Pharmacological and Parenteral Therapies

1
Pharmacological and Parenteral Therapies

• Dena Evans, MPH, BSN, RN
• Assistant Professor
• Department of Nursing
• The University of North Carolina at Pembroke

2
Aminoglycosides

• What are they?
• Give examples
• What do they treat specifically?
• Toxicity
• Labs associated
• Routes of administration

3
Answers

• They are bacteriocidal antibiotics
• Amikacin gentamicin neomycin streptomycin
• Gram negative bacteria like pseudomonas,
  enterobacter and TB

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Toxicity

• Dose related
• Given based on clients weight
• Can cause ototoxicity and nephrotoxicity
• Why ½ life in renal cortex is 100 hours so------

5
Labs

• What labs should we monitor and why?

6
Normal Creatinine

• 0.6 to 1.3 mg/dL

7
Drug Interactions

• Cephalosporins (Keflex Ceclor) increase the risk
  of nephrotoxicity
• Loop diuretics (Lasix) increase the risk of
  ototoxicity

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Questions

• The nurse is reviewing the clients record and
  notes that the physician has documented that the
  client has a renal disorder. On review of the
  laboratory results, the nurse would most likely
  expect to see which of the following
• a. Decreased hgb
• b. Elevated creatinine
• c. Decreased RBCs
• d. Decreased WBCs

9
Dosage Calculation Based on Weight

• The MD orders Gentamycin 50mg/kg/day and the
  recommended dosage is 200-500 mg/kg/day. Your
  patient weighs 10 kg.
• Question 1 How many mg has the MD ordered?
• Question 2 Is the dosage safe
• Question 3 How do you know if it is safe?

10
Dosage Calculation Tobramycin

• The physician order tobramycin 15mg IV q 6h for a
  child with a severe systemic infection who weighs
  10kg. You have on hand 20mg/2mL. Recommended
  pediatric parameters are 6-7.5 mg/kg/day in four
  divided doses.
• Question 1 How many mL will you give?
• Question 2 Is the order safe?
• Question 3 How do you know?

11
Drug Question-Kidney

• Following kidney transplantation, cyclosporine is
  prescribed for a patient. Which lab result would
  indicate an adverse effect from the use of this
  medication?
• Decreased creatinine level
• Decreased hemoglobin level
• Elevated blood urea nitrogen level
• Decreased white blood cell count

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Drug Question-Kidney

• Following kidney transplantation, cyclosporine is
  prescribed for a patient. Which lab result would
  indicate an adverse effect from the use of this
  medication?
• Decreased creatinine level
• Decreased hemoglobin level
• Elevated blood urea nitrogen level
• Decreased white blood cell count
• Indicates nephrotoxicity

13
Drug Therapy-Kidney

• A client with chronic renal failure is receiving
  epoetin alfa (Epogen, Procrit). Which lab result
  would indicate a therapeutic effect of the
  medication?
• a. Hematocrit of 32
• b. Platelet count of 400,000 cells/mm3
• c. BUN of 15mg/dL
• d. WBC of 6,000 cells/mm3

14
Drug Therapy-Kidney

• A client with chronic renal failure is receiving
  epoetin alfa (Epogen, Procrit). Which lab result
  would indicate a therapeutic effect of the
  medication?
• a. Hematocrit of 32
• b. Platelet count of 400,000 cells/mm3
• c. BUN of 15mg/dL
• d. WBC of 6,000 cells/mm3
• This is the intended effect of the drug

15
Drug Therapy-Steroids

• Prednisone is prescribed for a client with
  diabetes mellitus who is taking daily NPH
  insulin. Which of the following medication
  changes would the nurse anticipate during therapy
  with prednisone
• a. An additional daily prednisone dose
• b. A decreased amount of daily NPH
• c. An increased amount of daily NPH
• d. The addition of an oral hypoglycemic agent

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Drug Therapy-Steroids

• Prednisone is prescribed for a client with
  diabetes mellitus who is taking daily NPH
  insulin. Which of the following medication
  changes would the nurse anticipate during therapy
  with prednisone
• a. An additional daily prednisone dose
• b. A decreased amount of daily NPH
• c. An increased amount of daily NPH
• d. The addition of an oral hypoglycemic
  agent
• Steroids can trigger diabetes and worsen in
  existing cases

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TPN

• Total Parenteral Nutrition

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What is it?

• Mixture
• Specifically designedindividualized
• Sugar, carbs, protein, lipids, electrolytes,
  trace elements
• Should be clearno sediment

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Why would someone need it?

• Cant eat
• Needs nutritional support
• Cancer patient transplant patient stabilization
  of electrolytes in the elderly

20
How is it administered? Pay attention
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Electrolytes--revisited

• Sodium
• Potassium
• Chloride
• Phosphate
• Calcium
• Magnesium

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Question

• Does having too much or too little of any
  electrolyte have the potential to cause health
  problems?
• Give me an example

23
So

• If you have a patient who is already
  nutritionally challenged and you are giving them
  a solution of electrolytes via a central line,
  what signs and symptoms would you observe for?

24
Possibilities

• Could you see an EKG changes? Why? What
  specifically?
• Could you see issues with muscle strength? Why?
  What specifically?
• Could you see an problems with mental status?
  Why? What specifically?

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EKG Changes

• Hyperkalemia may cause spiked T waves

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Muscles

• Hypocalcemia
• Chvosteks Sign
• Trousseaus

www.sohnurse.com
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Mental Status

• Hypomagnesemia
• Psychotic behavior/sedation/confusion

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Side Effects of TPN

• Mouth sores skin changes fever, chills,
  stomach pain, SOB, rapid wt. loss or gain
  muscle weakness or twitching, jumpy reflexes,
  swelling of hands or feet
• What type of patient do you think TPN should be
  use cautiously with?

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Answer

• Renal
• Cardiac Insufficiency
• Diabetics
• Remember Fluid overload (report SOB/ rapid wt.
  gain/swelling of hands and feet).
• Hypokalemia ESRD and poor nutrition coupled with
  extra fluid, sodium, potassium.
• And TPN has a lot of sugar in it

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What labs will you monitor?

• Electrolytes
• Kidney specific
• ?Infection at site of central line? WBCs
• Blood sugar due to high amounts of sugar in the
  mixture

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Storage

• Should be kept in fridge or freezer
• Remove 4-6 hours before giving (why)?
• Do not refreeze

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TPN Question

• A patient with Chrons disease is receiving TPN
  via a subclavian triple lumen catheter. The nurse
  recognizes that a priority is to
• Assess the insertion site for signs of infection
• Complete the administration within 8 hours
• Discontinue the infusion if the patient
  experiences hyperglycemia
• Change the IV tubing and dressing every 72 hrs.

Coonan, P.R. (2006). NCLEX for dummies.
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TPN Question

• A patient with Chrons disease is receiving TPN
  via a subclavian triple lumen catheter. The nurse
  recognizes that a priority is to
• Assess the insertion site for signs of infection
• Complete the administration within 8 hours
• Discontinue the infusion if the patient
  experiences hyperglycemia
• Change the IV tubing and dressing every 72 hrs.

Coonan, P.R. (2006). NCLEX for dummies.
34
Rationale

• Infection is a major concern for clients
  receiving TPN
• Usually given continuous drip
• Never stop abruptly (hyPOglycemia
• Change bag each time and dsg. Per policy

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TPN Question

• When caring for a patient who is receiving TPN,
  what should the nurse do to prevent infection in
  the patient?
• a. Encourage the patient to take fluids by
  mouth each day
• b. Monitor the serum blood urea nitrogen and
• blood sugar daily
• c. Maintain strict IO records
• d. Use strict aseptic technique when caring for
• the IV site

36
TPN Question

• When caring for a patient who is receiving TPN,
  what should the nurse do to prevent infection in
  the patient?
• a. Encourage the patient to take fluids by
  mouth each day
• b. Monitor the serum blood urea nitrogen and
• blood sugar daily
• c. Maintain strict IO records
• d. Use strict aseptic technique when caring for
• the IV site

37
TPN Question

• A patient is started on TPN. Which of the
  following lab tests should the nurse monitor
  several times a day?
• a. Serum calcium and magnesium
• b. Urine specific gravity
• c. Blood glucose
• d. Serum total protein

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TPN Question

• A patient is started on TPN. Which of the
  following lab tests should the nurse monitor
  several times a day?
• a. Serum calcium and magnesium
• b. Urine specific gravity
• c. Blood glucose
• d. Serum total protein

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Rocephin and Clostridium Difficile
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Questions

• What is Clostridium Difficile?
• Where is it found?
• What is Rocephin?
• What is it used for?

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Answers

• Clostridium Difficile is a resident flora of your
  intestinal tract.
• It is not the most abundant flora
• Rocephin is a broad-spectrum antibiotic.
• What does that mean?

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Rocephin and C-Diff

• Give broad spectrum antibioticspotentially wipe
  out good bacteria that keep flora in check
  (C-Diff).
• This allows C-Diff, usually a minority bacteria,
  to multiply.
• Causes pseudomembranous enter colitis.

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What is that?

• Condition marked by diarrhea, abdominal pain and
  foul smelling stool.
• AKA Antibiotic-Associated colitis

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Question

• How do you diagnose pseudomembranous
  entercolitis?

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Stool Sample-Sterile Container
46
Question

• How do you think you would treat C-Diff?

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Treatment

• Stop the broad spectrum antibiotics
• Give Flagyl or Vancomycin

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Long term use of Steroids

• Side Effects

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Questions

• What are steroids commonly used to treat?
• What hormone do they mimic?
• Where does this hormone come from?
• What does this hormone do?

50
Answers

• Anti-inflammatory
• COPD Asthma Infections
• Mimic cortisol
• Comes from the adrenal cortex
• Cortisol helps body cope during times of stress
  illness/surgery/infection
• Also triggers insulin release

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Pathway

• Stressor Pituitary Send down some ACTH
  Adrenal cortex Cortisol

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Problem with LT Use of Steroids

• They mimic bodys natural production of cortisol
• Pituitary cant tell the difference
• Taken LT potential that the body will essentially
  stop or decrease natural productionbad thing.
• Short-term Usually taper off so the adrenals can
  adjust and resume work

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Side Effects of Steroids

• Mimic Cushings disease (Over production of
  cortisol).
• Moon-face and buffalo hump
• Increased appetite diabetes wt. gain fat
  deposits on face and back Na and H2O retention
  HTN, slow healing

54
Question

• A patient is receiving methylprednisone
  (Solu-Medrol) to treat a spinal cord injury at
  L-1. What action should the nurse take to monitor
  one of the adverse effects of this medication
• a. Monitor LOC every hour
• b. Conduct a 24-hour creatinine clearance
• c. Take blood glucose readings every 4 hours
• d. Check skin turgor every two hours

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Question

• A patient is receiving methylprednisone
  (Solu-Medrol) to treat a spinal cord injury at
  L-1. What action should the nurse take to monitor
  one of the adverse effects of this medication
• a. Monitor LOC every hour
• b. Conduct a 24-hour creatinine clearance
• c. Take blood glucose readings every 4 hours
• d. Check skin turgor every two hours

56
Question

• A nursing instructor asks a student to describe
  the pathophysiology of Cushings disease. Which
  statement by the student indicates an accurate
  understanding of the disorder?
• a. Cushings disease results from an
  undersecretion of corticotropic hormones.
• b. Cushings disease results from an
  oversecretion of insulin.
• c. Cushings disease results from an
  undersecretion of mineralocorticoids.
• d. Cushings disease results from an
  increased pituitary secretion of
  adrenocorticotropic hormone.

57
Question

• A nursing instructor asks a student to describe
  the pathophysiology of Cushings disease. Which
  statement by the student indicates an accurate
  understanding of the disorder?
• a. Cushings disease results from an
  undersecretion of corticotropic hormones.
• b. Cushings disease results from an
  oversecretion of insulin.
• c. Cushings disease results from an
  undersecretion of mineralocorticoids.
• d. Cushings disease results from an
  increased pituitary secretion of
  adrenocorticotropic hormone.

58
Question

• The nurse is teaching a patient with chronic COPD
  about the side effects of long-term
  corticosteroid therapy. The nurse realizes that
  the patient will need further teaching when he
  states
• a. I may experience some facial swelling
• b. I will need to take the drug every day to
  avoid serious side effects
• c. My doctor will be checking my blood sugar
  regularly
• d. I will heal faster if I get injured

59
Question

• The nurse is teaching a patient with chronic COPD
  about the side effects of long-term
  corticosteroid therapy. The nurse realizes that
  the patient will need further teaching when he
  states
• a. I may experience some facial swelling
• b. I will need to take the drug every day to
  avoid serious side effects
• c. My doctor will be checking my blood sugar
  regularly
• d. I will heal faster if I get injured

60
Side Effects of Tricyclic Antidepressants
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Question

• What is a tricyclic antidepressant?
• Give examples
• How do they work?

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Answers

• Called tricyclic because of their structural
  makeup (3 atoms)
• Inhibit the reuptake of serotonin, norepinephrine
  and dopamine
• Also increase histamine which is why they have
  more sedative effects
• Elavil, Anafranil, Tofranil
• Can be used to treat OCD

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Side Effects

• Drowsiness, dry mouth, constipation, impaired
  sexual function, low BP, photophobia, tachycardia
• These are old school antidepressants

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Keep in Mind

• May reduce effectiveness of HTN meds
• Dont use with ETOH or Benadryl (antihistamines)
• Using with MAOIs HTN crisis
• Takes several weeks for therapeutic effects
• Monitor for suicidal ideations
• Long term Renal and liver function-monitor
• Taper off

65
Question

• The home health nurse visits a client who takes
  Anafranil. The nurse notices that the client has
  not taken the medication in 2 months. What
  behavior observed in this client would validate
  his noncompliance
• Complaints of insomnia
• Complaints of hunger and fatigue
• Pulse rate less than 60 beats per minute
• Frequent hand washing with hot soapy water

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Question

• The home health nurse visits a client who takes
  Anafranil. The nurse notices that the client has
  not taken the medication in 2 months. What
  behavior observed in this client would validate
  his noncompliance
• Complaints of insomnia
• Complaints of hunger and fatigue
• Pulse rate less than 60 beats per minute
• Frequent hand washing with hot soapy water

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Question

• The nurse is teaching a client who is being
  started on imipramine hydrochloride (Tofranil)
  about the medication. The nurse informs the
  client that the maximum desired effects may
• a. Start during the first week of
  administration
• b. Not occur for 2-3 weeks of administration
• c. Start during the second week of
  administration
• d. Not occur until after 2 months of
  administration

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Question

• The nurse is teaching a client who is being
  started on imipramine hydrochloride (Tofranil)
  about the medication. The nurse informs the
  client that the maximum desired effects may
• a. Start during the first week of
  administration
• b. Not occur for 2-3 weeks of administration
• c. Start during the second week of
  administration
• d. Not occur until after 2 months of
  administration

69
Question

• The client receiving tricyclic antidepressants
  arrives at the mental health clinic. Which
  observation would indicate that the client is
  following the medication plan correctly
• a. Client reports not going to work for this
  past week
• b. Client arrives at the clinic neat and
  appropriate in appearance
• c. Client complains of not being able to do
  anything anymore
• d. Client reports sleeping 12 hours per night
  and 3-4 hours during the day

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Question

• The client receiving tricyclic antidepressants
  arrives at the mental health clinic. Which
  observation would indicate that the client is
  following the medication plan correctly
• a. Client reports not going to work for this
  past week
• b. Client arrives at the clinic neat and
  appropriate in appearance
• c. Client complains of not being able to do
  anything anymore
• d. Client reports sleeping 12 hours per night
  and 3-4 hours during the day

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Identifying the need for Additional Pain
Medication
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Pain (The 5th vital sign)

• Believe the patient
• Assess the patient
• Use a combination of drug and nondrug therapies
• Dont wait until severe pain strikes
• Be aware of side effects
• Teach your patient

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Assessing your Client

• Use a pain scale
• Be aware of nonverbal indicators
• Reassess after administration
• Narcotics Respiratory rate

74
Questions

• A client with metastatic breast cancer and bone
  metastasis has continuous, poorly localized pain.
  The nurse teaches the patient to use pain
  medications
• a. As often as needed to keep pain under
  control
• b. On an around the clock basis
• c. By alternating two different types to
  avoid addiction
• d. When the pain cannot be controlled with
  complementary therapies

75
Questions

• A client with metastatic breast cancer and bone
  metastasis has continuous, poorly localized pain.
  The nurse teaches the patient to use pain
  medications
• a. As often as needed to keep pain under
  control
• b. On an around the clock basis
• c. By alternating two different types to
  avoid addiction
• d. When the pain cannot be controlled with
  complementary therapies

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Questions

• A postoperative patient is receiving IV morphine
  via a PCA pump for severe incisional pain.
  Nursing assessment will include what parameters.
  Select all that apply
• Respiratory rate and depth
• Level of sedation
• Pain level and quality
• Frequency of bowel movements
• Urine output
• Serum glucose level

77
Questions

• A postoperative patient is receiving IV morphine
  via a PCA pump for severe incisional pain.
  Nursing assessment will include what parameters.
  Select all that apply
• Respiratory rate and depth
• Level of sedation
• Pain level and quality
• Frequency of bowel movements
• Urine output
• Serum glucose level

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Pharmacological Interactions

• Lasix
• TB Meds and Dilantin

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Lasix (Not all inclusive)

• Lasix and aminoglycosides (ototoxicity)
• Lasix and salicylates (rheumatoid patients) drugs
  compete with excretory sites in kidney
  salicylate toxicity
• Lasix and Lithium can lead to Lithium toxicity
• Carafate and Lasix may reduce antihypertensive
  effect of Lasix

80
TB Medications and Dilantin (Phenytoin)

• Clients receiving TB medications and dilantin may
  be at risk for Dilantin toxicity because the TB
  medication (Isoniazid) increases serum Dilantin
  levels.
• Theophylline also increases the risk of Dilantin
  toxicity

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Signs and Symptoms of Dilantin Toxicity

• Rapid eye movements
• Difficulty speaking or slurred speech
• Lethargy
• Problems with coordination or balance
• Dizziness
• Drowsiness
• Unusual body movements or shakiness
• And seizures!

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Pudendal Blocks
83
Perforating the sacrospinous ligament and
injecting 1 Lidocaine.
www.brooksidepress.com
84
Why are they used?

• Less painful delivery
• Painless episiotomy repair
• Lasts for 30 minutes
• Has no impact on contractions
• Usually given at 2nd stage of labor

85
Risks

• Infection
• Hematoma
• Anesthetic toxicity

86
Medication Dosage Adjustments Based on Age
87
Questions

• Can everyone take the same dosage of medication?
• Should adjustments be based entirely on age?
• What are the formulas used for determining
  dosages for children?

88
Answers

• No
• Actually the least accurate
• Weight is actually better mg/kg
• However---

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Clarks Rule

• An old rule for an approximate child's dose,
  obtained by dividing the child's weight in pounds
  by 150 and multiplying the result by the adult
  dose.
• example a child weighs 14 lbs. the adult dose is
  100 mg. Using clarks rule 14/150 .09 x adult
  dose .09x100 9.3 mg

www.wikianswers.com
90
Youngs Rule

• It is a way of calculating pediatric doses for
  children over the age of 2 based on the adult
  dose. Take the age of the child in years and
  divide that by their age plus 12. Multiply this
  number times the adult dose. Pediatric dose
  age/(age 12) x adult dose

91
Body Surface AreaThe Best

• Order Gantrisn 2g/m2 daily in 4 divided doses.
  The client weighs 110 lbs and is 60 inches tall.
  How many mg will the client receive per dose?
• Need Nomogram
• 1.5m2 x 2g 3g/day or 3000 mg/day divided by 4
  is 750 mg per dose.

92
Cardiac Glycosides

• Client Education to Reduce Risk

93
What are they?

• Used to tx. CHF and arrhythmias
• Inhibit the Na/K ATPase which balances cell
  membrane potential (ionic concentration)
• Improves contraction
• Increases cardiac output
• Reduces heart distention

94
Example

• Digoxin (Lanoxin)

95

• Inhibit the Na/K ATPase which balances cell
  membrane potential (ionic concentration)
• Moves sodium out of the cell and pulls potassium
  in
• Digoxin competes with K for binding sites on Na/K
  ATPase. If a client has low K this frees up more
  binding sites for Digoxin and can cause Digoxin
  toxicity

96
Biggest Threat

• Overdose/Toxicity
• Digoxinclassic sign-yellow/green halos around
  objects
• Apathy, blurred vision, slow, irregular heart
  beat, weakness, confusion.

97
Question

• A patient with a history of atrial fibrillation
  is currently receiving digoxin (Lanoxin) 0.25 mg
  po daily. Before administering the medication,
  the nurse will assess the patient carefully for
  which condition that may precipitate digoxin
  toxicity
• Hypokalemia
• Hypocalcemia
• Hyperthyroidism
• Hypotension

98
Question

• A patient with a history of atrial fibrillation
  is currently receiving digoxin (Lanoxin) 0.25 mg
  po daily. Before administering the medication,
  the nurse will assess the patient carefully for
  which condition that may precipitate digoxin
  toxicity
• Hypokalemia
• Hypocalcemia
• Hyperthyroidism
• Hypotension

99
References

• Coonan, P.R. (2006). NCLEX-RN for dummies. New
  Jersey Wiley Publishing Inc.
• Kee, J.L., Marshall, S.M. (2004). Clinical
  calculations with applications to general and
  specialty areas (5th ed.). St. Louis, MO
  Elsevier.
• Silvestri, L.A. (2008). Comprehensive review for
  the NCLEX-RN examination (4th ed.). St. Louis,
  MO Elsevier.