Anti-Cancer drugs concepts:
Normal Cell Growth: “Purposeful Growth”: Controlled splitting and proliferation by
suppressor genes.
Cancer Cell Growth: “Abnormal Growth”: Loss of control over cell splitting, showing no
response to the suppressor genes.
Malignant Transformation: Changes of normal cells to cancer cells.
• Damage to suppressor genes
• Oncogenes are activated.
Characteristics
Cell Division:
Appearance:
Differentiated functions:
Adherence:
Migratory:
Growth:
Normal Cells
None or slow
Specific features to site
Many
Tight
No
Well Regulated
Cancer Cells
.
Rapid, Continuous
Anaplastic, small, round, non-id
Some or none.
Loose
Yes
Unregulated, invasive
Primary Tumor: Original site where cells develop into cancer.
Metastatic or secondary tumor: Tumor that has spread and created new tumors in other areas.
Such as liver tumor that migrates into the lungs.
Causes: Exposure to carcinogens, genetic predisposition, lowered immune function
Treatment approach: Surgery, Radiation, Traditional Chemotherapy, Hormonal Manipulation,
Biologics for targeted therapy. Best if used in combination.
Outline of Therapies:
Surgery: cancerous tissue with normal tissues that contain cancer are removed
Radiation or Radiotherapy: Uses radioactive waves to enter cancer cells from an external
source, achieved by external or internal source inside or outside the tumor.
Traditional Chemotherapy/Hormone Therapy, and Biologic Targeted therapy: These drugs
are injected, ingested, and absorbed in the blood and distributed throughout the body.
Specifics:
Traditional Cancer Chemotherapy: High Alert Drug; treatments with chemical agents to
damage cell DNA and interfering with cell division. Cytotoxic effects can kill metastatic cancer.
Damages both normal and cancer cells. Selection is based on know tumor sensitivity, and degree
of side effects expected.
Six categories: Alkylating agents, Antimetabolites, Antitumor antibiotics, Topoisomerase
inhibitors, Mitotic inhibitors, Miscellaneous agents
Alice And Tim Took My Muffin
Alice for Alkylating Agents
And for Antimetabolites
Tim for Antitumor Antibiotics
Took for Topoisomerase Inhibitors
My for Mitotic Inhibitors
Muffin for Miscellaneous Agents
Imagine Alice and Tim eagerly taking your muffin while you’re going through chemotherapy
categories for the final.
Issues with Traditional Chemotherapy:
• Administration requires special training and established PPE for handling.
• Workers are at risk of exposure to these agents.
Extravasations: All workers are responsible for providing care and comfort. Chemotherapy
agents and other drugs are known as “Vesicants” and when exposed to the body outside of the
vein, extravasation occurs resulting in possible pain, infection, and tissue loss.
IF EXTRAVASATION OCCURS: MEDICAL EMERGENCY!!!
1. Stop infusion IMMEDIATELY! (Anyone)
2. Medical staff of the treating team should be informed immediately of any
extravasation injury or suspicions to further evaluate injury.
Documentation of Extravasation:
1. Documentation of Time and Date the extravasation was identified, the date and time the
infusion was started and when it was stopped.
2. Document exact contents of infusion infused; the estimated amount of fluid lost into the
tissues. Document the Cathalon IV type and size used.
3. Diagram of insertion site, and number of attempts
4. Photograph documentation of site
5. Record time between extravasation and last known blood return. Record all known agents
administered in 24 hours period from event. Record Vital Signs and other interventions provided
6. Record patient education given and follow up appointments
7. Document any consultation requested
Administering Chemotherapy agents:
Special preparation: specific PPE, Biologic safety cabinet or vertical laminar flow hood, mixed
in separate location to prevent cross contamination with non-hazardous drugs (Pharmacy).
Check before:
• IV patency, large vein with good blood return
• Calculations are based on the type of cancer and patient’s size/weight
• Patients are weighed daily to ensure accuracy of dosing
•
•
•
Take vital signs and assess mental status. Documenting all assessments
Check baseline labs, CBC, CMP at a minimum
Administer pre-medications as prescribed
Check During:
• Stay with the patient during the first 15 minutes of therapy
• Check every 15 minutes after for any signs of an allergic reaction
o -If reaction occurs – stop infusion and change tubing
• Assess IV flow rate every 30 minutes
• Closely monitor IV access site
• Document any extravasation
Check After:
• After completion of infusion, discontinue infusion set.
• Dispose of tubing/materials per agency policy and with proper PPE
• Compare all patient assessment findings before and after therapy
• Assess the infusion site and document any findings
• Assess client and notify HCP of any changes
• Monitor labs, vital signs, and for any side effects or adverse effects
Patient Teaching: Best done as a collaborative effort
• Temporary and permanent physical damage can occur to normal cells because this exerts
an effect on both normal and abnormal tissues.
• Side effects on the blood producing cells system can be life threatening. Anemia,
neutropenia, and thrombocytopenia.
Hormone Manipulation for Cancer Therapy:
• Hormones circulate to all body areas but target specific tissues.
• Some hormones can control growth of certain cancers but accelerate growth in others
• Therapy does not cure the cancer only slows it’s progression
Hormone Therapy – Breast Cancer:
Only effective if the cancer cells are hormone receptor positive, especially estrogen positive
Works by reducing the availability of estrogen to breast cancer cells
Side Effects:
• Perimenopausal symptoms that include vaginal dryness and hot flushes
• Women who have not undergone menopause, menses becomes irregular and heavy
• Aromatase Inhibitors: bone, muscle, and joint pain
• Estrogen receptor antagonists: Headaches and nausea; given IM reactions at injection site
• Luteinizing Hormone Releasing Hormone (LHRH): Breast atrophy, GI problems, pain,
flatulence, and diarrhea; increased emotional ups and downs and more depression.
• Selective Estrogen Receptor Modulators (SERMs): Increased bone pain for tumors in
bone, but resolves
Adverse Effects:
•
•
•
•
•
All hormone therapy drugs for breast cancer increase serum cholesterol levels, cause
fluid retention with peripheral edema, increased blood pressure and for venous
thromboembolic events (VTEs) such as stroke and heart attack.
Elevated liver enzymes
Aromatase inhibitors: changes in serum calcium levels and increased risk for
osteoporosis and bone fractures
Luteinizing Hormone Releasing Hormone (LHRH): Hyperglycemia and risk for seizures
Selective Estrogen Receptor Modulators (SERMs): Increased risk of endometrial cancer
and cataract development
Hormone Therapy for Prostate Cancer:
• Similar to Breast Cancer, growth increases when androgen receptors are bound with
testosterone.
• Androgen suppression drugs are used to control the growth of cancer cells in place of
surgical removal of tissues and organs that produce or promote androgen production.
• Feminizing responses: Thinning facial hair, breast tissue enlargement, facial skin
smoothness, body fat redistribution, Testicular and Penile size decrease
Side Effects:
• All hormone therapy for prostate cancer results in symptoms related to reduced
testosterone levels or functions. These include gynecomastia, reduced libido or sexual
dysfunction, and some degree of testicular atrophy
• Other hormonal changes include hot flushes, fluid retention, and peripheral edema
• Fatigue and general body aches
Adverse Effects:
• All classes: Elevated liver enzymes and increased for liver impairment, hypertension,
osteoporosis with increased risk of bone fractures, and increased risk for venous
thromboembolic events (VTEs) to include heart attack and stroke. Injection site reactions
• Androgen Receptor Antagonists: Hyperglycemia and seizures
• Luteinizing Hormone Releasing Hormone (LHRH): increased risk for seizure activity or
pituitary infarction.
Hormone Therapy for Endometrial Cancer:
Is available, but not as effective as breast or prostate cancers.
Side Effects/ Adverse Effects:
Increased appetite, weight gain, breakthrough vaginal bleeding, hypertension, hyperglycemia,
and fatigue. More serious possible effect is adrenal insufficiency (rare).
---------------------------------------------------------------------------------------------------------------------
Chapter 6: Antibacterial Drugs:
The body has immune protection and normal barriers, sometimes bacteria can invade and
multiply, damage tissues, and cause disease.
Microbiome: a personal normal flora or normal bacteria
Opportunistic Infection: Any infection caused by a microorganism that does not normally cause
disease in humans
Bactericidal Drugs: Kill the bacteria
Bacteriostatic Drugs: Prevents bacterial from reproducing
Patients who are immunocompromised should receive bactericidal drugs to kill the bacteria
Gram-positive bacteria show blue or purple after gram-staining in a laboratory test. They have
thick cell walls. Gram-negative bacteria show pink or red on staining and have thin walls.
Gram-positive bacteria
Gram-negative bacteria
Color after gram testing
Blue or purple
Pink or red
Cell wall thickness
Thick
Thin
Toxins
• emetic toxin
• diarrheal enterotoxins
• neurotoxins
• enterotoxin
endotoxins
Types
• Staphylococcus aureus
• Staphylococcus epidermidis
• Staphylococcus saprophyticus
• Streptococcus pneumoniae
• Streptococcus pyogenes
• Streptococcus agalactiae
• Enterococci
• Corynebacterium diphtheriae
• Bacillus anthracis
• Vibrio cholerae
• Escherichia coli
• Bartonella henselae
• Campylobacter
• Legionella
• Salmonella
• Salmonella typhi
A culture is a test to find germs (such as bacteria or a fungus) that can cause an infection.
A sensitivity test checks to see what kind of medicine, such as an antibiotic, will work best to
treat the illness or infection.
Antibacterial Drug Resistant Bacteria:
Caused from overused, over prescribed, improperly used antibacterial drugs
• Multidrug-resistant (MDR) organisms
• Also known as “superbugs”
• Cause “superinfections”
• Examples:
• Methicillin-resistant Staphylococcus aureus (MRSA)
• Drug-resistant Streptococcus pneumoniae
Antibacterial therapy:
• Broad spectrum – does not mean more effective
• Susceptibility as determined by C&S has better outcomes for treatment
• Goal of therapy is to kill the bacteria or stop the replication of new bacterial from
forming
Measuring effectiveness:
• Normal body temperature
• May vary from facility to facility. White blood cell counts 5,000-10,000
cells/mm3
• No drainage or redness in the area of infection, less warmth
• Client states they are feeling better
Types of antibacterial drugs:
Classified on how they kill the bacteria or how they stop the reproduction
Several factors influence on what is prescribed
• Based on whether we know what organism is the cause (by C&S testing)
• How serious the infection is
• Which drugs are known to kill or harm it
• How well the client’s immune system is working
• Client’s overall health (especially kidney, liver, and bone marrow function)
• Any known drug allergies.
General Issues with Antibiotics:
• Intended response:
• Disappearance of signs and symptoms of infection: normal body temperature,
WBC between 5000-10,000 cells/𝑚𝑚3 , absence of drainage, redness
• Eradication of the infectious bacteria
• Side effects:
• GI disturbances, diarrhea, oral and vaginal yeast infections
• Adverse effects:
• Allergic reactions, anaphylaxis, pseudomembranous colitis (C.Diff), Oral allergic
reactions can appear days after starting the antibiotic.
Nursing Responsibilities:
Before giving: Checking lab values WBCs, Checking IV patency and interactions, VS/MMSE
During:
• If giving IV check patient every 15 minutes during therapy (Given over 30-60 minutes)
o If receiving IV and client starts to have symptoms of allergic reaction, stop the
infusion, change tubing if the port is high up and maintain IV patency
After: Ask and monitor bowel movements, monitor for symptoms of effectiveness, monitor
mouth for thrush, monitor IV site minimally every 2 hours.
Teaching priorities:
• Take as prescribed and finish completely, take evenly spread out through the day.
• If symptoms of an allergic reaction notify the HCP or go to ER immediately
Symptoms of Anaphylactic reaction:
Tightness in the chest, trouble breathing, low blood pressure, hives around the IV site, swelling
of the face, mouth, and throat (angioedema), hoarse voice, weak, thready pulse, sense that
something bad is happening
Types of Antibacterial Drugs:
• Cell wall synthesis inhibitors
• Protein synthesis inhibitors
• Metabolism inhibitors
• DNA synthesis inhibitors
--------------------------------------------------------------------------------------------------------------------Cell Wall Synthesis Inhibitors: Bactericidal (kills)
Names:
Penicillin (amoxicillin, Penicillin, -cillin), Cephalosporins (cefazolin, cefdinir, ceftriaxone),
Monocatams (aztreonam), Carbapenems (Ertapenem, imipenem -penem), Glycopeptide
inhibitors (vancomycin)
Uses (Mechanism of Action):
Prevents the walls from forming on the bacteria
Responsibilities of the Nurse:
Before giving:
• Allergies to penicillin, the risk for a cephalosporin allergy is increased
• Oral cephalosporins are poorly absorbed with iron supplements and antacids
o Taken one hour before, or four hours after
• If receiving IV penicillin, check that it is injectable and can be given IV
o Procaine penicillin contains a local anesthetic and cannot be given IV – has a
milky white appearance rather than clear
•
•
Carbapenem can lower seizure threshold – ask about history of seizures – notify
prescriber
Glycopeptide antibiotics such as vancomycin have many adverse effects if given too fast
o These include Low BP; a histamine release that causes dilation of blood vessels
and a red appearance to the face, neck chest, back, and arm (Red Man Syndrome),
and cardiac dysrhythmias. To reduce this risk never bolus or “push” a dose –
given over 60 mins
During:
• Same as General
• IV Every 15 to 30 minutes for first 2 hours after first IV dose
After:
Oral – check hourly for first four hours after first dose for allergic reaction
Side Effects:
Common:
• Side effects: (less side effects, but more likely for allergic reaction-esp. PCN)
• PCN and Cephalosporins: diarrhea and itchiness
• Carbapenems and glycopeptides: nausea, vomiting, fever, chills, “red man
syndrome,” reduced hearing
• Adverse effects:
• Carbapenems: CNS changes
• Cephalosporins, carbapenems, and glycopeptides: kidney damage
Education (patient teaching):
• Weigh self, check Heart rate, pulse, cardiac rhythm and record daily
• Take cephalosporins at least 1 hr before or
4 hrs after iron or antacid
• Liquid oral dosages-keep in fridge, tightly sealed and shake well before using
Safety (Who can take this drug?):
Pregnancy and Lactation:
• Penicillin, most cephalosporins—low risk for fetal harm
• Carbapenems, monobactams, vancomycin—low to moderate risk for fetal harm
• Excreted in breast milk-reduce infant to exposure (pump and dump)
Older Adult:
• Carbapenems and glycopeptide antibiotics—ototoxicity, nephrotoxicity more likely
• Monitor hearing and I & O
---------------------------------------------------------------------------------------------------------------------
Protein synthesis inhibitors: Bacteriostatic or Bactericidal (higher doses)
Names:
• Aminoglycosides - amikacin, gentamicin, streptomycin
• Macrolides – azithromycin, clarithromycin, erythromycin
• Tetracyclines – doxycycline, minocycline, omadacycline, sarecycline, tetracycline,
tigecycline
Uses (Mechanism of Action):
Aminoglycosides are commonly used for:
• Burns, CNS infections, joint and bone infections, intra-abdominal infections, peritonitis,
and sepsis. Given IV or IM
Macrolides (extended or broad-spectrum effects:
• Skin, mucous membrane, and other soft tissue infections, chlamydia, and respiratory
infections. Given to those allergic to penicillin or cephalosporins
• Used for Legionnaires’ disease, diphtheria, and mycobacterial infections
Tetracyclines: broad spectrum
• Bacteriostatic, give only to people with healthy immune systems
• Prescribed to those allergic to penicillin or cephalosporins
• Treat acne, urinary tract infections, skin and mucous membrane infections, gonorrhea,
and respiratory tract infections, STI’s, Rocky Mountain Spotted Fever, Lyme Disease and
typhoid fever as well as anthrax after exposure
Responsibilities of the Nurse:
Before:
• Aminoglycosides—assess kidney labs, hearing, dilute it and administer it properly
• Macrolides—other medications (digoxin, warfarin, pimozide, astemizole, terfenadine,
ergotamine; Only use solutions of erythromycin that were mixed less than 8 hours
earlier
• Tetracyclines—food, antacids, dairy products decrease absorption (give 1 hour before
or 2 hours after meal; check the dosages for doxycycline and minocycline carefully
because they are lower than other tetracyclines and other types of antibiotics
• Other protein synthesis inhibitors—check client’s lab work carefully (BUN and
Creatinine); give drug slowly,
• Streptogramins can only be mixed with dextrose 5% in water when given parenterally
After:
• Aminoglycosides—hearing, temperature, I&O, lab values (especially BUN and
creatinine)
• Macrolides—heart rate and rhythm every 4 hours
• Tetracyclines—if client is on warfarin, observe carefully for bleeding
• Other protein synthesis inhibitors—blood pressure for client taking an oxazolidinone
Side Effects/Adverse Effects:
Common:
• Aminoglycosides (amikacin, gentamicin, streptomycin)
• Nausea, vomiting, rash, fever, lethargy, increased salivation
•
Macrolides (azithromycin, clarithromycin, erythromycin)
• Abdominal pain, n/v, taste changes, photosensitivity
• Tetracyclines (doxycycline, minocycline, omadacyclin, tetracyclines
• N/V, glossitis (sore tongue), rash, photosensitivity
• Yeast infections early in course of treatment
• Lincosamides (clindamycin)
• Rash, pain at injection site, thrombophlebitis
• Oxazolamides (linezolid)
• Nausea, diarrhea, headache, HTN
• Streptogramin (dalfopristin/quinupristin)
• Muscle/joint pain, IV pain/inflammation, rash, nausea, vomiting
Adverse:
• Aminoglycosides
• Ototoxicity, nephrotoxicity, neuromuscular blockade
• Macrolides
• Many serious drug interactions, liver irritation, irritation (parenteral forms)
• Increase risk of digoxin toxicity, increased bleeding if taking warfarin
• Parenteral forms are irritating to veins and tissues
• Dysrhythmias
• Tetracyclines
• Increased intracranial pressure, decrease kidney function at high levels as well as
increase liver enzymes
• Lincosamides
• Reduced liver function, decreased WBC counts, if given too quickly can cause
shock and cardiac arrest
• Oxazolidinones
• Reduced blood cell counts, damage to optic nerve (long term)
• Streptogramin
• Increased blood levels of many drugs
Education (patient teaching):
• Macrolides
• Take with food to decrease GI side effects
• Avoid sun exposure
• Check with provider before taking other drugs
• Do not crush or chew
• If taking warfarin, keep all blood draw appts
• Tetracyclines
• Avoid sun exposure
• Take 1 hour before or 2 hours after meals; do not take with milk
• Take with full glass of water
• Oxazolidinones and Linezolid
• Linezolid: Avoid taking with foods containing tyramine
• Drink with a full glass of water to prevent esophageal irritation
Safety (who can take this drug?):
Pediatric:
• Aminoglycosides can cause severe respiratory depression and kidney damage
• Tetracyclines should be avoided in children younger than 8 years-teeth staining
Pregnancy and Lactation:
• Avoid aminoglycosides and tetracyclines with pregnancy and breastfeeding
• Most macrolides are generally safe; pass into breast milk causing colic and diarrhea in the
infant
Older Adults:
• Aminoglycosides: Ototoxicity, nephrotoxicity more likely
• Macrolides also ototoxic and risk increases if also taking loop diuretics together
--------------------------------------------------------------------------------------------------------------------Metabolism Inhibitors: Bacteriostatic
Names: Sulfonamides and Trimethoprim, Combination: SMX-TMP
Uses (Mechanism of Action):
Prevent a specific enzyme from converting substances to folic acid, then DNA do not have
enough folic acid to replicate
• Treat some nonbacterial infections (e.g., shigellosis, toxoplasmosis, Pneumocystis
pneumoniae)
• UTI, middle ear infections, pneumonia, infectious diarrhea; eye, skin, vaginal infections
Responsibilities of the Nurse:
Before:
• Ask about “Sulfa” allergies, Blood disorders – G6PD (African-Americans or persons of
Mediterranean descent)
• Assess Labs; liver function studies and counts of white and red blood cells and platelets.
• Check client for jaundice
• Check if client is on thiazide diuretic-increased risk of anemia/bleeding
• Giving IV - check compatibility and patency
• Give with full glass of water – prevents crystals forming in kidneys
• Closely monitor male patients who are of African-American or Mediterranean decent for
anemia and jaundice when receiving a metabolism inhibitor
During: See General
After:
•
•
•
•
Assess for jaundice, bruises, petechiae, blisters
Offer water every 4 hours
Monitor labs: WBC, RBC, Platelets
Check skin for rash, blisters or other skin eruptions
Side Effects/Adverse Effects:
Common:
• Sulfonamides: Headache, fever, rash, photosensitivity
• Trimethoprim: Headache, nausea, vomiting, skin rashes
Adverse:
• Suppression of bone marrow cell division
• Stevens-Johnson syndrome
• Hyperkalemia (trimethoprim): especially if also taking ACE inhibitors or ARBs
• Kidney stones or failure (sulfonamides)
• Avoid in people with G6PD deficiency
Education (patient teaching):
• Avoid direct sunlight and wear sunscreen
• Avoid tanning beds and salons
• Drink a full glass of water and drink throughout day
• Tell clients to notify the prescriber if yellowing of the skin or eyes, a sore throat, fever,
rash, blisters, or multiple bruises develop.
Safety (Who can take it?):
Pediatric:
• Infants younger than 2 months more likely to become jaundiced
Pregnancy and Lactation:
• Avoid during last 2 months of pregnancy; avoid breastfeeding during therapy
Older Adults:
• More intense side effects (anemia, increased risk of bleeding especially if taking thiazide
diuretic)
--------------------------------------------------------------------------------------------------------------------DNA Synthesis Inhibitors: Fluoroquinolones Bacteriostatic or Bactericidal (high doses)
Names:
ciprofloxacin, delafloxacin (spelled differently in book), Gemifloxacin, levofloxacin,
moxifloxacin, ofloxacin
Uses (Mechanism of Action):
• Prevent bacteria reproduction by suppressing action of enzymes essential in making
bacterial DNA
• Broad spectrum antibacterial drugs
Responsibilities of the Nurse:
Before: Along with General
• Assess if taking amiodarone, quinidine, procainamide, or sotalol – notify prescriber as it
may lead to deadly arrythmias
•
•
Give with full glass of water to drink and encourage more fluids throughout the day – this
drug concentrates in the urine and can be irritating to the urethra and skin if exposed
Fluoroquinolones can only be taken orally or by IV infusion. Do not give as a bolus, IM,
or Subq
During: see General or pg. 90 in the book
After:
• Assess heart rate and rhythm every 4 hours during therapy of a patient who either has a
known cardiac dysrhythmia or is taking a fluoroquinolone for the first time. If a new
change in rhythm develops, check again in 15 minutes; if changes persist notify the
prescriber.
• For Diabetic patients – assess blood glucose level more often than usual
• Monitor for mental status changes, including acute confusion, especially among older
patient’s
Side Effects/Adverse Effects:
• Side effects:
• Rash, nausea/vomiting, headache, muscle and joint pain, sun sensitivity, burning
with urination because drug can concentrate in urine
• Adverse effects:
• Acute confusion in older adults (black box warning), serious heart dysrhythmias
(especially when taken with other drugs for dysrhythmias), peripheral neuropathy,
changes in blood glucose level, tendon rupture (rare)
Education (patient education):
• Take with full glass of water; increase fluids throughout day
• Check pulse twice daily – report any irregular, palpitations, or dizziness
• If diabetic, check blood glucose levels more often
• Avoid direct sunlight, use sunscreen, wear protective clothing outdoors
• Report tingling, burning, numbness, and pain in the hands or feet
• If taking warfarin, keep blood draw appts
• Take 2 hours before or 4 hours after multivitamin, iron, or antacid
• If joint, tendon pain or swelling occur, stop drug and notify provider – nerve damage
• if older than 75 years, have another person stay with you – confusion and hallucinations
Safety (who can take this?):
Pediatric:
• Not recommended for those under 18 years unless life threatening illness
• Can cause damage to bones, joints, muscles, tendons and other soft tissues when
given to clients who are still growing
Pregnancy and Lactating:
• Avoid use in pregnancy, use alternate feeding method during therapy if breastfeeding
Older Adults:
• Tendon rupture more common
• Risk increases if using with corticosteroids
• Can occur up to 1 month after drug is stopped
--------------------------------------------------------------------------------------------------------------------Chapter 7: Anti-infectives Antiviral drugs
•
•
•
A virus is subcellular, submicroscopic parasite that is unable to reproduce on it’s own
Must invade in greater numbers to grow and overwhelm normal immune systems
Viruses are very small and can more easily enter the body than bacteria and funguses can.
• Two types:
o Retroviruses: Have RNA as genetic material. Use reverse transcription to convert
their RNA into DNA, which then integrates into the host cell's genome. Integrate
their genetic material into the host cell's DNA. HIV is an example
o Non-Retroviruses: Can have DNA or RNA. Replicate their genetic material using
various methods; DNA viruses usually do so in the host cell nucleus. Typically do
not integrate into the host genome; their genetic material exists separately.
Influenza, Herpes, and Adenoviruses are examples.
•
What diseases are caused by common viruses? Chickenpox, shingles, measles, mumps,
herpes, warts, hepatitis, common cold
The more virulent a virus is, the greater it can invade and grow, the fewer viruses are needed
to cause infection and disease.
Efficiency of infection: the ease of which an organism causes disease through infection
Viral Load: the number of viral particles in blood sample, which indicates the degree of the
infection.
Anti-viral drugs: Drugs that are virustatic against nonretroviruses and prevents them from
either replicating or reproducing or releasing their genetic material
•
•
•
•
•
•
•
Anti-Viral Therapy General
Virustatic: Reduces the number of viruses
• Antiviral drugs do not kill viruses, they suppress their reproduction and growth
Intended responses:
• Shorten the duration or intensity of an existing viral disease
• Prevent reactivation of a dormant viral infection
• Prevent a viral infection from multiplying to the point of disease
Allergic reactions always possible
• More serious reactions occur when given intravenously
• What should the nurse do if a client has an allergic reaction? First, prevent any more
drug from entering the client. If administration is IV, stop the drug from infusing but
keep the IV access.
Before giving:
Ask if any drug allergies
Check IV patency and drug compatibility
During/After:
• After first dose of IV antiviral drug assess the patient every 15 minutes for signs or
symptoms of an allergic reaction.
• Inspect IV site during – if patient reports discomfort at the site, slow the infusion and
check for blood return. Monitor for any redness, pain, or cord-like veins. Follow facility
policies and procedures for removing the IV
Education:
• Antiviral drugs must be taken exactly as prescribed; must take drug long enough to work
• If a client stops taking the drug as soon as he or she feels better, then symptoms of
infection may recur, and resistant viruses may develop.
Take the drug evenly spaced throughout the day and plan an easy to remember schedule
--------------------------------------------------------------------------------------------------------------------Drugs for Herpes Simplex Infection:
Names:
acyclovir, famciclovir, valacyclovir
Uses (Mechanism of Action):
• Slow viral reproduction by inhibiting the enzymes needed to complete the formation of
viral DNA chains
• Most effective against genital herpes infections, Epstein-Barr virus, cytomegalovirus,
varicella-zoster virus
Responsibilities of the Nurse:
Before:
• If client is taking anticonvulsants, especially phenytoin, it reduces effectiveness of
phenytoin. Dosage of phenytoin may need to be adjusted
• Check IV status if administering via IV route, check compatibility and flush IV line prior
to administration. Also, give med slowly over 60 minutes
• Ensure diluting properly and use sterile water
During/After: See General;
• Increase fluid intake of at least 3 liters unless another health problem requires fluid
restriction
Side Effects/Adverse Effects:
Common:
• Headache, dizziness, nausea, diarrhea
Adverse Effects:
• These drugs can reduce kidney function and can lead to damage/failure
◦ Precipitating in the tubules - most likely if the patient is not hydrated
•
•
Reduce the effectiveness of antiseizure drugs – frequent labs, may need to increase dose
Pain and irritation at injection site with IV especially if given rapidly – give slowly over
60 minutes to reduce risk for irritation
Education for the Patient:
Same as general – take as prescribed and increase fluid intake
Safety (who can take these?):
Pregnancy and Lactation:
• Low likelihood of increasing risk for birth defects or fetal harm. Benefits should be
weighted against the risks.
• Do appear in breast milk – Pump and Dump is recommended
--------------------------------------------------------------------------------------------------------------------Drugs for Respiratory Viral Infections:
Names:
Baloxavir, oseltamivir, peramivir, zanamivir
Uses (Mechanisms of Action):
• Baloxavir - inhibits influenza specific enzyme needed for viral gene transcription-virus
cannot replicate
• Oseltamivir, peramivir, and zanamivir: bind to and inhibit the enzyme neuraminidase - viral
particles that are released from one infected cell cannot infect new cells
Responsibilities of the Nurse:
Before:
• Baloxavir, oseltamivir, and zanamivir are orally or inhaled drugs that are largely
prescribed for community-dwelling independent people and follow general antiviral
therapy see pages 109-110
• Peramivir is given intravenously only as a one-time dose – diluted carefully and has no
preservative. Given immediately after mixing or stored for no more than 24 hours – not to
be given with any other drugs.
•
•
•
•
•
•
Ribavirin can have toxic effects on many organs – before giving assess the patients heart
rate, rhythm, and pulse. Evaluate lung sounds, function and depth of respirations; pulse
oximetry, color of skin and mucous membranes; and level of consciousness.
Assess labs such as kidney function, BUN, creatinine levels, as well as I&Os.
Assess liver function by assessing the skin, mucous membranes, and sclera of the eyes as
well as labs. All of these should have a baseline.
Because ribavirin often suppresses growth of blood cells in the bone marrow – assess
recent cbc labs
Assess baseline vital signs to include temperature and mental status before starting.
Ribavirin can interact with many drugs to including almost all antiretroviral drugs with
HIV; these can result with sever liver problems and death.
•
•
When administering aerosolized form, ribavirin can be absorbed through the mucous
membranes and respiratory passages of the person administering the treatment and by
others in the room.
o Wear a mask to protect your self from inhaling the drug, ensure visitors are not
present
 If they must be present (minor) the visitors must wear a mask
Keep door to room closed during the treatment and for 20-30 minutes after to prevent
accidental exposure
During: See General – IV Drugs assess every 15 minutes
After: General care needs and precautions related to antiviral therapy pg 110
Monitor patient receiving Ribavirin closely for any side effect or organ toxicity.
Review lab values daily for RBCs & WBCs counts, bilirubin, liver enzymes, BUN and
Creatinine. I&Os, Assess hearing daily. Any changes document and contact Prescriber.
Side Effects/Adverse Effects:
Common side effects:
◦ Baloxavir, oseltamivir, peramivir, and zanamivir: Headache, nausea/vomiting,
diarrhea, dizziness
◦ Zanamivir: cough, bronchoconstriction, and nasal congestion
◦ Peramivir: hypertension and hyperglycemia
Adverse effects:
◦ Baloxavir, oseltamivir, peramivir, and zanamivir: May include acute confusion,
delirium, hallucinations
◦ Oseltamivir and peramivir: elevated liver enzymes
◦ Peramivir can interfere with antibody development with live virus vaccine
Education/Patient Teaching:
• Take drug exactly as prescribed
• Teach clients taking zanamivir how to use a dry powder inhaler
• If taking bronchodilators, use the bronchodilator 5-10 minutes prior to zanamivir
• Oseltamivir suspension comes with own mixing device, show how to measure and mix
Safety – Who can use this?:
Pregnancy and Lactation:
• Oseltamivir is drug of choice
• Zanamivir and peramivir can be used
• Baloxavir crosses placenta, weigh risks vs benefits, has not been studied in humans
Ribavirin:
Pregnancy and Lactation:
• Do not use during pregnancy or breastfeeding!
• Use two forms of contraception while taking the drug, and 1 month after discontinuing
the drug (male should wear a condom if taking and partner is pregnant)
• Pregnant women living in the house of someone taking this drug should not touch
Older adults:
• Administer cautiously due to age-related organ changes increasing toxicity risk
• May need lower dosage and should not receive aerosolized ribavirin
• Assess for anemia. Indications of anemia, Low RBC count, low hemoglobin level, pallor
or cyanosis, fatigue, increased heart and respiratory rate, low blood pressure
---------------------------------------------------------------------------------------------------------------------
Drugs for Hepatitis B Virus (HBV):
Names:
peginterferon, entecavir, tenofovir
Uses/MoA:
Increases immune cell production and activation of enzymes that destroy viral genetic material.
Entecavir is a ‘counterfeit’ form of the genetic base guanine, which suppresses viral replication
in infected cells, slowing or stopping RNA synthesis of HBV
Responsibilities of the Nurse:
Before:
• Liver function and blood cell counts, alcohol use
• Complete list of drugs, consult pharmacist for interactions
• Pregnancy/lactation status/plans
• Ensure correct dosage for peginterferon as vials and prefilled syringes are not the same
• Are premeditations ordered
• Warm refrigerated liquids by rolling between hands
• Aspirate before injecting when giving peginterferon
During: Same as General – IV assessment, 15 minute checks
After:
• Monitor client for at least 30 minutes after first injection of peginterferon
• Assess if client is able to self inject at home
• Educate on sub cut injection techniques
Side Effects/Adverse Effects:
Common Side effects:
• Fatigue, headache, fever, rash, muscle aches
• In addition, peginterferon: depression, injection site reactions, and alopecia
• In addition, entecavir: elevated blood glucose levels in diabetics
Adverse effects:
• Peginterferon: Psychiatric disorders worsen, bone marrow suppression, worsen thyroid
disorders
• Entecavir: liver toxicity, lactic acidosis, shallow breathing, sleepiness
• Lots of drug interactions
Education for the Patient:
• Avoid alcohol during therapy
• Take entecavir on empty stomach (2 hours before or 2 hours after meal)
• Use correct injection technique and ensure client knows to pull back on syringe (aspirate)
prior to injecting drug
• Take premeditations one hour prior to injection
• May take before bed
• Notify provider of symptoms of liver toxicity i.e. jaundice
• If swelling occurs on face, tongue, throat call 911
• Females should use two reliable forms of birth control up to one month after and contact
provider immediately if pregnancy is suspected
• Check with provider prior to starting all meds
• If diabetic, check glucose levels more frequently
• Increased depression or new depression, contact provider immediately
• Notify provider immediately if persistent abdominal and stomach discomfort, fast
shallow breathing, unusual sleepiness, tiredness, or weakness
Safety, who can take this medication?:
Pregnancy and lactation:
• Studies have not been performed
• Strong likelihood of peginterferon causing pregnancy loss
• Peginterferon and entecavir contraindicated during pregnancy and breastfeeding
--------------------------------------------------------------------------------------------------------------------Drugs for Hepatitis C Virus (HCV):
Names:
Direct acting Antivirals
• Mayvyret (glecaprevir; pibrentasvir)
• Vosevi (sofosbuvir/velpatasvir/voxilaprevir)
• ZEPATIER (elbasvir; grazoprevir)
Uses/MoA:
Inhibits viral proteins and enzymes important to virus replication and reproduction
Responsibilities of the Nurse:
Before: in addition to general pages 109-110
• Alcohol use
• Genotype testing - drugs are highly effective
• Liver function, RBC’s, WBC’s
• Pregnancy test
• Complete medication list
After:
• Monitor liver function, RBC’s, and WBC’s
Side Effects/Adverse Effects:
Common Side effects:
• Headache, GI discomfort, rashes, fatigue, weakness
Adverse effects:
• Elevated liver enzymes, jaundice, bone marrow suppression, angioedema, drug
interactions
• Contraindicated: liver dysfunction, cirrhosis, alcoholism, and co-infection with HBV or
HIV
• Allergic reactions
Education for the patient:
• Take drug exactly as prescribed
• Do not use alcohol
• Use 2 reliable forms of birth control including a month after finishing therapy
• Facial swelling-call 911
• Mavyret, vosevi, zepatier with food
• Harvoni and epclusa –with or without food
• Symptoms of liver problems and when to notify provider
• Tell all providers that you are taking these drugs
• Check with provider prior to starting ANY new drugs
Safety – who can take this?
Pregnancy and Lactation
◦ Breastfeeding not recommended
◦ Take measures to prevent birth defects i.e.: negative pregnancy test, abstain from
intercourse or use 2 reliable forms of birth control
---------------------------------------------------------------------------------------------------------------------
Drugs for Covid-19:
Names:
• Remdesivir, casirivimab/imdevimab, Paxlovid
• Other treatments:
o Convalescent serum containing antibodies from recovered clients, additional
antibiotics and anti-inflammatories
Uses/MoA:
• Remdesivir is a counterfeit form of the genetic base adenine. Suppresses viral replication
in infected epithelial cells of the human airway tract.
• Casirivimab/imdevimab is a biologic treatment composed of synthetic human
immunoglobulin G antibodies that can neutralize COVID-19 virus
• Nirmatrelvir is a protease inhibitor and works by preventing critical proteins required for
viral replication from being fully activated. Ritonavir has few antiviral effects; its main
action is to slow the breakdown of nirmatrelvir, so it stays in the body longer.
Responsibilities of the Nurse:
Check before/after:
• Confirm COVID-19 infection
• Maintain strict asepsis when giving intravenously
• Follow infusion time allotments
• Do not give chloroquine or hydroxychloroquine during treatment of remdesivir
• Monitor for allergic reaction can occur up to 24 hours after infusion is complete
• No vaccines with 90 days of receiving casirivimab/imdevimab
Side Effects/Adverse Effects:
Common Side effects:
• Injection site reactions, fever, muscle aches, nausea, taste changes, diarrhea,
hypertension
Adverse effects:
• Unknown; likely include allergic reaction, renal toxicity, increased liver enzymes,
anemia, liver toxicity
Education for the patient:
• Must be administered by licensed health care professional at setting with emergency
equipment and support is readily available.
• Remdesivir is given IV inpatient over 5 to 10 days
• Casirivimab/imdevimab is often recommended as an IV but can be given subcutaneously
• Cannot take chloroquine or hydroxychloroquine at the same time they are receiving
Remdesivir
• Instruct not to receive any vaccinations for 90 days after receiving monoclonal antibodies
as the effectiveness would be reduced.
Safety:
Not yet established – Benefits outweigh the risk
Drugs for HIV:
• Acquired Immune Deficiency Syndrome - Most severe form of immune deficiency
disease caused by HIV
• Everyone with AIDS has HIV infection but Not everyone with HIV infection has AIDS
• HIV is a retrovirus that attacks the immune system
• Once HIV enters the CD4+ cell, it can create more virus particles
• Once the HIV particles overwhelms the immune system, opportunistic infections can
occur, in a person with AIDS, the client can die without treatment
o E.g. salmonella infection, yeast infections, Herpes Simplex Virus
•
•
•
•
•
•
•
Nucleoside analog reverse transcriptase inhibitors (NRTIs)
Non-nucleoside analog reverse transcriptase inhibitors (NNRTIs)
Protease inhibitors (PIs)
Fusion inhibitors
CCR5 antagonists
Integrase strand transfer inhibitors (INSTIs)
Attachment inhibitors
Names: Seven Classes of Antiretroviral Drugs:
• Nucleoside Analog Reverse Transcriptase Inhibitors (abacavir, emtricitabine, lamivudine,
tenofovir, zidovudine)
• Non-Nucleoside Analog Reverse Transcriptase Inhibitors (doravirine, efavirenz,
etravirine, nevirapine, rilpivirine)
• Protease Inhibitors (atazanavir, darunavir, fosamprenavir, tipranavir)
• Fusion Inhibitors (enfuvirtide)
• CCR5 Antagonists (maraviroc)
• Integrase Strand Transfer Inhibitors (INSTI’s) (cabotegravir, dolutegravir, raltegravir)
• Post attachment Inhibitors (fostemsavir, ibalizumab-uiyk)
Uses/MoA:
• Nucleoside Analog Reverse Transcriptase Inhibitors
• Inhibit reverse transcriptase and viral DNA synthesis, slowing viral reproduction
• Non-Nucleoside Analog Reverse Transcriptase Inhibitors
• slow the action of the enzyme reverse transcriptase by binding directly to the
enzyme, which prevents it from converting viral RNA to DNA and as a result
viral reproduction is suppressed
• Protease Inhibitors
• Prevent HIV replication and release of HIV particles from infected cells
• Fusion Inhibitors
• Block viral docking protein from fusing with host cell, thus infection of new cells
does not occur
• CCR5 Antagonists
• Bind to and block CCR5 receptor on host immune cell and prevents HIV from
binding to it for entry into host cells
•
•
Integrase Strand Transfer Inhibitors (INSTI’s)
• Bind to integrase and preventing it from inserting newly formed viral DNA in the
host’s DNA. Virus then cannot be replicated
Post attachment Inhibitors
• Some bind to the viral gp120 docking protein and interfere with HIV entering
host cells, others block the host cell’s receptor and interfere with HIV entering
host cells
Responsibilities of the Nurse:
Before/After: cART
• Check client for liver problems, glucose levels (if diabetic)
• Lifelong treatment; ensure appropriate, in-depth education
• Obtain a list of all drugs client is currently taking and check with pharmacist for
interactions
• Cabenuva is a combination of 2 drugs, each drug is given separately into different IM
sites
• Monitor for side/adverse effects
Side Effects/Adverse Effects:
General issues with antiretroviral therapy
• allergic reaction, worsening hyperglycemia, liver toxicity
• Lots of drug interactions
• Some must be taken with food and some without
Common Side effects of cART:
• Rash, nausea, vomiting, abdominal pain, headache, fatigue, weight gain, difficulty
sleeping, vivid dreams or nightmares
Adverse effects:
• Elevated liver enzymes, jaundice, increased risk of birth defects, many interactions with
other drugs
• Contraindicated in people with chronic hepatitis or other liver problems
• Avoided during pregnancy
Education:
• Take drug exactly as prescribed
• Call 911 if swelling of face, tongue, lips, throat
• Combo juluca can be given with or without food
• No alcohol consumption
• Symptoms of liver problems and when to notify provider; jaundice
• Notify all providers you are taking cART
• If taking a statin, notify provider of muscle weakness or pain
• Check with provider prior to starting ANY new drugs
• Do not take oral Art with 2 hours of taking an antacid
• Notify provider immediately if you become pregnant
• Monitor blood glucose closely if taking juluca
•
If taking dovato, report muscle aches, tiredness, abdominal pain, hypotension slow
heartbeat immediately
Safety:
Pediatric considerations:
• Not approved for use in children
Pregnancy and lactation:
• Not approved; HIV positive mothers are instructed not to breastfeed.
o Specific drugs may be used instead of combo drugs
Older adults:
• Be careful of drug interactions
Drugs for Preexposure Prophylaxis of HIV Infection:
•
•
•
Prevent sexual transmission of HIV
Combination drugs emtricitabine and tenofovir for HIV-1 negative clients with a partner
who is HIV-1 positive
Does not replace safer sex practices
--------------------------------------------------------------------------------------------------------------------Chapter 8 Anti-infective: Antitubercular and Antifungal Drugs
Tuberculosis (TB)
• Spreads by aerosol (airborne) transmission
• When inhaled, bacteria multiply freely in lungs and form a primary lesion
• Lesions usually resolve
• Immune responses develop 2 to 10 weeks after the first infection
• Take a TB skin test
• Infection may progress if person is heavily exposed and has little resistance
• Lesions may progress by entering bloodstream
• Usually affects only the lungs
• May take years for symptoms to develop
• Secondary TB: Reactivation of the disease in a previously infected person whose primary
lesions never completely resolved
Latent
TB bacteria lives but does
not grow withing body
Doesn’t make a person feel sick
Or have symptoms
Can’t spread from person to person
Can advance to TB disease
vs
Active Tb
TB grows in the Body
Makes person feel sick and
have symptoms
Can spread from person to person
Can cause severe disease if not
treated
First-line antitubercular drugs
• Risk of transmission is reduced after 2 to 3 weeks of therapy
• Combination drug therapy is needed
• Therapy continues until infection is under control
• Current first-line therapy for TB uses isoniazid, rifampin, pyrazinamide, and ethambutol
in different combinations and schedules
Names:
• Ethambutol (EMB)(Myambutol)
• Isoniazid (INH)(Nydrazid)
• Pyrazinamide (PZA)
• Rifampin (RIF)(Rifadin, Rimactane)
Uses/Mechanism of Action:
• Isoniazid works by inhibiting several enzymes important to mycobacteria metabolism and
reproduction
• Rifampin prevents reproduction of the TB organism by binding to the enzyme that allows
RNA to be transcribed
• Pyrazinamide reduces the pH of the intracellular fluid of WBCs in which the TB bacillus
resides
• Ethambutol suppresses the reproduction of TB bacteria by an unknown mechanism
Intended Response:
• Cough, sputum production, and fatigue are reduced and weight is gained (decreased TB
symptoms)
• Control of active TB
• Sputum culture is negative
Responsibilities of the Nurse:
Before:
• Assess for liver problems
• Review liver enzymes
• ?Enlarged prostate (men)
• ?Urinary retention
• Check anemia (rifampin)
• Review RBC’s, Hb, Hct, etc.
• Gout history (uric acid)
• Assess vision
• Directly Observed Therapy is recommended
After:
• Check vitals every 15 min. for first hour of treatment if receiving IV
• Monitor for jaundice
• Monitor glucose in diabetics
•
•
•
•
•
Ask about numbness or tingling
Monitor I & O
• How much water and other fluids are you taking in?
Encourage water intake
Ask about joint pain
Client should wear a surgical mask when being transported in hospital, staff should wear
respirator
Side Effects/Adverse Effects:
Common Side effects:
• Diarrhea
• Headache
• Nausea/vomiting
• Difficulty sleeping
Side effects- Drug Specific
• Isoniazid: Breast tenderness or enlargement (in men), loss of appetite, difficulty
concentrating, and sore throat
• Rifampin: abdominal pain, urinary retention, stains secretions a reddish orange color
• Pyrazinamide: muscle aches and pains, acne, photosensitivity
• Ethambutol and pyrazinamide: cause or worsen gout due increased formation of uric acid
Adverse:
• Liver toxicity which can progress to permanent liver damage and failure
• Potential to interact with other drugs
• Isoniazid: Peripheral neuropathy with loss of sensation
• Rifampin: Anemia
• Ethambutol: Optic neuritis, vision changes (at high doses)
• Pyrazinamide: (rare) jaundice
Education
• Keep a supply of drug at all times
• Take drugs for length of time prescribed, even when no longer contagious (after 2-3
weeks of continuous therapy and symptom improvement)
• Avoid alcohol and drugs containing acetaminophen
• Notify provider if become jaundice and symptoms
• Take dose at bedtime if nausea occurs
• Check blood sugars regularly, notify provider if consistent abnormals
• Avoid caffeine if HTN hx
• Rifampin stains secretions reddish orange including soft contact lenses
• Drink full glass of water and increase fluids during day to 3L when possible
• Cause photosensitivity
• Notify provider of vision changes if taking ethambutol
• Tell all providers you are on medications
• Check with provider before starting OTC drugs
Safety (who can take it?):
Pediatric:
• Infants and children of any age with active TB should take these drugs (except
ethambutol)
Pregnancy and Lactation:
• Approved for treatment during pregnancy
• Higher risk of liver toxicity
• Supplement with B complex vitamins during pregnancy when taking isoniazid
• Avoid breastfeeding when possible. Supplementation of B complex vitamins necessary
when it cannot be avoided
Older Adult:
• Gout is more common
• Higher risk of liver toxicity
• Should follow ophthalmologist
--------------------------------------------------------------------------------------------------------------------Antitubercular Drug Therapy for Drug-Resistant Tuberculosis
• Some strains are resistant to first-line drugs and even to second-line antibiotics
• Treatment is limited and requires powerful and dangerous drugs to prevent progression
• Requires three drugs used together
Names:
• Bedaquiline
• Pretomanid
• Linezolid
Uses:
Bedaquiline – Stops productions of the high-energy substance ATP in the TB organism, making it
unable to complete it’s critical metabolic functions or reproduce.
Pretomanid - inhibits the synthesis of a substance important for building cell walls in actively
dividing TB organisms
Linezolid - is a protein synthesis inhibitor.
Responsibilities:
Before
• Must be administered as Direct Observation Therapy (DOT)
• Ask about other drugs, botanicals, and nutritional supplements
• Obtain a baseline blood pressure
• Ensure blood work Is ordered and performed
• Assess vision and obtain a baseline visual assessment
After
• Ensure the client drinks a full glass of water with the tablets
• Check that tablets have actually been swallowed
• Teach about potential side effects and adverse reactions
Side Effects/Adverse Effects:
Common Side effects:
• Hypertension, abdominal pain, headache, nausea, joint pain, rash
Adverse effects:
• Liver toxicity
• Many drug interactions
• Other effects associated with individual drugs
• bedaquiline and linezolid: cardiac changes
• Pretomanid and linezolid: blurry vision, optic nerve damage
• Pretomanid: peripheral neuropathy and seizures
• Linezolid: kidney toxic and decreased blood counts (RBC’s and Platelets)
Education:
• Keep daily appointments for drugs and lab work
• Do not chew the drugs
• Avoid grapefruit juice
• Drink Full glass of water and increase water during day
• Do not drink alcohol or take acetaminophen
• Do not take any OTC drugs, vitamins, or herbal supplements
• Watch for liver and kidney problems
• Monitor for cardiac problems, vision problems, blood cell production problems, changes
in sensation in hands and feet
Safety:
• Dangers of use balanced against the likelihood of death from drug-resistant TB for
populations
• Pregnancy and lactation:
• Breastfeeding is not recommended while on this treatment
--------------------------------------------------------------------------------------------------------------------Drugs for Fungal Infections
• Fungi have a thick, tough cell wall and a plasma membrane
• Fungi live in moist and dark places
• Some types are part of normal skin flora
• If untreated, they can become widespread
• Superficial infections change appearance and function of infected area
Teaching point Box 8.1
General
• Report any signs or symptoms of allerigic reactions
• Immediately after applying the drug, wash your hands
• If another person applies the drug, ensure that they use gloves and wash hands after
wards
• Avoid getting any antifungal drug in your eye. If the drug does get into eye wash the eye
with large amounts of water and notify the prescriber
Powders
• Esure that the skin area is clean and completely dry before applying the powder
• Hold your breath while applying to prevent inhalation
• For the foot area, be sure to apply the powder between your toes. Wear clean cotton socks
(night and day). Change the socks twice a day.
• For the groin area, wear clean, close-fitting but not tight cotton underwear
Skin Creams, Lotions, Ointments
• Ensure that the skin area is clean and dry before applying the drug
• Be careful to apply it only to the skin that has the infection. Keep it away from
surrounding area
• Apply a thin coating as often as prescribed
• Wash and dry the area right before applying the next dose
•
Loosely cover the area to prevent spreading the drug to other body areas, clothing, or
furniture
Oral Lozenges
• Brush your teeth and tongue before using the tablet or trouche
• Let the tablet or troche completely dissolve in your mouth
• Clean your toothbrush daily by running it through the diswasher or soaking in a solution
of bleach 1:9 and risnsing thouroughly
Vaginal Creams or Suppositories
• Blace creams or suppositories just before going to bed to keep them in the vagina longer
• Wash your hands before inserting the drug
• Insert the suppository (rounded end first) into the vagina as far as you can with your
finger
• Wash the applicator and your hands with warm, soapy water; rinse well; and dry
• A sanitary napkin can be worn to protet your clothing and the bed from drug leakage
• Avoid sexual intercourse during the treatment period. If you do have intercourse, the drug
can create holes in condomes and increase risk for unplanned pregnancy. In addition, you
could spread the infection or become reinfected
• Use the drug on the consecutive days as long as prescribed.
Names:
• Azoles (fluconazole, ketoconazole, itraconaolse, posaconazole, voriconazole)
• Allylamines (terbinafine)
• Antifungal Antibiotics (griseofulvin
• Antimetabolites (flucytosine)
• Echinochandins (anidulafugin, caspofungin)
• Polynes (amphotericin B)
Uses:
• Azoles, polyenes, and allylamines
• Prevent the fungus from making ergosterol
• Bind to the ergosterol and prevent it from being properly placed in the fungal
membrane
• Antifungal antibiotics: Inhibit spindle fiber formation which stops reproduction
• Antimetabolites: Act as counterfeit DNA which prevents reproduction
• Echinocandins: Stop production of glucan (glucan holds the proteins which make up the
cell, together) which makes the cell wall weak and cannot protect the fungal cell
Responsibilities:
Before:
• Be sure client isn’t anemic and has no liver problems
• Check current lab work
• Carefully plan dosing schedule around meals
• For amphotericin B, a test dose is recommended
•
After:
•
•
•
•
•
Check any premedication orders
Check the client every 15 minutes for any signs or symptoms of an allergic reaction
Check skin for skin eruptions
Check daily for yellowing skin or eyes
Check apical pulse for 60 seconds twice daily
Check lab values whenever they are taken
Side Effects:
Common Side Effects:
• Taste changes, nausea, vomiting, diarrhea, headache, hair thinning
Adverse effects:
• Anemia, liver toxicity, hypokalemia, severe rashes, abnormal heart rhythms,
reduced kidney function, skin irritation, rashes, drug interactions; other effects
drug-specific
• Allylamines (Terbinafine) and antimetabolites (flucytosine) can reduce WBC’s
• Azoles and polyenes (amphotericin B) - renal insufficiency
• Antifungal antibiotics (Griseofulvin) - liver toxicity
• Antimetabolites (Flucytosine) and echinocandins-peripheral neuropathy with loss
of sensation
• Azoles - cardiac dysrhythmias, prolonged QT interval, torsade's de pointes, can
interfere with other cardiac drugs
• Echinocandins - increase clot formation
• Amphotericin B - more reactions than other drugs, only used for serious life
threatening fungal infections. Adverse effects: fever, chills (shake and bake),
flushing, red man syndrome, hypotension, shock, allergic reactions, electrolyte
imbalances. Causes renal insufficiency in all taking it
Education:
• Be sure clients understand whether to take drug with or without food
• Check pulse for irregularities
• Notify prescriber of yellowing skin or eyes
• Check weekly for increased fatigue
• Check entire skin surface daily
• Avoid direct sunlight and use sunscreen when taking ketoconazole, voriconazole, or
griseofulvin
Safety (Who can take these drugs):
Pediatric
• Use cautiously for severe infections
Pregnancy and Lactation
• Not recommended during pregnancy unless the fungal infection is serious or life
threatening
• Breastfeeding not recommended
Older Adult
• With amphotericin B, older adults may develop neurologic reactions
• Increased risk of DVT
--------------------------------------------------------------------------------------------------------------------Chapter 19: Drug Therapy for Gastrointestinal Problems
•
•
•
•
•
•
Defenses of GI system
Signs of altered body function
Vomiting results from powerful contractions of the abdominal and chest wall muscles
When balance or sense of position is upset, vomiting can occur
Mechanoreceptors initiate vomiting, and chemoreceptors respond to toxins
The vomiting center located in the medulla is responsible for initiating the vomiting
reflex
Names:
Antiemetic Drugs:
• Control nausea and vomiting
• Phenothiazines (promethazine and prochlorperazine)
• Anticholinergics (hyoscyamine, scopolamine)
• Antihistamines (meclizine)
• 5HT3-receptor antagonists (ondansetron)
• 5HT3 receptor antagonists: bind to and block serotonin receptors in the
intestinal tract and chemotrigger zone of the brain
• Dopamine antagonists (metoclopramide)
• Dopamine antagonists: block dopamine from binding to receptors in the
chemotrigger zone and intestinal tract
•
•
Can cause food to move quickly through the intestinal tract and are less likely to
trigger vomiting reflex
Many times people who are receiving tube feedings may receive this to prevent
nausea
Uses/MoA:
• Each drug affects different receptors, and some drugs affect several sites
• Phenothiazines block dopamine receptors in chemotrigger zone
• Anticholinergic drugs inhibit other pathways of the vomiting reflex
• Antihistamines: dulls the inner ears ability to sense motion.
• Opioids can cause dizziness or vertigo and so the antihistamines may be helpful in
treating the nausea that accompanies it
Responsibilities of the Nurse:
Before:
• Baseline vital signs
• Level of consciousness
• Weight
• Electrolyte levels
• Bowel sounds; assess for abdominal distention
• Obtain a complete list of drugs the client is currently taking
After:
• Episodes of nausea and vomiting
• Vital signs
• Daily weights
• Status of abdomen
• Immediately report any signs of respiratory depression
• Watch for signs of side effects or adverse effects
Side Effects/Adverse Effects:
Common Side Effects:
• Insomnia, double vision, tinnitus, hypertension, photosensitivity, ECG changes
Adverse Effects:
• Vary with drug type
• Neuroleptic malignant syndrome (promethazine, metoclopramide, and prochlorperazine)
• Tardive dyskinesia (promethazine and metoclopramide),
• Neutropenia (promethazine and prochlorperazine),
• Respiratory depression (promethazine),
• Tissue necrosis (promethazine-undiluted administered as IVP)







Neuroleptic Malignant Syndrome
F: Fever
E: Encephalopathy (confusion, mental status changes)
V: Vital sign instability (tachycardia, tachypnea, labile BP)
E: Enzyme elevation (creatinine phosphokinase increased because of rhabdomyolysis)
R: Rhabdomyolysis
R: Rigidity
 Tardive Dyskinesia-late, abnormal, uncontrolled movements (rapid blinking, chewing
motions, lip smacking, tongue thrusting)
 Neutropenia- low neutrophils (a type of WBC that fights infection)
 Fever
 Sore throat
 Chills
Education/Teaching:
• Caution clients about driving or operating heavy equipment
• Change positions slowly
• Report new or increased depression to provider
• Prochlorperazine may turn urine reddish brown and is usually temporary
• Drink plenty of fluids
• Avoid other drugs that cause drowsiness or sedation including alcohol
• Do not skip doses
• Use a mild analgesic for headache
• Complete frequent oral care and rinses for dry mouth
• Visit dentist regularly
• Instruct clients to use sunscreen, wear protective clothing, and avoid tanning beds
• Teach clients about the signs and symptoms of malignant neuroleptic syndrome (check
their temp daily) and tardive dyskinesia
• Tell clients about eating foods with increased bulk and about the importance of drinking
enough fluids to prevent constipation
Safety/Who can take this:
Pediatric:
• Children may have muscle spasms of the jaw, neck, and back, along with jerky
movements of the head and face, balance disturbance
Pregnancy and Lactation:
• Consult prescriber; avoid while breastfeeding
Older Adults:
• More likely to experience side effects like confusion and dizziness, shaking hands,
balance disturbance
Drugs for Constipation
Names:
• Several classes; available OTC
• Bulk-forming laxatives (e.g., psyllium)
• Stool softeners (e.g., docusate)
• Lubricants (e.g., castor oil, glycerin suppository)
• Osmotic laxatives (e.g. magnesium hydroxide, polyethylene glycol, lactulose)
• Stimulant laxatives (e.g., bisacodyl, senna)
Uses/MoA:
• Soften, pass stool
• Relieve, prevent constipation
• Class gives the clue as to how they work
Responsibilities of the Nurse:
Before:
• Complete list of drugs being used
• Current bowel habits
• Abdomen for distention, bowel sounds
• Baseline vital signs (blood sugar if diabetic)
• Prepare 8 ounces of fluid to give with oral drugs
• Lubricate suppositories
• Give antacids 1 hour before or after
After:
• Recheck the client’s abdomen for distention and bowel sounds
• Monitor for bowel movements and assess quality of stools
• Increase fluids if allowed
Side Effects/Adverse Effects:
Common:
• Diarrhea, skin rash, stomach cramps, abdominal distention, nausea, gas, headache, reflux
Adverse effects
• Severe, life-threatening effects are rare
• Psyllium and docusate may cause allergic reactions
• Castor Oil: confusion, irregular heartbeat, muscle cramps, skin rash, unusual tiredness or
weakness
• Lactulose and bulk forming drugs: hyperglycemia in diabetic clients
• Bisacodyl: hypokalemia (7 L’s)
• Fleets enemas: electrolyte imbalance with frequent use
Education/Teaching:
• Take with 8 ounces of fluid
• Keep a daily record of bowel movements
• Teach clients to drink at least 1500 to 2000 mL of fluid every day
• Remind clients that most laxatives should be used only short term
•
•
Teach clients not to take oral forms of these drugs within 1 hour of taking an antacid drug
Contact provider for unrelieved constipation or symptoms of electrolyte imbalance or
bleeding
Safety/Lifespan Considerations:
Peds:
• Usually half the adult dose
• Should not be given without specific instructions from prescriber
Pregnancy/Lactation:
• Most drugs safe; prescriber must assess benefits
Older Adults:
• Often use laxatives for a longer period and at higher dosages, which places them at risk
for diarrhea and fluid imbalance
--------------------------------------------------------------------------------------------------------------------Drugs for Diarrhea
Names/Actions:
• Antimotility (diphenoxylate with atropine, loperamide, paregoric)
• Adsorbent/absorbent (bismuth subsalicylate, calcium polycarbophil)
• Antisecretory (bismuth subsalicylate
Uses:
• GI motility and diarrhea are decreased
• Fluid from bowel is reabsorbed and secretion of fluids decreased, activity of bacteria is
decreased
Responisbilties:
Before:
• Complete list of drugs client is taking, ask about anticoagulants
• Baseline weight and vital signs
• Abdomen, skin turgor for dehydration
• Ask about allergies (contraindicated for aspirin allergy)
• Do we know cause of diarrhea?
After:
• Reassess abdomen for bowel sounds and distention
• Watch for signs of toxic megacolon
• Monitor vital signs, diarrhea stools, skin turgor
Side Effects/Adverse Effects:
• Common Side effects:
• Uncommon in healthy adults, vary by drug (pg. 351 Common Side Effects of
Antidiarrheal Drugs)
• Constipation
•
Adverse effects:
• Calcium polycarbophil may cause intestinal obstruction
• Toxic megacolon (potentially life-threatening)
• Fever, abdominal pain, rapid heart rate, dehydration
Education/Patient Teaching:
• Take drug exactly as prescribed
• Do not double-dose; may cause constipation
• Avoid driving, activities that require alertness
• If no relief in 2 days; fever develops, abdominal pain or distention occurs; blood or
mucous appears in stool, notify prescriber
• Avoid alcohol, other CNS depressants
• Frequent oral care, mouth rinses, sugar free candy to help relieve dry mouth
• Bismuth Subsalicylate may turn stool and tounge gray-black
Safety/Who can take these:
Peds:
• Avoid bismuth subsalicylate (contains aspirin)
• Infants, children at risk for dehydration
Pregnacy/Lactation
• Consult Prescriber
Older Adult:
• At risk for dehydration
• Do not use bismuth subsalicylate (Kaopectate); more likely to experience side effects
--------------------------------------------------------------------------------------------------------------------Chapter 20: Drugs for Gastric Ulcers, Reflux, and IBD
•
•
•
•
Peptic Ulcer Disease
Gastric ulcer (stomach)
Duodenal ulcer (duodenum)
Esophageal ulcer (lower part of esophagus)
•
Causes of ulcers
• Infection with Helicobacter pylori bacteria
• Lifestyle (stress, diet, excess acids, smoking)
Gastric mucosa resists damage
Antibiotics are important in treating of PUD
Treatment involves both drugs and lifestyle changes
Gastric ulcers: Avoid NSAIDs
•
•
•
•
Smoking increases acid secretion; reduces protaglandin, mucus, and bicarbonate production,
and decreases mucosal blood flow.
Risk Factors for Gastroesophageal Reflux Disease
Overweight
Pregnant
Certain disease such as diabetes, asthma, peptic ulcers
Cetain drugs such as NSAIDs
Drinking Alcohol and Caffeinated Beverages
Eating food with High Acid Content such as tomatoes and orange juice
Eating Fatty and Spicy Foods
Lying down too soon after meals
Smoking
Signs ulcers are worsening:
• Blood in stools
• Continuing nausea or repteated vomiting
• Feeling cold or clammy
• Feeling weak or dizzy
• Losing weigh
• Pain that doesn’t go away after taking drugs
• Pain that radiates to the back
• Sudden sever pain
• Comiting blood comiting food eaten hours or days ago.
Stages of Treatment
Stage 1: Lifestyle changes
Stage 2: As needed drug therapy
• Antacid or H2 blocker
Stage 3: Scheduled Pharmacologic therapy
• H2 Blocker for 8-12 Weeks
• PPI first choice for errosive esophagitis
Stage 4: Maintenance therapy
• Relapse patient or complicated disease
• Lowest effective dosage of H2 blocker or PPI
Stage 5: Surgery
Lifestyle changes:
• Avoid eating within 3 hours of bedtime
• Stop Smoking
• Avoid alcohol, caffeine, chocolate, citrus fruits and juices, fatty foods, milk, peppermint,
pepper seasoning, speamint, and tomato products
• Decrease portions at mealtimes
• Elevate the HOB or Matress 6-10 inches
• Lose weight if Overweight
General for Administering Drugs for PUD, GERD, IBD
Before:
• Complete list of drugs being used by client
• Baseline vital signs, baseline weight
• Bowel habits, appearance of stools, vomiting, bleeding, reflux
• Assess for bleeding, vomiting, reflux
• Abdomen for distention, pain
After:
• Vital signs; daily weights
• Monitor for abnormal heart rhythms
• Track bowel movement frequency and consistency
• Abdominal assessments
Education:
• Take drug exactly as prescribed
• Do not take a double dose
• Increased fluid intake, fiber-containing foods, and exercise can help prevent constipation
• Avoid alcohol, aspirin products, NSAIDs, irritating foods
Drug Specific
Names:
• Histamine H2 Blockers (end in -dine; cimetidine, famotidine)
Uses:
• Decrease secretion of gastric acid, GERD symptoms
• Heal and prevent ulcers
Responsibilities of the Nurse:
Before:
• Baseline level of consciousness
• Give with meals to prolong therapeutic effects, unless ordered daily, then take at bedtime
• Check IV site every 2-4 hours
After:
• Call light within easy reach
• Watch for side effects
Side effects/Adverse effects:
Common Side Effects:
• Confusion, dizziness, drowsiness, headache, altered taste, nausea, diarrhea, constipation
Adverse effects:
• Dysrhythmias, seizures, agranulocytosis, aplastic anemia
Education/Patient Teaching:
• If more than 2 weeks of therapy, contact prescriber
• Avoid smoking and driving or operating heavy machinery
• Avoid irritating foods, alcohol, and aspirin
• Do not take a double dose and take exactly as prescribed
• Report bruising, fatigue, diarrhea, black tarry stools, sore throat, or rash
Safety/Who can take:
Pregnancy/Lactation:
• Consult health care provider before taking drugs
• Avoid while breastfeeding
Older Adults:
• Increased dizziness and confusion
• Avoid falls, use handrails on stairs
• Avoid driving and using heavy machinery
Proton Pump Inhibitors
Little “-Azole” drugs
Names:
Esomeprazole, lansoprazole, omeprazole, pantoprazole, rabeprazole, dexlansoprazole
Uses/MoA:
Completely block the production of stomach acid -Most powerful drugs for treating PUD or
GERD
Responibilities of the Nurse:
Before:
• Give before meals, preferably in morning
• Check IV site for patency and signs of infection
After:
• Assess for black, tarry stools
Side/Adverse Effects:
Common:
• Diarrhea, constipation, belching, gas, abdominal pain, headache
Adverse effects:
• Depression, swollen ankles, joint pain, itching, dizziness, blurry vision, and dry mouth
Education/Patient Teaching:
• Take drug exactly as prescribed
• Report black, tarry stools
• Report diarrhea, abdominal pain, persistent headaches
• Safety/fall precautions while in hospital
• Use sunscreen if taking rabeprazole
Safety:
Pregnancy/Lactation:
• Do not take omeprazole, pantoprazole, and rabeprazole
• Not recommended while breastfeeding
Older Adults:
• Increased risk of side effects
• May decrease absorption of calcium; greater risk of hip fracture
• May decrease absorption of vitamin B12
Antacids
Names:
Aluminium Hydroxide, Calcium Carbonate, Magnesium Hydroxide/Aluminum
Hydroxide/Simethicone
Uses/MoA:
• Neutralize gastric acids
• Relieve heartburn, indigestion
• Decrease GERD symptoms, ulcer pain, ulcers healing
Responsibilities of the Nurse:
Before
• Ensure that antacids are given 1 hour after or 2 hours before any other drug
• History of Heart failure
After:
• Ask about symptom relief
• Assess for bowel movements
• Report constipation or diarrhea to provider
Side/Adverse Effects:
• Constipation (calcium, aluminum salts)
• Diarrhea (magnesium salts)
Education/Patient Teaching:
• Contact prescriber if they have been taking an antacid for more than 2 weeks
• Don’t take an aluminum hydroxide or calcium antacid within 1 to 2 hours of other drugs
• Talk about side effects of constipation and diarrhea
• Antacids should be avoided if any signs of appendicitis or inflamed bowel are present
• Avoid salt containing antacids if heart failure
• Shake liquid antacids well
Safety/Lifespan:
Peds:
• Do not give unless directed by prescriber
Pregnancy/Lactation:
• Generally safe
• Long-term use of antacids may have negative effects on the fetus
Older Adults:
• Avoid aluminum-containing drugs with bone problems, Alzheimer disease
Cytoprotective Drugs
Names:
Bismuth subsalicylate, sucralfate
Uses/MoA:
Work by coating some part of the GI mucosa and reducing its exposure to stomach acids
• Sucralfate reacts with stomach acids to form a thick coating that covers the surface of an
ulcer
• Bismuth subsalicylate also coats the stomach and intestine, protecting the mucosa
Responsibilities:
Before:
• General Responsibilities
• Assess for abdominal discomfort
• Ask about tinnitus
After:
• General responsibilities
• Ask about relief of symptoms
• Assess for behavior changes
• Assess for tinnitus
Side/Adverse Effects:
Common:
• Constipation, dizziness, drowsiness, dry mouth, rashes
Adverse effects:
• Behavior changes with nausea and vomiting, and ringing in the ears (bismuth
subsalicylate)
Education/Patient Teachings
Take the drug exactly as directed by the prescriber
Increase fluid and dietary fiber
Exercise
Avoid antacids with 30 min.
Safety/Lifespan:
Pregnancy and lactation—sucralfate appears to be safe
Promotility Drugs:
Metoclopramide given 30 minutes before meals for 4 to 12 weeks
Increases LES tone and speed of empying food out of stomach
Antibiotics for H. Pylori Infection
Amoxicillin, clarithromycin, metronidazole, tetracycline
Drugs for Inflammatory Bowel Disease
Names:
• Balsalazide, mesalamine, olsalazine, sulfasalazine
Uses:
• Limit the inflammation in the lining of the intestinal tract
Responsibilities:
Before:
• Ask about kidney problems and ensure kidney function lab tests complete
• Assess stool
• Give client a full glass of water to drink with each dose
After:
• Monitor for allergic reactions
• Monitor stool and abdominal discomfort
• Monitor renal function tests for signs of toxicity
Side/Adverse Effects:
Common Side effects:
• Headache, nausea, abdominal pain and cramping, loss of appetite, vomiting, rash, fever
Adverse effects:
• Kidney injury, decreased sperm production, diarrhea, pancreatitis
Education/Patient Teaching:
• Take exactly as prescribed and with a full glass of water
• If enema form is prescribed, hold in colon for at least 20-40 minutes
• Wear protective clothing and sunscreen due to increased risk of sunburn
• Notify provider of any signs of allergic reaction
Safety/Lifespan:
Pregnancy and lactation:
 If pregnant or planning to become pregnant take 2 mg of folate daily
 Considered safe during pregnancy and breastfeeding
Corticosteroids for IBD
Names:
Prednisone (misspelled in book), budesonide, hydrocortisone (different formulations of drugs)
Uses:
• Limit the inflammation in the lining of the intestinal tract by slowing or stopping
mediator production
Responsibilities:
Before:
• Inspect mouth and throat for signs of thrush
• Check for other signs of infection
• Assess skin condition (especially the perianal area)
• Obtain baseline vital signs and glucose levels
After:
• Monitor stool and for signs of infection
• Assist client to brush teeth and rinse oral cavity
• Monitor vital signs and glucose and potassium levels
Side/Adverse Effects:
Common Side Effects:
• Increased risk of infection (especially yeast infections), dry mouth, bad taste
Adverse effects:
• Infections, hypertension, diabetes, osteoporosis, avascular necrosis, myopathy, cataracts,
glaucoma
Education/Patient Teaching:
• Take exactly as prescribed and with a full glass of water
• Do not suddenly stop taking the medication
• Notify provider of any signs of infection
• Brush your teeth and rinse to remove any drug from the oral cavity
• Short term use only to prevent adverse effects
• Consult provider before taking OTC or herbal preparations
Safety/Lifespan:
Pregnancy and lactation:
• May increase risk of pregnancy complications
• No adverse effects reported in breastfed infants
Immunomodulators for IBD
Names:
• Azathioprine, cyclosporine, methotrexate, tacrolimus
Uses:
• Suppress the overly active immune system, decreased inflammation, immunosuppression,
decreased need for long-term steroids, decreased episodes of flares
Responsibilities of the Nurse:
Before:
• Check lab results
• Ask about liver or kidney problems
• Ask about recent vaccinations (esp. pneumonia, influenza, shingles)
• Assess for signs of liver toxicity
• Obtain baseline weight and vital signs
After:
• Monitor vital signs and lab results
• Weigh daily and monitor urine output
• Monitor for signs of infection and nervous system changes
Side Effects:
• Headache, fatigue, nausea/vomiting, diarrhea, mouth sores, increased risk of infection,
rash, flu-like symptoms
Adverse:
• Azathioprine and 6-MP: pancreatitis and bone marrow suppression, serious bleeding,
non-Hodgkin lymphoma, hepatotoxicity
• Cyclosporine: seizures, encephalopathy, hepatotoxicity, pancreatitis, lymphoma, and
nephrotoxicity
• Tacrolimus: seizures, hypertension, prolonged QT segment, GI bleeding, renal failure,
anemia, lung problems, and anaphylaxis
•
Methotrexate: liver scarring and lung inflammation, renal failure, tumor lysis syndrome,
leukopenia, thrombocytopenia, and anemia
Education/Patient Teaching:
• Take exactly as prescribed and with a full glass of water
• Avoid crowds and people who are sick
• Notify provider of any signs of infection
• Report any mouth inflammation
• Protect from sun exposure
• Avoid live vaccines, alcohol, grapefruit juice
• Drink 10-12 glasses of fluid daily
Safety/Lifespan:
• Pregnancy and lactation—should be avoided in pregnant women; avoid tacrolimus when
breastfeeding
• Older adults—at higher risk of adverse events and have decreased treatment
responsiveness
Biologics for IBD
Names:
• Adalimumab, certolizumag, natalizumab, vedolizumab
Uses/MoA:
• Last resort; Improve GI symptoms, induce and maintain remission, prevent flares,
decrease need for hospitalization and surgery
Responsibilities of the Nurse:
Before:
• Ask about prior infections, especially tuberculosis and hepatitis B
• Test for TB a week before the first dose
• Ask about vaccinations for flu and pneumonia
• Allow the drug to come to room temperature before administering
After:
• Check for signs of infection or reactivation of tuberculosis or hepatitis B
• Do not massage the site after infection
• Observe client for 30-60 minutes after injection and monitor oxygenation and blood
pressure every 5-10 minutes
Side/Adverse Effects:
Common Side Effects:
• Injection site reaction, headaches, fever, chills, nausea, cough, aches, sore throat
Adverse effects:
• Increased risk of infection, reactivation of previous infections, increased risk of
lymphoma
Education/Patient Teaching:
Watch for signs of allergic response and report immediately or call 911
Notify provider of signs or symptoms of infection
Get vaccinated for flu and pneumonia
Teach techniques for self administration
Consult with provider regarding OTC or herbal drugs or remedies
Avoid crowds
Safety/Lifespan:
• Pediatric—long term safety is unknown
• Pregnancy and lactation—appear safe in early pregnancy, low level risk during lactation
but not recommended
• Older adults—increased risk of malignancy and infection
--------------------------------------------------------------------------------------------------------------------Chapter 26: Drugs for Insomnia
This study guide… seriously did you take a break at all?!
Names:
Benzodiazepine Receptor Agonists:
Eszopiclone, zaleplon, zolpidem, zopiclone
Benzodiazepines:
Estazolam, flurazepam, quazepam, temazepam, triazolam
Antihistamines:
Diphenhydramine
Herbal Supplement:
Melatonin
Uses:
Sleep, sedation, length of time to fall asleep is decreased
Responsibilities:
Before:
Assess usual sleep patterns, difficulty with sleeping, history of mental health illness, liver or
kidney disease
After:
Check vital signs, sedation/LOC, assess for hypotension
Side/Adverse Effects:
Common Side Effects:
Dizziness, Confusion, Drowsiness, Lethargy, Headache, Nausea, Vomiting, Diarrhea, Blurry
Vision, Dry Mouth
Adverse:
Somnabulism or sleepwalking, Addiction, slower elimination causing overdose
Education/Patient Teaching:
Take exactly as prescribed
Take for short periods of time 1-4 weeks
Benzos you may become dependent
Do not take unless you have adequate time for sleep 4 to 8 hours
Amnesia side effect is reduced if able to get 4 or more hours of sleep
Benzodiazepine receptor agonist – have another person with you to determine whether
somnambulism will be a problem.
Safety/Lifespan:
Peds: Paradoxial response or sedation
Pregnancy/Lactation:
Not for Pregnancy, can cause sedation if breastfeeding
Older Adults:
More likely to experience side effects and increased risk for falls