manual for the list of specific foods that
may be served for each level of the dysphagia progression.
Heartburn and Gastroesophageal Reflux Disorder
o What type of meals are best to avoid GERD?
§ to avoid high-fat meals.
§ Slow emptying of the stomach from eating high-fat food increases sphincter relaxation,
leading to potential reflux.
§ Foods such as chocolate, alcohol, peppermint, spearmint, liqueurs, caffeine, and highacid foods (tomatoes, vinegar-based foods, citrus fruits, and juices) may irritate the
esophagus and cause heartburn.
§ Patients should also avoid overeating, which slows emptying.
o What are some ways the nurse can educate the patient on reducing symptoms?
§ Suggest prevention and treatment strategies to reduce pressure in the stomach so that the
cardiac sphincter is not opened by excessive pressure from stomach contents.
§ Straining to defecate affects the contents of the stomach by creating additional pressure;
prevention and management of constipation are important.
§ Patient education: avoid lying down shortly after eating, avoid tight clothing, Avoid
eating “on the run”, Avoid some medication
§ If heartburn often occurs when taking birth control pills, antihistamines,
tranquilizers (e.g., diazepam [Valium]), or any drug taken often, check with the
primary care provider.
Esophagitis and Hiatal Hernia
o What are some factors that may decrease sphincter pressure?
§ Factors that may decrease sphincter pressure include smoking, chocolate, alcohol,
caffeine, and some medications
§ Unlike gastric mucosa, esophageal mucosa can be damaged when exposed to gastric
contents.
§ If not treated, chronic reflux can result in esophagitis (inflammation of the lower
esophagus).
§
•
•
•
Reflux is aggravated by reclining after eating, stress, and increased intraabdominal
pressure.
o What foods can these patients avoid to minimize symptoms?
§ Patients may be able to minimize symptoms of esophagitis or hiatal hernia by
manipulating the way they eat and by avoiding certain foods, especially those high in fat.
Vomiting
o What disorders may lead to excessive vomiting?
§ Nausea and vomiting are found in GI diseases as well as in conditions unrelated to a GI
disorder.
§
Mixed messages regarding the body's sense of equilibrium during air or sea travel can
result in motion sickness; nausea and vomiting may result.
§ Pregnant women are often affected by vomiting with the hormonal shifts that occur,
especially during the first trimester.
§ In addition, some patients with cancer suffer from episodes of vomiting because of
chemotherapy, radiation treatments, or use of medicines such as opioids.
o What damage can occur with excessive vomiting?
§ Repetitive self-induced vomiting can injure the esophagus and wear away tooth enamel.
o What are some strategies to maintain hydration with vomiting?
§ When patients are experiencing periods of nausea or vomiting, small cold meals may be
better tolerated than large hot meals.
§ For example, crackers and cheese, gelatin, fruit, or lemonade might be tolerated.
§ Avoid mixing hot and cold foods, which may aggravate the problem.
§ Hot, fried, spicy, and strong-smelling foods should also be avoided.
§ Some patients find relief with broth-based soups, warm tea with mint, and
ginger ale or other carbonated beverages
§ Nursing personnel manage many patients who are experiencing nausea and vomiting.
§ Offering small meals at frequent intervals is a good place to start.
§ Breathing exercises and repositioning may be helpful in some patients.
§ Eliminate strong odors when possible.
§ Good oral health is important, and patients can be given antiemetics (Zofran,
Compazine, Phenergan) 30 to 60 minutes before meals are served.
Peptic Ulcer Disease
o What nutritional strategies can be used to help meet the treatment goals?
§ There is no evidence that a “bland diet” (or any specific diet) improves symptoms of
ulcers or promotes their healing.
§ Any dietary modifications must be individualized to include avoidance of foods that a
patient can associate with symptoms.
§ Some individuals avoid red and black pepper, chili pepper, coffee (caffeinated and
decaffeinated), other caffeinated beverages, and alcohol.
§ Foods and spices that are irritants, cause superficial mucosal damage, or worsen existing
disease should be omitted.
§ Patients need encouragement to take prescribed medications.
§ Triple therapy often requires more than one round of treatment to eradicate H. pylori
completely.
Dumping Syndrome
o What are some important nursing interventions to prevent this syndrome?
§ When part or all of the stomach (partial or total gastrectomy) is removed for treatment of
stomach cancer or a severe ulcer or is bypassed to control obesity, dumping syndrome
may develop.
§ Impairment of the normal reservoir function of the stomach causes a large volume of
particles to be dumped rapidly into the small intestine.
§ These hyperosmolar contents draw water into the lumen and stimulate bowel motility.
§ Coping with dumping syndrome may seem overwhelming to newly diagnosed
clients.
§ Help them understand what is happening; discuss foods to avoid.
§
•
•
•
•
Make sure patients consume adequate fluids between meals to prevent
dehydration; I&O records will be important.
Intestinal Gas (Flatus)
o What are common foods to avoid to prevent gas?
§ Indigestible carbohydrates are found in legumes, such as soybeans and black beans, and
cruciferous vegetables, such as broccoli and cabbage.
§ Another indigestible carbohydrate may be the lactose in milk.
Diarrhea
o What are some strategies to maintain hydration with diarrhea?
§ Adequate hydration is essential in high-risk populations with diarrhea.
§ Infants cannot easily communicate their thirst, and a greater proportion of their bodies
consists of fluid; the excessive loss of fluid has serious consequences such as electrolyte
imbalance and a distorted ability to maintain body temperature and functions.
§ Eat small meals frequently throughout the day.
§ Chew with the mouth closed to avoid swallowing too much air.
§ Drink liquids 30 minutes before or after meals.
§ Limit use of apple juice, which may aggravate diarrhea (especially in children).
§ Include foods that are low in fiber (bananas, rice, applesauce, dry toast,
crackers).
§ Progress to foods that are high in potassium when tolerated: oranges, grapefruit,
bananas, apples, potatoes, dairy products, apricot nectar, baked squash, and
sweet potatoes.
§ Electrolyte solutions (Gatorade, Pedialyte, etc.) may be used to replenish lost
sodium and potassium. Take only under medical advisement.
Constipation
o What nutritional strategies can be used to avoid constipation?
§ Water helps lubricate the intestines, making bowel movements easier to pass.
§ To prevent dehydration and constipation, fluid intake should be approximately 8 to 10
glasses a day
§ The patient should use fiber-rich products such psyllium (Metamucil), whole-grain
breads and cereals, fruits, and vegetables.
§ However, mineral oil should not be used because it depletes fat-soluble vitamins (A, D,
E, and K) over time.
o What are some pharmacological and non-pharm strategies to treat constipation?
§ Bulking agents, stool softeners, osmotic and stimulant laxatives, and probiotics may be
used to prevent or alleviate constipation
Celiac Disease and Gluten Sensitivity
o
•
What are some foods to include and avoid for these conditions?
Irritable Bowel Syndrome & Inflammatory Bowel Disease
o What is a low-FODMAP diet?
§
o
The lowFODMAP (fermentable oligosaccharides, disaccharides, monosaccharides, and
polyols) diet is now accepted as a strategy.
§ The low-FODMAP diet limits high sugar intake, which increases osmolarity.
§ Foods containing fructose, sucrose, polyols (sorbitol and mannitol), and related
carbohydrates would be restricted.
What benefits do high protein and fiber have in IBD, and when are they each effective?
§
The nutrients that most commonly may be poorly absorbed are minerals (iron, calcium,
zinc, magnesium, selenium) and vitamins (folate, thiamine, riboflavin, pyridoxine,
vitamin B12 , and vitamins A, D, and E). A high-calorie, high-protein diet divided into
small, frequent meals is recommended
§ Increasing fiber without increasing fluid can lead to more constipation, abdominal pain,
bloating, and gas.
§ Fiber intake should be increased gradually, over a period of weeks while fluids are
simultaneously increased.
•
•
ileostomies and Colostomies
o What are the functional differences between these concerning fluid loss?
§ The more liquid the stool, the greater the loss of fluid and electrolytes.
§ Any restrictions placed on the patient should be based solely on individual tolerance.
Hepatitis
o What are the most important nutritional strategies for a patient with hepatitis?
§ During periods of nausea and vomiting in patients with hepatitis, hydration via IV fluids
may be necessary.
§ Oral feedings should be initiated as soon as possible, with frequent feedings high in kcal
and in high-quality protein, to promote adequate intake and minimize loss of muscle
mass.
§ Supplementation with a multivitamin that includes vitamin B complex (especially
thiamine and vitamin B12 because of decreased absorption and hepatic uptake), vitamin
•
•
•
K (to normalize bleeding tendency), vitamin C, and zinc for poor appetite is
recommended. Abstinence from alcohol is imperative.
o What is the importance of protein while dealing with a poor appetite?
§ Adequate protein, 1.0 to 1.2 g/kg body weight, is recommended for most persons.
§ Dietary fats should not be limited unless they are not well tolerated (e.g., steatorrhea).
§ Fluid intake should be adequate to accommodate the high protein intake unless otherwise
contraindicated.
Cirrhosis
o How do you promote a positive nitrogen balance for these patients?
§ Protein and energy malnutrition is commonplace in patients with end-stage liver disease
who have cirrhosis.
§ A minimum of 0.8 g protein per kg body weight per day is essential.
§ To promote positive nitrogen balance and avert breakdown of endogenous protein stores,
1.2 g protein/kg dry or appropriate body weight is recommended.
§ Protein restriction should be avoided, because it could possibly worsen malnutrition.
§ If a patient appears to be protein sensitive (e.g., increased occurrence of encephalopathy),
branched-chain amino acid–based formulas with restricted aromatic amino acids can be
used to ensure a sustained level of protein intake.
§ Plant proteins also produce less ammonia.
o What are some important nursing interventions?
§ Fluids are given in relation to input/output (I&O) records, daily weights, and electrolyte
values.
§ Fluid restrictions are often necessary, beginning at 1500 mL/day.
§ Limits may decrease to 1000 to 1200 mL/day, depending on the patient's response.
§ The nurse may provide suggestions on how to cope with thirst in an effort to improve
patient compliance with these kinds of fluid restrictions.
Gallbladder Disorders
o What is the connection between very low-calorie diets (VLCDs) and gallstones?
§ People who lose a great deal of weight rapidly through very low calorie diets (VLCDs)
and some commercial weight-loss programs are at a high risk for development of
gallstones.
§ Following a diet too low in fat or going for long periods without eating (e.g., skipping
breakfast) will decrease gallbladder contractions.
§ If the gallbladder does not contract often enough to empty out the bile, gallstones may
form.
§ People considering losing a significant amount of weight should see a physician first to
evaluate their medical history, individual circumstances, and the proposed method of
weight loss.
o What is the role of omega-3 polyunsaturated fatty acids (PUFAs) in Cholecystitis?
§ Cholecystitis occurs when gallstones block the cystic duct or as the result of stasis,
bacterial infection, or ischemia of the gallbladder.
§ This inflammation is associated with pain, tenderness, and fever.
§ Fat intolerance may manifest as regurgitation, flatulence, belching, epigastric heaviness,
indigestion, heartburn, chronic upper abdominal pain, and nausea.
§ Jaundice and steatorrhea may also be present.
§ Recommended therapy for symptomatic cholelithiasis and cholecystitis is surgical
removal of the gallbladder
Pancreatitis
o What are the complications of bowel rest, and what nutritional strategy can avoid them?
§ The primary goal in pancreatitis is to provide for nutritional needs while minimizing
pancreatic secretions.
§ Traditionally, gut rest with IV fluids or parenteral nutrition has been standard practice.
§ However, clinical evidence indicates that parenteral nutrition administered within 24
hours of admission worsens outcome by increasing the inflammatory response and
impairing the immune response.
§ Bowel rest leads to atrophy of intestinal mucosa and bacterial translocation.
§
o
In contrast, early introduction of enteral nutrition promotes fewer infections,
shorter hospital stays, and overall decreased medical costs.
How do enteral and parenteral feeding work concerning nutritional support?
§ Feeding into the lower small bowel, in the jejunum distal to the ligament of Treitz, allows
areas associated with pancreatic stimulation to be bypassed.
§ Low-fat, elemental formulas are recommended because they tend to reduce pancreatic
stimulation.
§ Patients receiving enteral feedings should be closely monitored for increases in
pancreatic enzymes, abdominal pain, and discomfort.
§ Enteral feedings should be terminated if any of these symptoms occurs
§ In addition to severe pain, patients with pancreatitis often experience nausea and
vomiting.
§ The first 24 hours after admission for acute pancreatitis require rapid response.
§ Evidence-based guidelines are used for appropriate fluid resuscitation and
antibiotic therapy
§ Early enteral feeding is important.
§ Placement of a percutaneous endoscopic gastro-jejunostomy feeding tube is
commonly required for individuals who will need enteral feeding for longer than
30 days
§ Parenteral support is recommended when there are contraindications to enteral
feeding, such as small bowel obstruction