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Chapters 1 - 28 All Materials in this presentation come from: Karch, A. (2008). Focus on: nursing pharmacology. New York, NY: Lippincott Williams & Wilkins.
Case Study # 1 Antibiotics
• Mrs. Smith, a lively 78 yr old woman, successfully receiving Lasix (a diuretic) for hypertension comes in to the office… complaining of UTI symptoms. She wants to know why the doctor did not prescribe Gentamicin. “I used to always take Gentamicin”…..what do you explain to her?
• Gentamicin is an aminoglycoside antibiotic…aminoglycosides and Lasix can cause severe ototoxicity
Mrs. Smith, are you listening to me?
Case Study # 2 Antibiotics
• Senator X receives a letter with a suspicious powder substance. What cephalosporin will he take for anthrax expsoure?
• CeClor (cefaclor) 250 mg PO q8h • The Nurse warns Senator X not to go to Happy Hour, why?
• Senator X should not consume alcohol while taking cephalosporins because of a possible disulfiram-like reaction-• Flushing, nuasea, vomiting, chest pain, palpitations, dyspnea, blurred vision, even consulsions!
Case Study # 3 Antibiotics
• Susan is ready to head to Florida for her Spring Break, too bad she has a UTI and is taking Cipro….. • Why?
• Cipro can cause a severe skin reaction when pt is exposed to sunlight or tanning beds. • Susan’s grandmother in the nursing home doesn’t see much sunlight, she just needs to avoid using NSAIDs when taking Cipro !
Case Study # 4 Antibiotics
• Uncle Larry seems confused lately…It’s a good thing the doctor prescribed Zithromax for his upper respiratory infection….. • Why?
• Half-life is 68 hours so patients only need to take it once a day….usefull for patients who have trouble remembering to take their pills.
Case Study # 5 Antibiotics
• LaTasha calls the nurse: “my baby is allergic to the amoxicillin” • The nurse will ask, “what are her symptoms?” • LaTasha says bad diarrhea…how will you council her?
LaTasha and her baby
• Sometimes patients may confuse side effects with allergic reactions. • Typical allergic reactions include:
– Hives, rash – Difficulty breathing, respiratory arrest – Increased BP, dilated pupils, – Increased heart rate, diaphoresis
Amoxicillin and other penicillins
• Common adverse effects include nausea, diarrhea and a furry tongue. • “A furry tongue! What are you talkin’ about?” says LaTasha… • Superinfections like yeast are very common…
Case Study # 6 Antibiotics
• Carrie’s husband has an abscessed tooth. The dentist prescribed Clindamycin (lincosamide)… • Great wife that she is, she is bummed because she just cleaned her toilets…what side effect is she thinking of?
Severe pseudomembranous colitis
• So what’s a little colitis? • Pseudomembranous colitis is actually another superinfection. Clindamycin may allow Clostridium difficile (C. diff) to infect the colon.
• • • • Ancef is one of the cephalosporins. Toxic to the kidneys Monitor the patient BUN levels No alcohol while taking Ancef
If pt has an allergic rxn, give parenteral epinephrine to cause vasoconstriction and bronchodilation.
*(Material from ATI prep)
Case Study # 7 Antibiotics
• Cheryl, a young nursing student, comes to the clinic with severe acne. The doctor has prescribed tetracycline. • The nurse advises her to take the medicine on an empty stomach.
• Most importantly of all, her nurse asks…..
Antibiotics and Oral Contraceptives
• Are you taking oral contraceptives? • Several antibiotics including tetracycline, are known to lead to failure of oral contraceptives. • Cheryl needs to know to use alternative methods for birth control.
Case Study # 8 Antimycobacterial Antibiotics
• Michael volunteers at a health clinic for refugees from other countries…He is surprised to see so many patients with T.B. • He explains the treatment lasts from 6 months to two years…why?
• The slow growing bacteria form a mycolic acid outer coating. Isoniazid, rifampin and ethionamide are the first line of defense….
Michael also learns to say: “Su pis hace naranja” spanish for “your pee will be orange” for patients taking rifampin
• Treatment for tuberculosis • Can cause lupus and jaundice from liver toxicity • Signs of jaundice: • Yellow skin • Discolored sclerae
(material from ATI prep)
Case Study # 9 Antiviral Agents
• Nathan says he feels “like crap!” • Jennifer says, “if it’s the flu and its been less than 2 days, you should try….
• 75 - 150 mg PO b.I.d. for 5 days • Also approved for use with children
Case Study # 10 Antiviral agents
Abreva for Relenza For the FLu cold sores
Hepsera For Hep. B (liver damage)
Aldara for skin cancers
Acyclovir For herpes
Retrovir (AZT) For HIV
Review antiviral agents
• • • • • • Flu symptoms Cold sores Hepatitis B HIV Herpes Skin cancers (also genital warts)
• • • • • •
Hepsera Aldara Abreva Relenza Acyclovir Retrovir (AZT)
Case Study # 11 Antifungals
There is a fungus, among us…
What common antifungal is used topically for onychomycosis ?
• Lamisil is commonly used cream and is pretty safe …however… other antifungals are not used topically Why would anyone need to take pills for fungus?
Case Study # 12 Antifungals
• Answer: Superinfections Azoles are used to treat Candidiasis, systemic fungal infecitons and to prevent candidiasis in bone marrow transplants
Remember the “furry tongue” see case # 5
Antifungal Drug to Drug interactions
• • • • • Systemic antifungals like azoles may become toxic with: Sounds like the digoxin average nursing home oral hypoglycemics cocktail to me… warfarin phenytoin cyclosporine
Case Study # 13 Antiprotozoal agents
• Michael decides to take his clinic to Africa… • What drug will he need to take to prevent malaria? • Should Michael and his wife plan to have kids while they are over there?
• Chloroquine (Aralen) blocks the reproduction of the plasmodium organisms. • Chloroquine has potential risk to pregancy • Also can cause serious eye damage and blindness
Case Study # 14 Antiprotozoals
• Cindy and Tara went backpacking in the Smoky Mtns. Cindy warned Tara not to drink the water, but she did…. • Now Tara has pale, mucous filled stools and rotten egg smelling diarrhea… sounds like she needs---
(Flagyl, MetroGel, Noritate) 750 mg PO tid for 5-10 days for amebiasis and giardiasis 2 g PO as one dose for Trichimoniasis The Travelers’ Real Friend…
Case Study # 15 Anti-inflamatory agents
• Grandpa believes “if one is good, two is better” when it comes to aspirin for his arthritis. • Lately, he complains about ringing in his ear…is there a connection?
Yes! Ringing in the ears is a classic sign of aspirin toxicity, called salicyclism. Also sweating, headache and dizziness, Granpa’s liver may not be meatbolizing the aspirin as fast as it use to ….
Case Study # 19 Anti-inflammatory agents
Brenda, an alcoholic, has had a migraine for three days. She’s been taking Tylenol extra strength whenever it starts to ache. Yesterday, she started to have flu symptoms so she’s been taking DayQuil (325 mg acetaminophen), a couple of swigs every few hours. She comes to ER with nausea, vomiting, and GI upset-The doctor recognizes Acetaminophen Toxicity and prescribes:
(Mucomyst) is 100% effective in preventing liver overdose
The Liver Can’t “live” Without it!
• Gold Salts are available for treatment of rheumatoid arthritis • Monitor the patient for mouth sores, GI inflamation and allergic rxns. And anaphylatic shock
• Allergic rxn where body produces histmaines • Immediate swelling and constricting of bronchi Symptoms include:
– urticaria (hives) – Shortness of breath
• Give epinephrine
• Hep B • Hib • Dtap 5 - dose series
• • • •
IPV MMR PVC Varicella
Anxiolytics and Hypnotic Agents
• • • • • • • Xanax - anxiety, panic Librium - anxiety, alcohol withdrawal Klonopin - restless leg syndrome, panic Valium - muscle relaxant, antiepiletptic ProSom - hypnotic, insomnia Ativan - anxiety, preanesthesia Serax - preferred for elderly
Case Study # 20 Benzodiazepines
• Mr. Mason came into ER. He is a known drug abuser. He was admitted for possible stroke. • Kim, his nurse asks when was the last time he had a beer? Mr. Mason says 3 days. • Kim calls the doctor to request Ativan (STAT), why?
(based on a true story)
• Kim has seen this before…. • Mr. Mason is probably an alcoholic and will begin to have withdrawal symptoms if he stays any longer at the hospital. • Ativan will prevent wild behavior and lasts 12 - 24 hours ------------> (that will cover her shift)
• Kim requests only 1 mg/day PO for Mr. Mason • The normal dosage is 2 -6 mg/day • Why?
• Mr. Mason is an African American.
Use lowest possible dose
• Kim knows special care needs to be taken because he may have a genetic predisposition to delayed metabolism of benzodiazepines. • She will closely monitor him for adverse effects like cardiovascular issues, urinary retention, sedation, confusion and blurred vision.
• Mr. Mason threatens to leave the hospital. “You can’t make me stay!” • Kim explains to him Ativan plus alcohol can cause serious CNS depression. • She flips on the movie channel and Mr. Mason calms down.
Just another day for Super Nurse!
• Amytal sodium - convulsions, sedative • Luminal - preanesthetic, seizures • Seconal - preanesthetic, seizures
Selective Serotonin Reuptake Inhibitors (SSRIs)
• • • • • • Luvox Paxil Zoloft Celexa Cymbalta Prozac
70 % experience Sexual dysfunction That’s depressing!
Inform patients: •May take 4 weeks To see improvement •May cause cystitis, •Urgency • sexual dysfunction •Need alternative birth control (If using oral contraceptives) •Do not combine with St. John’s Wort
Case Study # 20 Tricyclic Antidepressants
• TCAs treat depression • Clamipramine is for OCDs • TCAs are anticholinergic so caution with: • Cardiovascular disorders • Urinary disorders • Imipramine also treats…..?
• 25 mg/day 1 hr before bed For bed wetting Monitor for anticholinergic effects like dry mouth, constipation, rash, anxiety and bone marrow depressi
Case Study # 21 Tricyclic antidepressants
• Your patient is on Elavil (amitrptyline) (to elevate her mood obviously) What side effects will you monitor for?
I’m gonna push the ‘upper’ button
• TCAs have anticholinergic effects • Monitor for dry mouth and urinary retention!
Anxiolytic and Hypnotic Drugs
• Sonata • Ambien (zolpidem) • Lunesta
I need Lunesta
Cause sedation and are used for Short-term treatment insomnia of
• Phenergan • Benadryl
Used preoperatively May cause thick secretions
Case Study # 22 Antidepressant agents
• Tonya has been depressed for awhile, so the doctor prescribed Nardil (phenelzine). She was doing much better until her birthday: her nursing friends had a gala wine tasting event. • (Caviar, aged cheeses, wines, sausage) • She went to ER thinking she had a stroke……..
• Occipital headache, palpitations, nausea, vomiting,sweating, tachycardia, chest pain, … even stroke can result when MAOIs are combined with tyramine-containing foods (like wines and cheeses) • MAOIs can also cause hypoglycemia
• No worries, Tonya sued her nursing friends for a fortune……..
Case Study # 23 Antidepressant agents
• Nicole’s husband wants to quit smoking. The doctor prescribed Zyban (bupropion). The doctor forgot to mention a major side effect and Nicole is about ready to scream. • What is the side effect?
Bupropion (Wellbutrin, Zyban)
Major side effect: insomnia “Oh, well,” says the doctor, “at least he won’t be depressed”
• • • • • Treatment of: Schizophrenia Psychotic disorders Any adverse effects Combative behavior ? Agitation in elderly Hyperactivity
Adverse effects of Psychotherapeutic Agents
• CNS depression, tremor, drowsiness • Cardiovascular effects • Anticholinergic effects
– Dry mouth – Constipation, urinary retention
• Extrapyramidal effects
– Pseudoparkinsonism – Dystonia,akathisia
Case Study # 24 Psychotherapeutic agents
• Granpa’s Alzheimers’ is getting worse. Yesterday, he slugged the nurse when she tried to give him a shower… • Now,he is taking Seroquel (quetiapine) 50 mg PO bid • Grandma wants to know why he is drooling…he never did that before?
• Tell grandma that since grandpa still needs to take his beta-blocker for his heart, he is having an increased response to the Seroquel • The nurse will also monitor for dyspnea and heart arrhythmias.
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