ANTIFUNGAL Therapeutic Pharmacokinetics Assessment: History and Nursing Diagnoses Implementation with Rationale Evaluation

AGENTS Actions and Examination

Indications
1. SYSTEMIC
ANTIFUNGALS

A. AZOLE These drugs bind to Ketoconazole, ■ Assess the patient for ■ Acute Pain ■ Arrange for appropriate culture ■ Monitor patient
ANTIFUNGALS sterols and can itraconazole, contraindications or cautions: related to GI, CNS, and sensitivity tests before response to the drug
The azoles are a cause cell death or posaconazole, and history of allergy to and local effects of beginning therapy to ensure that the (resolution of fungal
large group of interfere with cell terbinafine are antifungals to prevent the drug ■ appropriate drug is being used. infection).
antifungals used to replication, administered orally. potential hypersensitivity Disturbed Sensory However, in some cases, treatment ■ Monitor for adverse
treat systemic and depending on the Ketoconazole is also reactions; history of liver or Perception can begin before test results are effects (orientation and
topical fungal type of fungus being available as a shampoo renal dysfunction that might (Kinesthetic) known because of the seriousness affect, nutritional state,
infections affected and the and a cream, and interfere with metabolism related to CNS of the systemic infections. skin color and lesions,
concentration of the terbinafine is also and excretion of the drug; effects ■ Administer the entire course of renal and hepatic
Agents include: drug available in a sprinkle and pregnancy or lactation ■ Deficient the drug to get the full beneficial function).
fluconazole formulation for children. because of potential adverse Knowledge effects; this may take as long as 6 ■ Evaluate the
(Diflucan), Fluconazole and effects to the fetus or infant. regarding drug months for some chronic infections. effectiveness of the
itraconazole voriconazole are available ■ Perform a physical therapy ■ Monitor IV sites to ensure that teaching plan (patient
(Sporanox), in oral and intravenous assessment to establish phlebitis or infiltration does not can name the drug,
ketoconazole (IV) preparations, making baseline data for assessing occur. Treat appropriately and dosage, possible adverse
(Nizoral), it possible to start the drug the effectiveness of the drug restart IV at another site if phlebitis effects to watch for, and
posaconazole intravenously for a serious and the occurrence of any occurs. specific measures to help
(Noxafil), infection and then switch adverse effects associated ■ Monitor renal and hepatic avoid adverse effects).
terbinafine to an oral form when the with drug therapy; test function before and periodically ■ Monitor the
(Lamisil), & patient’s condition orientation and reflexes to during treatment to assess for effectiveness of comfort
voriconazole improves and he or she is evaluate any CNS effects; possible dysfunction and arrange to and safety measures and
(Vfend) able to take oral and examine skin for color stop the drug if signs of organ compliance with the
medications. and lesions to monitor for failure occur. regimen.
Although azoles any dermatological effects. ■ Provide comfort and safety
are considered less ■ Obtain a culture of the provisions if CNS effects occur
toxic than some infected area to make an (e.g., side rails and assistance with
other antifungals, accurate determination of the ambulation for dizziness and
such as type and responsiveness of weakness, analgesics for headache,
amphotericin B, the fungus. antipyretics for fever and chills,
they may also be ■ Evaluate renal and hepatic temperature regulation for fever) to
less effective in function tests and complete protect the patient from injury.
very severe and Amphotericin B and blood count to determine ■ Provide small, frequent,
progressive flucytosine are available baseline function of these nutritious meals if GI upset is
infections. Other antifungal in IV form. organs and to assess possible severe. Monitor nutritional status
B. OTHER agents work to They are excreted in the toxicity during drug therapy. and arrange a dietary consultation
ANTIFUNGAL cause fungal cell urine, with an initial half- as needed to ensure nutritional
 AGENTS death or to prevent life of 24 hours and then a status. GI upset may be decreased
Other antifungal fungal cell 15-day half-life. Their by taking an oral drug with food.
drugs that are reproduction. metabolism is not fully ■ Instruct the patient to enhance
available do not fit Amphotericin B is a understood. Flucytosine is patient knowledge about drug
into either of these very potent drug well absorbed from the GI therapy and to promote compliance.
classes. with many tract, with peak levels ■ Provide the following patient
unpleasant adverse occurring in 2 hours. Most teaching:
These include effects. of the drug is excreted ■ Follow the appropriate dosage
=amphotericin B unchanged in the urine regimen.
(Abelcet, The drug binds to and a small amount in the ■ Take safety precautions,
AmBisome, and the sterols in the feces, with a half-life of including changing position slowly
Amphotec), fungus cell wall, 2.4 to 4.8 hours. and avoiding driving and
=flucytosine changing cell wall Griseofulvin is hazardous tasks, if CNS effects
(Ancobon), permeability. This administered orally and occur.
=griseofulvin change can lead to reaches peak levels in ■ Take an oral drug with meals
=nystatin cell death or prevent around 4 hours. It is and try small, frequent meals if GI
(Mycostatin, the fungal cells from metabolized in the liver upset is a problem.
Nilstat). reproducing. and excreted in the urine ■ Report to a health care provider
with a half-life of 24 any of the following: sore throat,
Because of the hours. unusual bruising and bleeding, or
many adverse Nystatin is not absorbed yellowing of the eyes or skin, all of
effects associated from the GI tract and which could indicate hepatic
with this agent, its passes unchanged in the toxicity; or severe nausea and
use is reserved for stool. vomiting, which could interfere
progressive, with nutritional state and slow
potentially fatal recovery.
infections.
Flucytosine is a less
toxic drug that alters
the cell membrane
of susceptible fungi,
causing cell death

Griseofulvin is an
older antifungal that
acts in much the
same way, changing
cell membrane
permeability and
causing cell death.

2. TOPICAL The topical These drugs are not ■ Assess for known allergy ■ Acute Pain ■ Culture the affected area before ■ Monitor patient
 ANTIFUNGALS antifungal drugs absorbed systemically and to any topical antifungal related to local beginning therapy to identify the response to the drug
Some antifungal work to alter the cell do not undergo agent to prevent effects of the drug causative fungus. (alleviation of signs and
drugs are available permeability of the metabolism or excretion hypersensitivity reactions. ■ Deficient ■ Ensure that the patient takes the symptoms of the fungal
only in topical fungus, causing in the body. ■ Perform a physical Knowledge complete course of the drug infection).
forms for treating prevention of assessment to establish regarding drug regimen to achieve maximal results. ■ Monitor for adverse
a variety of replication and Topical antifungals baseline data for evaluation therapy ■ Risk for ■ Instruct the patient in the correct effects: rash, local
mycoses of the fungal death. include the azole-type of the effectiveness of the impaired skin method of administration, irritation, and burning.
skin and mucous =These diseases antifungals— drug and the occurrence of integrity depending on the route, to improve ■ Evaluate the
membranes. Some include a variety of butoconazole(Gynazole) any adverse effects effectiveness and decrease the risk effectiveness of the
of the systemic tinea infections, clotrimazole (Lotrimin) associated with drug therapy. of adverse effects: teaching plan (patient
antifungals are which are often econazole (Spectazole) ■ Perform culture and ■ Troches should be dissolved can name the drug,
also available in referred to as ketoconazole (Nizoral) sensitivity testing of the slowly in the mouth. dosage, possible adverse
topical forms. ringworm, although miconazole (Fungoid) affected area to determine the ■ Vaginal suppositories, creams, effects to watch for, and
Fungi that cause the causal organism oxiconazole (Oxistat) causative fungus and and tablets should be inserted high specific measures to help
these mycoses are is a fungus, not a sertaconazole nitrate appropriate medication. into the vagina with the patient avoid adverse effects).
called worm. (Ertaczo) ■ Inspect the area of remaining recumbent for at least 10 ■ Monitor the
dermatophytes. =These mycoses sulconazole (Exelderm) application for color, to 15 minutes after insertion. effectiveness of comfort
include tinea terbinafine (Lamisil) temperature, and evidence of ■ Topical creams and lotions and safety measures and
infections such as terconazole (Terazol) and lesions to establish a baseline should be gently rubbed into the compliance with the
athlete’s foot (tinea tioconazole to monitor the effectiveness affected area after it has been regimen.
pedis), jock itch of the drug and to monitor cleansed with soap and water and
(tinea cruris), and Other antifungals: for local adverse effects of patted dry. Occlusive bandages
yeast infections of butenafine (Mentax) the drug. should be avoided.
the mouth and ciclopirox (Loprox) ■ Advise the patient to stop the
vagina often caused gentian violet drug if a severe rash occurs,
by Candida. naftifine (Naftin), especially if it is accompanied by
Because the tolnaftate (Aftate) and blisters or if local irritation and pain
antifungal drugs undecylenic acid (Cruex) are very severe. This development
reserved for use as may indicate a sensitivity to the
topical agents are drug or worsening of the condition
often too toxic for being treated.
systemic ■ Provide patient instruction to
administration, care enhance patient knowledge about
is necessary when drug therapy and to promote
using them near compliance.
open or draining ■ Provide the following patient
wounds that might teaching:
permit systemic ■ The correct method of drug
absorption administration; demonstrate
proper application.
■ The length of time necessary to
treat the infection adequately.
■ Use of clean, dry socks when
treating athlete’s foot, to help
eradicate the infection.
■ The need to keep the infected
area clean, washing with mild soap
and water and patting dry; keep
area dry.
■ The need to avoid scratching the
infected area; use of cool
compresses to decrease itching can
be advised.
■ The need to avoid occlusive
dressings because of the risk of
increasing systemic absorption.
■ The importance of not placing
drugs near open wounds or active
lesions because these agents are
not intended to be absorbed
systemically.
■ The need to report severe local
irritation, burning, or worsening of
the infection to a health care
provider.
ANTIPROTOZOA Therapeutic Pharmacokinetics Assessment: History and Nursing Diagnoses Implementation with Rationale Evaluation
L AGENTS Actions and Examination
 Indications
ANTIMALARIAL These drugs can be Chloroquine is readily ■ Assess for ■ Acute pain ■ Arrange for appropriate culture ■ Monitor patient
S schizonticidal absorbed from the contraindications or related to and sensitivity tests before response to the drug
=are usually given in (acting against the gastrointestinal (GI) tract, cautions: history of allergy gastrointestinal beginning therapy to ensure proper (resolution of malaria or
combination form to red-blood-cell with peak serum levels to any of the antimalarials (GI), CNS, and skin drug for susceptible Plasmodium prevention of malaria).
attack the phase of the life occurring in 1 to 6 hours. to prevent hypersensitivity effects of the drug species. Treatment may begin ■ Monitor for adverse
Plasmodium at cycle), It is concentrated in the reactions; liver dysfunction ■ Disturbed before test results are known. effects (orientation and
various stages of its gametocytocidal liver, spleen, kidney, and or alcoholism that might sensory perception ■ Administer the complete course affect, nutritional state,
life cycle. Using this (acting against the brain and is excreted very interfere with the (Kinesthetic, of the drug to get the full beneficial skin color and lesions,
approach, it is gametocytes), slowly in the urine, metabolism and excretion Visual) related to effects. Mark a calendar for hepatic function, and
possible to prevent sporontocidal primarily as unchanged of the drug; porphyria or CNS effects prophylactic doses. Use visual and auditory
the acute malarial (acting against the drug. Mefloquine is a psoriasis, which could be ■ Risk for injury combination therapy as indicated. changes).
reaction in parasites that are mixture of molecules that exacerbated by the drug related to CNS ■ Monitor hepatic function and ■ Evaluate the
individuals who developing in the are absorbed, metabolized, effects; retinal disease that changes ■ Deficient perform ophthalmological effectiveness of the
have been infected mosquito), or work and excreted at different could increase the visual knowledge examination before and periodically teaching plan (patient
by the parasite. against tissue rates. The terminal half- disturbances associated regarding drug during treatment to ensure early can name the drug,
schizonts as life is 13 to 24 days. with these drugs; and therapy detection and prompt intervention dosage, possible adverse
Quinine prophylactic or Metabolism occurs in the pregnancy and lactation with cessation of drug if signs of effects to watch for, and
(Qualaquin) was the antirelapse agents. liver; caution should be because these drugs could failure or deteriorating vision occur. specific measures to help
first drug found to be used in patients with affect the fetus and could ■ Provide comfort and safety avoid adverse effects).
effective in the hepatic dysfunction. enter the breast milk and be measures if CNS effects occur (e.g., ■ Monitor the
treatment of malaria; Primaquine is readily toxic to the infant. side rails and assistance with effectiveness of comfort
it was absent from absorbed and metabolized ■ Perform a physical ambulation if dizziness and and safety measures and
the market for a in the liver. Excretion assessment to establish weakness are present) to prevent compliance with the
while but is now occurs primarily in the baseline data for patient injury. Provide oral hygiene regimen.
available for the urine. Safety for use assessment of the and ready access to bathroom
treatment of during pregnancy has not effectiveness of the drug facilities as needed to cope with GI
uncomplicated been established. and the occurrence of any effects.
malaria. Pyrimethamine is readily adverse effects associated ■ Provide small, frequent,
absorbed from the GI tract, with drug therapy. Assess nutritious meals if GI upset is
Other antimalarials with peak levels occurring central nervous system severe to ensure adequate nutrition.
used today include within 2 to 6 hours. It is (CNS) (reflexes and muscle Monitor nutritional status and
=chloroquine metabolized in the liver strength). arrange a dietary consultation as
=mefloquine and has a half-life of 4 ■ Perform ophthalmic and needed. Taking the drug with food
=primaquine days. It usually maintains retinal examinations and may also decrease GI upset.
=pyrimethamine suppressive concentrations auditory screening to ■ Instruct the patient concerning
in the body for about 2 determine the need for the appropriate dosage regimen and
weeks. Quinine is rapidly cautious administration and the importance of adhering to the
absorbed from the GI tract, to evaluate changes that drug schedule to enhance patient
with peak serum levels occur as a result of drug knowledge about drug therapy and
occurring in 1 to 3 hours. therapy. to promote compliance.
It is metabolized in the ■ Assess the patient’s liver ■ Provide the following patient
liver with a half-life of 4 to
6 hours and is excreted in
the urine.
function, including liver
function tests to determine
appropriateness of therapy
and to monitor for toxicity.
■ Obtain blood culture to
identify the causative
Plasmodium species and
ensure appropriate use of
the drug.
■ Inspect the skin closely
for color, temperature,
texture, and evidence of
lesions to monitor for
adverse effects.
teaching:
■ Take safety precautions,
including changing position slowly
and avoiding driving and
hazardous tasks, if CNS effects
occur.
■ Take the drug with meals and try
small, frequent meals if GI upset is
a problem.
■ Report blurring of vision, which
could indicate retinal damage; loss
of hearing or ringing in the ears,
which could indicate CNS toxicity;
and fever or worsening of
condition, which could indicate a
resistant strain or noneffective
therapy.
 OTHER These Atovaquone is slowly
ANTIPROTOZOA antiprotozoal absorbed and is highly
L AGENTS agents act to protein bound in
Other drugs, inhibit DNA circulation. It is excreted
including some synthesis in slowly through the feces,
tetracyclines and susceptible with a half-life of 67 to 76
aminoglycosides, are protozoa, hours.
used for treating interfering with the Metronidazole is well
these conditions at cell’s ability to absorbed orally, reaching
various stages of the reproduce, peak levels in 1 to 2 hours.
disease. subsequently It is metabolized in the
leading to cell liver with a half-life of 8 to
Other antiprotozoals death These drugs 15 hours. Excretion occurs
include =atovaquone are indicated for primarily through the
=metronidazole the treatment of urine.
=nitazoxanide infections caused Nitazoxanide is rapidly
=pentamidine by susceptible absorbed after oral
=tinidazole protozoa. administration, reaching
peak levels in 1 to 4 hours.
Nitazoxanide is
metabolized in the liver
and excreted in the urine
and feces; it has a half-life
of 8 to 12 hours.
Pentamidine is readily
absorbed through the
lungs. Excretion occurs in
the urine, with traces
found in the urine for up to
6 weeks.
Tinidazole is rapidly
absorbed after oral
administration, reaching
peak levels within 60 to 90
minutes. It is excreted in
the urine with a half-life of
12 to 14 hours.
■ Assess for
contraindications and
cautions: history of allergy
to any of the antiprotozoals
to prevent hypersensitivity
reactions; liver dysfunction
that might interfere with
metabolism and excretion
of the drug or be
exacerbated by the drug;
pregnancy, which is a
contraindication, and
lactation because these
drugs could enter the breast
milk and be toxic to the
infant; central nervous
system (CNS) disease that
could be exacerbated by the
drug; and candidiasis that
could become severe as a
result of the effects of these
drugs on the normal flora.
■ Perform a physical
assessment to establish
baseline data for
determining the
effectiveness of the drug
and the occurrence of any
adverse effects associated
with drug therapy.
■ Evaluate the CNS to
check reflexes and muscle
strength to identify the need
for cautious drug use and to
evaluate changes that occur
as a result of drug therapy.
■ Examine the skin and
mucous membranes to
check for lesions, color,
■ Acute pain ■ Arrange for appropriate culture
related to and sensitivity tests before
gastrointestinal beginning therapy to ensure proper
(GI) and CNS drug for susceptible organisms.
effects of the drug Treatment may begin before test
■ Imbalanced results are known.
nutrition: Less than ■ Administer a complete course of
body requirements the drug to get the full beneficial
related to severe GI effects. Use combination therapy as
effects of the drug indicated.
■ Disturbed ■ Monitor hepatic function before
sensory perception and periodically during treatment to
(Kinesthetic, arrange to effectively stop the drug
Visual) related to if signs of failure or worsening liver
CNS effects ■ function occur.
Deficient ■ Provide comfort and safety
knowledge measures if CNS effects occur,
regarding drug such as side rails and assistance
therapy ■ Diarrhea with ambulation if dizziness and
related to GI effects weakness are present, to prevent
of the drug injury to the patient.
■ Provide oral hygiene and ready
access to bathroom facilities as
needed to cope with GI effects.
■ Arrange for the treatment of
superinfections as appropriate to
prevent severe infections.
■ Provide small, frequent,
nutritious meals if GI upset is
severe to ensure proper nutrition.
Monitor nutritional status and
arrange a dietary consultation as
needed. Taking the drug with food
may also decrease GI upset.
■ Instruct the patient about the
appropriate dosage regimen to
enhance patient knowledge about
drug therapy and to promote
compliance.
■ Monitor patient
response to the drug
(resolution of infection
and negative cultures for
parasite).
■ Monitor for adverse
effects (orientation and
affect, nutritional state,
skin color and lesions,
hepatic function, and
occurrence of
superinfections).
■ Evaluate the
effectiveness of the
teaching plan (patient
can name the drug,
dosage, possible adverse
effects to watch for, and
specific measures to help
avoid adverse effects).
■ Monitor the
effectiveness of comfort
and safety measures and
compliance with the
regimen.
temperature, and texture to
monitor for adverse effects
and superinfections.
■ Evaluate liver function,
including liver function
tests, to determine the
appropriateness of therapy
and to monitor for toxicity.
■ Obtain cultures to
determine the exact
protozoal species causing
the disease.
■ Provide the following patient
teaching:
■ Take safety precautions,
including changing position slowly
and avoiding driving and
hazardous tasks, if CNS effects
occur.
■ Take the drug with meals and try
small, frequent meals if GI upset is
a problem.
■ Follow drug dosing guidelines
carefully.
■ Report severe GI problems and
interference with nutrition; fever
and chills, which may indicate the
presence of a superinfection, and
dizziness, unusual fatigue, or
weakness, which may indicate CNS
effects.
INTESTINE-INVADING WORM INFECTIONS
Infections by Nematodes
Pinworm Infections
Whipworm Infections
Threadworm Infestation
Ascaris
Hookworm Infections
Infections Caused by Platyhelminths
Cestodes
Tissue-Invading Worm Infections
Trichinosis
Nematodes, or roundworms, include the commonly encountered pinworms, whipworms, threadworms, Ascaris, and hookworms.
These worms cause diseases that range from mild to potentially fatal.
Pinworms are usually transmitted when the worm eggs are ingested, either by transfer by touching the eggs when they are shed to
clothing, toys, or bedding; or by the inhalation of eggs that become airborne and are then swallowed. Pinworms, which remain in the
intestine, cause little discomfort except for perianal itching or occasionally vaginal itching. Infection with pinworms is the most common
helminthic infection among schoolaged children
Whipworms are transmitted when eggs found in the soil are ingested. Whipworms attach to the wall of the colon. In large numbers, they
cause colic and bloody diarrhea. In severe cases, whipworm infestation may result in prolapse of the intestinal wall and anemia related to
blood loss.
Threadworms can cause more damage to humans than most of the other helminths. Threadworms are transmitted as larvae found in the
soil and inadvertently ingested. The larvae mature into worms, and, after burrowing into the wall of the small intestine, female worms
lay eggs. These eggs hatch into larvae that invade many body tissues, including the lungs, liver, and heart. In very severe cases, death
may occur from pneumonia or from lung or liver abscesses that result from larval invasion.
Worldwide, Ascaris infection is the most prevalent helminthic infection. It may occur wherever sanitation is poor. Eggs in the soil are
ingested with vegetables or other improperly washed foods. Many individuals are unaware that they have this infestation unless they see
a worm in their stool. However, others become quite ill. Initially, the individual ingests fertilized roundworm eggs, which hatch in the
small intestine and then make their way to the lungs, where they may cause cough, fever, and other signs of a pulmonary infiltrate. The
larvae then migrate back to the intestine, where they grow to adult size (i.e., about as long and as big around as an earthworm), causing
abdominal distention and pain. In the most severe cases, intestinal obstruction by masses of worms can occur.
Hookworms eggs are found in the soil, where they hatch into a larva that molts and becomes infective to humans. The larvae penetrate
the skin and then enter the blood and within about a week reach the intestine. Hookworms attach to the small intestine of infected
individuals. The worms suck blood from the walls of the intestine, damaging the intestinal wall and leading to severe anemia with
lethargy, weakness, and fatigue. Malabsorption problems may occur as the small intestinal mucosa is altered. Treatment for anemia and
fl uid and electrolyte disturbances is an important part of the therapy for this infection
The platyhelminths (fl atworms) include the cestodes (tapeworms) that live in the human intestine and the flukes (schistosomes) that live
in the intestine and also invade other tissues as part of their life cycle. Because schistosomes invade tissues, they are discussed in the
following section on tissue-invading worm infections.
Cestodes are segmented flatworms with a head, or scolex, and a variable number of segments that grow from the head. Cestodes enter
the body as larvae that are found in undercooked meat or fish; they sometimes form worms that are several yards long. Persons with a
tapeworm may experience some abdominal discomfort and distention, as well as weight loss because the worm eats ingested nutrients.
Many infected patients require a great deal of psychological support when they excrete parts of the tapeworm or when the worm
occasionally exits through the mouth or nose.
Some of the worms that invade the body exist outside of the intestinal tract and can seriously damage the tissues they invade.
Because of their location within healthy tissue, they can also be more difficult to treat.
Trichinosis is the disease caused by ingestion of the encysted larvae of the roundworm, Trichinella spiralis, in undercooked pork.
Once ingested, the larvae are deposited in the intestinal mucosa, pass into the bloodstream, and are carried throughout the body.
 They can penetrate skeletal muscle and can cause an inflammatory reaction in cardiac muscle and in the brain. Fatal pneumonia,
heart failure, and encephalitis may occur. The best treatment for trichinosis is prevention. Because the larvae are ingested by
humans in undercooked pork, freezing pork meat, monitoring the food eaten by pigs, and instructing individuals about properly
cooking pork can be most beneficial
Filariasis Filariasis refers to infection of the blood and tissues of healthy individuals by worm embryos, which enter the body via insect
bites. These thread-like embryos, or filariae, can overwhelm the lymphatic system and cause massive inflammatory reactions.
This may lead to severe swelling of the hands, feet, legs, arms, scrotum, or breast—a condition called elephantiasis.
Schistosomiasis Schistosomiasis is a platyhelminthic infection by a fluke that is carried by a snail. This disease is a common problem in parts of
Africa, Asia, and certain South American and Caribbean countries that have climates and snails conducive to the life cycle of
schistosomes. Eggs that are excreted in the urine and feces of infected individuals hatch in fresh water into a form that infects a
certain snail. In the snail, larvae known as cercariae develop. The snail sheds the cercariae back into the freshwater pond or lake.
People become infected when they come in contact with the infested water. The larvae attach to the skin and quickly burrow into
the bloodstream and lymphatics. Then they move into the lungs, and later to the liver, where they mature into adult worms that
mate and migrate to the intestines and urinary bladder. The female worms then lay large numbers of eggs, which are expelled in
the feces and urine, and the cycle begins again. Signs and symptoms may include a pruritic rash, often called swimmer’s itch,
where the larva attaches to the skin. About 1 or 2 months later, affected individuals may experience several weeks of fever,
chills, headache, and other symptoms. Chronic or severe infestation may lead to abdominal pain and diarrhea, as well as
blockage of blood fl ow to areas of the liver, lungs, and CNS. These blockages can lead to liver and spleen enlargement, as well
as signs of CNS and cardiac ischemia.

ANTIHELMENT Therapeutic Actions Pharmacokinetics Assessment: History and Nursing Diagnoses Implementation with Rationale Evaluation
IC AGENTS and Indications Examination
Anthelmintics Anthelmintic agents Mebendazole is available ■ Assess for possible Nursing diagnoses ■ Arrange for appropriate culture ■ Monitor patient
The anthelmintic are indicated for the in the form of a chewable contraindications or related to drug and sensitivity tests before response to the drug
drugs act on treatment of tablet, and a typical 3-day cautions: history of allergy therapy might beginning therapy to ensure (resolution of helminth
metabolic infections by certain course can be repeated in to any of the anthelmintics include: identification of the correct cause infestation and
pathways that are susceptible worms 3 weeks if needed. Very to avoid hypersensitivity ■ Acute Pain and use of the appropriate drug. improvement in signs
present in the and are very specific little of the mebendazole reactions; history of hepatic related to ■ Administer the complete course and symptoms).
invading worm but in the worms that is absorbed systemically, or renal dysfunction that gastrointestinal of the drug to obtain the full ■ Monitor for adverse
are absent or they affect; they are so adverse effects are few. might interfere with drug (GI), central beneficial effects. Ensure that effects (changes in
significantly not interchangeable The drug is not metabolism and excretion nervous system chewable tablets are chewed. Give orientation and affect,
different in the for treating various metabolized in the body, of the drug; and current (CNS), or skin the drug with food if necessary, but nutritional state, skin
human host. worm infections. and most of it is excreted status related to pregnancy effects of drug avoid giving the drug with high-fat color and evidence of
unchanged in the feces. A and lactation, which are ■ Disturbed meals, which might interfere with lesions, hepatic and
Anthelmintic drugs Anthelmintics small amount may be contraindications to the use Personal Identity drug effectiveness. renal function, and
include interfere with excreted in the urine. of these drugs. related to diagnosis ■ Monitor hepatic and renal reports of abdominal
=albendazole metabolic processes Albendazole is poorly ■ Perform a physical and treatment function before and periodically discomfort and pain).
=ivermectin in particular worms, absorbed from the GI assessment to establish ■ Deficient during treatment to allow for early ■ Evaluate the
=mebendazole as described tract, reaching peak baseline data for Knowledge identification and prompt effectiveness of the
=praziquantel previously. plasma levels in about 5 determining the regarding drug intervention if signs of failure due teaching plan (patient
=pyrantel hours. It is metabolized in effectiveness of the drug therapy to albendazole administration can name the drug,
the liver and primarily
excreted in urine.
Ivermectin is readily
absorbed from the GI tract
and reaches peak plasma
levels in 4 hours. It is
completely metabolized in
the liver with a half-life of
16 hours; excretion is
through the feces.
Praziquantel is taken in a
series of three oral doses
at 4- to 6-hour intervals. It
is rapidly absorbed from
the GI tract and reaches
peak plasma levels within
1 to 3 hours. It is
metabolized in the liver
with a half-life of 0.8 to
1.5 hours. Excretion of
praziquantel occurs
primarily through the
urine.
Pyrantel is poorly
absorbed, and most of the
drug is excreted
unchanged in the feces,
although a small amount
may be found in the urine.
and the occurrence of any
adverse effects associated
with drug therapy.
■ Obtain a culture of stool
for ova and parasites to
determine the infecting
worm and establish
appropriate treatment.
■ Examine reflexes and
muscle strength to evaluate
changes that occur as a
result of drug therapy.
■ Evaluate liver function
and renal function tests to
determine appropriateness
of therapy and to monitor
for toxicity.
■ Examine skin, including
color, temperature, and
texture, and note any
lesions to assess for
possible adverse effects.
■ Assess the abdomen to
evaluate for any changes
from baseline related to the
infection, identify possible
adverse effects, and
monitor for improvement.
occur. dosage, possible adverse
■ Provide comfort and safety effects to watch for, and
measures if CNS effects occur (e.g., specific measures to help
side rails and assistance with avoid adverse effects).
ambulation in the presence of ■ Monitor the
dizziness and weakness) to protect effectiveness of comfort
the patient from injury. Provide oral and safety measures and
hygiene and ready access to compliance with the
bathroom facilities as needed to regimen.
cope with GI effects.
■ Provide small, frequent,
nutritious meals if GI upset is
severe to ensure adequate nutrition.
Monitor nutritional status and
arrange a dietary consultation as
needed. Taking the drug with food
may also decrease GI upset.
■ Instruct the patient about the
appropriate dosage regimen and
other measures to enhance patient
knowledge about drug therapy and
to promote compliance
■ Provide the following patient
teaching:
■ Take safety precautions,
including changing position slowly
and avoiding driving and hazardous
tasks, if CNS effects occur.
■ Take the drug with meals and try
small, frequent meals if GI upset is
a problem.
■ Identify the importance of strict
hand washing and hygiene
measures, including daily
laundering of underwear and bed
linens, daily disinfection of toilet
facilities, and periodic disinfection
of bathroom floors
■ Report fever, severe diarrhea, or
aggravation of condition, which
could indicate a resistant strain or
noneffective therapy, to a health
 care provider.

ANTINEOPLASTIC drug used to combat cancer or the growth of neoplasms

AGENT:
NEOPLASM: new or cancerous growth; occurs when abnormal cells have the opportunity to multiply and grow
CANCER Cancer is a disease that can strike a person at any age. It remains second only to coronary disease as the leading cause of death in the United States. Treatment of
cancer can be prolonged and often debilitating. The patient can experience numerous and wide-ranging complications and effects.
■ Cancers arise from a single abnormal cell that multiplies and grows.
■ Cancer cells lose their normal function (anaplasia), develop characteristics that allow them to grow in an uninhibited way (autonomy), and have the ability to
travel to other sites in the body that are conducive to their growth (metastasis). They also have the ability to grow new blood vessels to feed the tumor
(angiogenesis)
METASTASIS: ability to enter the circulatory or lymphatic system and travel to other areas of the body that are conducive to growth and survival; property of cancer cells
Types of Cancer Cancers can be divided into two groups:
(1) Solid tumors - Solid tumors may originate in any body organ and may be further divided into carcinomas, or tumors that originate in epithelial cells, and
sarcomas, or tumors that originate in the mesenchyme and are made up of embryonic connective tissue cells. Examples of carcinomas include granular cell tumors
of the breast, bronchogenic tumors arising in cells that line the bronchial tubes, and squamous and basal tumors of the skin. Sarcomas include osteogenic tumors,
which form in the primitive cells of the bone, and rhabdomyosarcomas, which occur in striated muscles.
(2) Hematological malignancies such as the leukemias and lymphomas, which occur in the blood-forming organs. Hematological malignancies involve the blood-
forming organs of the body, the bone marrow, and the lymphatic system. These malignancies alter the body’s ability to produce and regulate the cells found in the
blood.
Causes of Cancer  What causes the cells to mutate and become genetically different is not clearly understood.
 In some cases, a genetic predisposition to such a mutation can be found. Breast cancer, for example, seems to have a definite genetic link.
 In other cases, viral infection, constant irritation and cell turnover, and even stress have been blamed for the ensuing cancer. Stress reactions suppress the
activities of the immune system, so if a cell is mutating while a person is under prolonged stress, research suggests that the cell has a better chance of
growing into a neoplasm than when the person’s immune system is fully active.
 Pipe smokers are at increased risk for development of tongue and mouth cancers because the heat of the pipe and chemicals in the pipe tobaccos and smoke
continuously destroy normal cells, which must be replaced rapidly, increasing the chances for development of a mutant cell.
 People living in areas with carcinogenic or cancer-causing chemicals in the air, water, or even the ground are at increased risk of developing mutant cells in
response to exposure to these toxic chemicals. Cancer clusters are often identified in such high-risk area.
 Not everyone exposed to carcinogens or undergoing stress or having a genetic predisposition to develop cancer actually develops cancer. Researchers have
not discovered what the actual trigger for cancer development is or what protective abilities some people have that other people lack. Most likely, a mosaic
of factors coming together in one person leads to development of the neoplasm.
■ The goal of cancer chemotherapy is to decrease the size of the neoplasm so that the human immune system can deal with it.
ANTINEOPLASTIC Therapeutic Pharmacokinetics Assessment: History and Nursing Diagnoses Implementation With Rationale Evaluation
DRUGS Actions and Examination
Indications
1. ALKYLATING Alkylating agents The alkylating agents ■ Assess for Nursing diagnoses ■ Arrange for blood tests before, ■ Monitor patient
AGENTS produce their vary in their degree of contraindications or related to drug periodically during, and for at least response to the drug
Because alkylating cytotoxic effects absorption, and little is cautions: history of allergy therapy might 3 weeks after therapy to monitor (alleviation of cancer
agents can affect cells by reacting known about their to any of the alkylating include the bone marrow function to aid in being treated, palliation
even in the resting chemically with distribution in the tissues. agents to avoid following: ■ Acute determining the need for a change of signs and symptoms
phase, these drugs are portions of the They are metabolized and hypersensitivity reactions; Pain related to GI, in dose or discontinuation of the of cancer). ■ Monitor
said to be non–cell RNA, DNA, or sometimes activated in bone marrow suppression CNS, and skin drug for adverse effects (bone
cycle specific. They are other cellular the liver, with many of to prevent further effects of the drug ■ Administer medication according marrow suppression, GI
most useful in the proteins, being these agents using the suppression; renal or ■ Disturbed Body to scheduled protocol and in toxicity, and
treatment of slow- most potent when cytochrome P450 hepatic dysfunction that Image related to combination with other drugs as neurotoxicity, and
growing cancers, which they bind with systems. They are might interfere with drug alopecia, skin indicated to improve effectiveness. alopecia, renal or
have many cells in the cellular DNA. The excreted in the urine. metabolism and excretion; effects, impaired ■ Ensure that the patient is well hepatic dysfunction). ■
resting phase. oldest drugs in this and current status related to fertility hydrated to decrease risk of renal Evaluate the
class are the pregnancy or lactation to ■ Imbalanced toxicity. effectiveness of the
Alkylating agents nitrogen mustards, prevent potentially serious Nutrition, less than ■ Protect the patient from exposure teaching plan (patient
include the following and modifications adverse effects on the fetus body requirements to infection; limit invasive can name the drug,
drugs: =altretamine of the structure of or nursing baby. ■ Risk for Infection procedures when bone marrow dosage, possible adverse
=bendamustine these drugs have ■ Perform a physical ■ Fear, Anxiety suppression limits the patient’s effects to watch for, and
=carboplatin led to the assessment to establish related to diagnosis immune/ inflammatory responses. specific measures to
=carmustine development of the baseline data for and treatment ■ Provide small, frequent meals, help avoid adverse
=chlorambucil nitrosoureas. determining the ■ Deficient frequent mouth care, and dietary effects).
=cyclophosphamide These drugs are effectiveness of the drug Knowledge consultation as appropriate to
=dacarbazine most useful in the and the occurrence of any regarding drug maintain nutrition when GI effects
=ifosfamide =lomustine treatment of slow- adverse effects associated therapy are severe. Anticipate the need for
=mechlorethamine growing cancers with drug therapy. antiemetics if necessary
=melphalan such as various ■ Assess orientation and ■ Arrange for proper head covering
=oxaliplatin lymphomas, reflexes to evaluate any at extremes of temperature if
=procarbazine leukemias, central nervous system alopecia occurs; a wig, scarf, or hat
=streptozocin myelomas, some (CNS) effects; respiratory is important for maintaining body
=temozolomide ovarian, testicular, rate and adventitious temperature. If alopecia is an
=thiotepa and breast cancers, sounds to monitor the anticipated effect of drug therapy,
and some disease and to evaluate for advice the patient to obtain a wig or
pancreatic cancers. respiratory or head covering before the condition
hypersensitivity effects; occurs to promote self-esteem and
pulse, rhythm, and a positive body image.
auscultation to monitor for ■ Provide patient teaching about
systemic or cardiovascular the following:
effects; and bowel sounds ■ Follow the appropriate dosage
and mucous membrane regimen, including dates to return
status to monitor for for further doses.
gastrointestinal (GI) ■ Cover the head at extremes of
effects. temperature.
■ Monitor the results of ■ Maintain nutrition if GI effects
laboratory tests such as are severe.
complete blood count with ■ Avoid exposure to infection.
differential to identify ■ Plan for appropriate rest periods
possible bone marrow because fatigue and weakness are
suppression and toxic drug common effects of the drugs.
effects and establish ■ Consult with a health care
appropriate dosing for the provider, if appropriate, related to
drug; and renal and liver the possibility of impaired fertility.
function tests to determine ■ Use barrier contraceptives to
need for possible dose reduce the risk of pregnancy during
adjustment and identify therapy.
toxic drug effects.
2.ANTIMETABOLIT Antimetabolites Methotrexate is absorbed ■ Assess for ■ Acute Pain ■ Arrange for blood tests to Monitor patient
ES inhibit DNA well from the GI tract and contraindications and related to GI, CNS, monitor bone marrow function response to the drug
Antimetabolites are production in cells is excreted unchanged in cautions: history of allergy or skin effects of before, periodically during, and for (alleviation of cancer
drugs that have that depend on the urine. Patients with to the specific the drug at least 3 weeks after therapy to being treated, palliation
chemical structures certain natural renal impairment may antimetabolite to avoid ■ Disturbed Body arrange to discontinue the drug or of signs and symptoms
similar to those of metabolites to require reduced dose and hypersensitivity reactions; Image related to reduce the dose as needed of cancer, palliation of
various natural produce their increased monitoring bone marrow suppression alopecia, skin ■ Administer medication according rheumatoid arthritis or
metabolites that are DNA. They when taking to prevent further effects, impaired to the scheduled protocol and in psoriasis).
necessary for the replace these methotrexate. suppression; renal or fertility combination with other drugs as ■ Monitor for adverse
growth and division of needed metabolites Methotrexate readily hepatic dysfunction that ■ Fear, Anxiety indicated to improve the effects (bone marrow
rapidly growing and thereby crosses the blood–brain might interfere with drug related to diagnosis effectiveness of drug therapy. suppression, GI toxicity,
neoplastic cells and prevent normal barrier. metabolism and excretion; and treatment ■ Ensure that the patient is well neurotoxicity, and
normal cells. cellular function. current status related to ■ Imbalanced hydrated to decrease the risk of alopecia, renal or
Many of these Cytarabine, clofarabine, pregnancy or lactation to Nutrition, less than renal toxicity. hepatic dysfunction).
Antimetabolites agents inhibit floxuridine, fluorouracil, prevent potentially serious body requirements ■ Provide small, frequent meals, ■ Evaluate the
include: =capecitabine thymidylate gemcitabine, effects to the fetus or ■ Risk for Infection frequent mouth care, and dietary effectiveness of the
=clofarabine synthetase, DNA floxuridine, nursing baby; and a history ■ Deficient consultation as appropriate to teaching plan (patient
=floxuridine polymerase, or pralatrexate, and of gastrointestinal (GI) Knowledge maintain nutrition when GI effects can name the drug,
=fludarabine folic acid pemetrexed are not ulcerative disease, which regarding drug are severe. Anticipate the use of dosage, possible adverse
=fluorouracil reductase, all of absorbed well from the GI could be exacerbated with therapy antiemetics as necessary effects to watch for, and
=gemcitabine which are needed tract and need to be the use of these drugs. ■ Arrange for proper head covering specific measures to
=mercaptopurine for DNA synthesis. administered parenterally. ■ Perform a physical at extremes of temperature if help avoid adverse
=methotrexate They are They are metabolized in assessment to establish alopecia occurs; a wig, scarf, or hat effects).
=pemetrexed considered to be S the liver and excreted in baseline data for is important for maintaining body ■ Monitor the
=pentostatin phase specific in the urine, necessitating determining the temperature. If alopecia is an effectiveness of comfort
=pralatrexate the cell cycle. close monitoring of effectiveness of the drug anticipated effect of drug therapy, and safety measures and
=thioguanine They are most patients with hepatic or and the occurrence of any advice the patient to obtain a wig or compliance with the
effective in rapidly renal impairment who are adverse effects associated head covering before the condition regimen.
dividing cells, receiving these drugs. with drug therapy. occurs to promote self-esteem and
preventing cell Mercaptopurine and ■ Assess orientation and a positive body image.
replication, and thioguanine are absorbed reflexes to evaluate any ■ Protect the patient from exposure
leading to cell slowly from the GI tract central nervous system to infections because bone marrow
death The and are metabolized in the (CNS) effects; respiratory suppression will limit immune/
antimetabolites are liver and excreted in the rate and adventitious inflammatory responses.
indicated for the urine. sounds to monitor the ■ Provide support and
treatment of disease and to evaluate for encouragement to help the patient
various leukemias respiratory or cope with the diagnosis and the
and some GI and hypersensitivity effects; effects of drug therapy.
basal cell cancers. pulse, rhythm, and cardiac ■ Provide the following patient
Use of these drugs auscultation to monitor for teaching:
has been systemic or cardiovascular ■ Follow the appropriate dosage
somewhat limited effects; and bowel sounds regimen, including dates to return
because neoplastic and mucous membrane for further doses. Patients needed to
cells rapidly status to monitor for GI be reminded to report all other
develop resistance effects. drugs and alternative therapies that
to these agents. ■ Monitor the results of they might be using.
For this reason, laboratory tests such as ■ Maintain nutrition if GI effects
these drugs are complete blood count with are severe.
usually differential to identify ■ Cover the head at extremes of
administered as possible bone marrow temperature if alopecia is
part of a suppression and toxic drug anticipated.
combination effects; and renal and liver ■ Plan for appropriate rest periods
therapy. function tests to determine because fatigue and weakness are
the need for possible dose common effects of the drugs.
adjustment and toxic drug ■ Avoid situations that might lead
effects. to infection, including crowded
 places, sick people, and working in
the soil.
■ Use safety measures such as not
driving or using dangerous
equipment, due to possible
dizziness, headache, and
drowsiness.
■ Think about consulting with a
health care provider, if appropriate,
due to the possibility of impaired
fertility.
■ Use barrier contraceptives to
reduce the risk of pregnancy during
therapy.
3. Some The antineoplastic ■ Assess for ■ Acute Pain ■ Arrange for blood tests to ■ Monitor patient
ANTINEOPLASTIC antineoplastic antibiotics are not contraindications and related to GI, CNS, monitor bone marrow function response to the drug
ANTIBIOTICS antibiotics break absorbed well from the cautions: history of allergy or local effects of before, periodically during, and for (alleviation of cancer
Antineoplastic up DNA links, and GI tract. They are given to the antibiotic in use to the drug at least 3 weeks after therapy to being treated and
antibiotics although others prevent intravenously (IV) or avoid hypersensitivity ■ Disturbed Body arrange to discontinue the drug or palliation of signs and
selective for bacterial DNA synthesis. injected into specific reactions; bone marrow Image related to reduce the dose as needed. symptoms of cancer).
cells, are also toxic to The antineoplastic sites. They are suppression to prevent alopecia or skin ■ Monitor cardiac and respiratory ■ Monitor for adverse
human cells. Because antibiotics are metabolized in the liver further suppression; renal effects function, as well as clotting times effects (bone marrow
these drugs tend to be cytotoxic and and excreted in the urine or hepatic dysfunction that ■ Imbalanced as appropriate for the drug being suppression, GI toxicity,
more toxic to cells that interfere with at various rates. Many of might interfere with drug Nutrition, less than used, to arrange to discontinue the neurotoxicity, alopecia,
are multiplying rapidly, cellular DNA them have very long half- metabolism and excretion; body requirements drug or reduce the dose as needed. renal or hepatic
they are more useful in synthesis by lives (e.g., 45 hours for respiratory or cardiac ■ Risk for Infection ■ Protect the patient from exposure dysfunction, and cardiac
the treatment of certain inserting idarubicin; more than 5 disease that could be ■ Fear, Anxiety to infection because bone marrow or respiratory
cancers. themselves days for mitoxantrone). further aggravated by the related to diagnosis suppression will decrease immune/ dysfunction).
between base pairs Daunorubicin and toxic effects of these drugs; and treatment inflammatory reactions. ■ Evaluate the
Antineoplastic in the DNA chain. doxorubicin do not cross current status related to ■ Deficient ■ Administer medication according effectiveness of the
antibiotics include: This, in turn, the blood–brain barrier, pregnancy or lactation to Knowledge to scheduled protocol and in teaching plan (patient
=bleomycin causes a mutant but they are widely prevent potentially serious regarding drug combination with other drugs as can name the drug,
=dactinomycin DNA molecule, distributed in the body adverse effects to the fetus therapy indicated to improve the dosage, possible adverse
=daunorubicin leading to cell and are taken up by the or nursing baby; and effectiveness of drug therapy. effects to watch for, and
=doxorubicin death. Like other heart, lungs, kidneys, and gastrointestinal (GI) ■ Ensure that the patient is well specific measures to
=mitomycin antineoplastics, the spleen. This can lead to ulcerative disease, which hydrated to decrease the risk of help avoid adverse
=mitoxantrone main adverse toxic effects in these could be exacerbated by renal toxicity. effects).
=valrubicin effects of these organs. these drugs. ■ Provide small, frequent meals,
drugs are seen in ■ Perform a physical frequent mouth care, and dietary
cells that multiply assessment to establish consultation appropriate to
rapidly, such as baseline data for maintain nutrition when GI effects
those in the bone determining the are severe. Anticipate the need for
 marrow, GI tract, effectiveness of the drug
and skin. Their and the occurrence of any
potentially serious adverse effects associated
adverse effects with drug therapy.
may limit their ■ Assess orientation and
usefulness in reflexes to evaluate any
patients with central nervous system
preexisting (CNS) effects; respiratory
diseases and in rate and adventitious
those who are sounds to monitor the
debilitated and, disease and evaluate for
therefore, more respiratory or
susceptible to hypersensitivity effects;
these effects. pulse, rhythm, cardiac
auscultation, and baseline
electrocardiogram to
monitor for systemic or
cardiovascular effects; and
bowel sounds and mucous
membrane status to monitor
for GI effects.
■ Monitor the results of
laboratory tests such as
complete blood count with
differential to identify
possible bone marrow
suppression and toxic drug
effects, as well as renal and
liver function tests, to
determine the need for
possible dose adjustment.
4. MITOTIC The mitotic Generally, these drugs are ■ Assess for
INHIBITORS inhibitors interfere given intravenously contraindications or
Mitotic inhibitors are with the ability of because they are not well cautions: history of allergy
antiemetics as necessary
■ Arrange for proper head covering
at extremes of temperature if
alopecia occurs; a wig, scarf, or hat
is important for maintaining body
temperature. If alopecia is an
anticipated effect of drug therapy,
advice the patient to obtain a wig or
head covering before the condition
occurs to promote self-esteem and
a positive body image.
■ Provide the following patient
teaching:
■ Follow the appropriate dosage
regimen, including dates to return
for further doses.
■ Maintain nutrition if GI effects
are severe.
■ Cover the head at extremes of
temperature if alopecia is
anticipated.
■ Plan for appropriate rest periods
because fatigue and weakness are
common effects of the drugs.
■ Avoid exposure to possible
infection, including avoiding
crowded places, sick people, and
working in soil.
■ Use safety measures such as
avoiding driving or using
dangerous equipment to prevent
injury due to possible dizziness,
headache, and drowsiness.
■ Consult with a health care
provider, if appropriate, regarding
possibility of impaired fertility.
■ Use barrier contraceptives to
reduce the risk of pregnancy
during therapy.
■ Acute Pain ■ Arrange for blood tests to ■ Monitor patient
related to GI, CNS, monitor bone marrow function response to the drug
or local effects of before, periodically during, and for (alleviation of cancer
drugs that kill cells as a cell to divide; absorbed from the GI to the drug used (or related the drug ■ at least 3 weeks after therapy to being treated and
the process of mitosis they block or alter tract. They are drugs) to avoid Disturbed Body arrange to discontinue the drug or palliation of signs and
begins These cell DNA synthesis, metabolized in the liver hypersensitivity reactions; Image related to reduce the dose as needed. symptoms of cancer).
cycle–specific agents thus causing cell and excreted primarily in bone marrow suppression alopecia, skin ■ Avoid direct skin or eye contact ■ Monitor for adverse
inhibit DNA synthesis. death. They work the feces, making them to prevent further effects ■ Risk for with the drug. Wear protective effects (bone marrow
Like other in the M phase of safer for use in patients suppression; renal or injury clothing and goggles while suppression, GI toxicity,
antineoplastics, the the cell cycle. with renal impairment hepatic dysfunction that ■ Fear, Anxiety preparing and administering the neurotoxicity, alopecia,
main adverse effects of These drugs are than the antineoplastics might interfere with drug related to diagnosis drug to prevent toxic reaction to the renal or hepatic
the mitotic inhibitors used for the that are cleared through metabolism and excretion; and treatment drug. dysfunction, and local
occur with cells that treatment of a the kidney. current status of pregnancy ■ Deficient ■ Administer medication according reactions at the injection
rapidly multiply: those variety of tumors or lactation to prevent Knowledge to scheduled protocol and in site).
in the bone marrow, GI and leukemias. potentially serious adverse regarding drug combination with other drugs as ■ Evaluate the
tract, and skin. effects on the fetus or therapy indicated to improve the effectiveness of the
nursing baby; and effectiveness of drug therapy. teaching plan (patient
Mitotic inhibitors gastrointestinal (GI) ■ Ensure that the patient is well can name the drug,
include: ulcerative disease, which hydrated to decrease the risk of dosage, possible adverse
=cabazitaxel could be exacerbated by renal toxicity. effects to watch for, and
=etoposide these drugs. ■ Monitor injection sites to arrange specific measures to
=ixabepilone ■ Perform a physical appropriate treatment for help avoid adverse
=paclitaxel =teniposide assessment to establish extravasation, local inflammation, effects).
=vinblastine baseline data for or cellulitis.
=vincristine determining the ■ Protect the patient from exposure
=vinorelbine effectiveness of the drug to infection because bone marrow
and the occurrence of any suppression will decrease immune/
adverse effects associated inflammatory responses.
with drug therapy. ■ Provide small, frequent meals,
■ Assess orientation and frequent mouth care, and dietary
reflexes to evaluate any consultation as appropriate to
central nervous system maintain nutrition if GI effects are
(CNS) effects; skin to severe. Anticipate the need for
evaluate for lesions; hair antiemetics as necessary
and hair distribution to ■ Arrange for proper head covering
monitor for adverse effects; at extremes of temperature if
respiratory rate and alopecia or epilation occurs; a wig,
adventitious sounds to scarf, or hat is important for
monitor the disease and to maintaining body temperature. If
evaluate for respiratory or alopecia is an anticipated effect of
hypersensitivity effects; drug therapy, advice the patient to
and bowel sounds and obtain a wig or head covering
mucous membrane status to before the condition occurs to
monitor for GI effects. promote self-esteem and a positive
■ Monitor the results of body image.
 laboratory tests such as ■ Provide the following patient
complete blood count with teaching:
differential to identify ■ Follow the appropriate dosage
possible bone marrow regimen, including dates to return
suppression and toxic drug for further doses.
effects; and renal and liver ■ Maintain nutrition if GI effects
function tests to determine are severe.
the need for possible dose ■ Plan for appropriate rest
adjustment as needed and periods because fatigue and
to evaluate toxic drug weakness are common effects of the
effects. drugs.
■ Regularly inspect IV ■ Avoid situations that might be
insertion sites for signs of lead to infection, including
extravasation or crowded areas, sick people, and
inflammation, which need working in the soil.
to be treated quickly. ■ Use safety measures such as
avoiding driving or using
dangerous equipment, due to
possible dizziness, headache, and
drowsiness.
■ Consult with a health care
provider, as appropriate, related to
the possibility of impaired fertility.
■ Use barrier contraceptives to
reduce the risk of pregnancy
during therapy
5. HORMONES AND The hormones and These drugs are readily Assess for ■ Acute Pain ■ Arrange for blood tests to ■ Monitor patient
HORMONE hormone absorbed from the GI contraindications or related to GI, CNS, monitor bone marrow function response to the drug
MODULATORS modulators used as tract, metabolized in the cautions: history of allergy or menopausal before and periodically during (alleviation of cancer
Some cancers, antineoplastics are liver, and excreted in the to the drug in use or any effects of the drug therapy to discontinue the drug or being treated and
particularly those receptor-site urine. Caution must be related drugs to avoid ■ Disturbed Body reduce the dose as needed palliation of signs and
involving the breast specific or used with any patient who hypersensitivity reactions; Image related to ■ Provide small, frequent meals, symptoms of cancer
tissue, ovaries, uterus, hormone specific has hepatic or renal bone marrow suppression antiestrogen frequent mouth care, and dietary being treated).
prostate, and testes, are to block the impairment. These drugs to prevent further effects, virilization consultation as appropriate to ■ Monitor for adverse
sensitive to estrogen stimulation of cross the placenta and suppression; renal or ■ Fear, Anxiety maintain nutrition when GI effects effects (bone marrow
stimulation. Estrogen- growing cancer enter into breast milk. hepatic dysfunction that related to diagnosis are severe. suppression, GI toxicity,
receptor sites on the cells that are might interfere with drug and treatment ■ Provide comfort measures to help menopausal signs and
tumor react with sensitive to the metabolism and excretion; ■ Deficient the patient cope with menopausal symptoms, hypercalcea,
circulating estrogen, presence of that current status of pregnancy Knowledge signs and symptoms such as and cardiovascular
and this reaction hormone These or lactation to prevent regarding drug hygiene measures, temperature effects).
stimulates the tumor drugs are indicated potentially serious adverse therapy control, and stress reduction. ■ Evaluate the
cells to grow and for the treatment of effects on the fetus or Expect to reduce the dose if these effectiveness of the
divide. breast cancer in nursing baby; history of effects become severe or teaching plan (patient
postmenopausal hypercalcemia and intolerable. can name the drug,
Hormones and women or in other hypercholesterolemia to ■ Advise the patient of the need to dosage, possible adverse
hormone modulators women without avoid further increases in use barrier contraceptive measures effects to watch for, and
include ovarian function. levels. while taking these drugs to avert specific measures to
=anastrazole Some drugs are ■ Perform a physical serious fetal harm. ■ Provide the help avoid adverse
=bicalutamide indicated for the assessment to establish following patient teaching: effects).
=degarelix treatment of baseline data for ■ Follow the appropriate dosage
=estramustine prostatic cancers determining the regimen, including dates to return
=exemestane that are sensitive to effectiveness of the drug for further doses.
=flutamide =fulvestrant hormone and the occurrence of any ■ Maintain nutrition even if GI
=goserelin manipulation. adverse effects associated effects are severe.
=histrelin Table 14.5 shows with drug therapy. ■ Use barrier contraceptives to
=letrozole usual indications ■ Assess orientation and prevent pregnancy during therapy
=leuprolide =megestrol for each of the reflexes to evaluate any ■ Try using comfort measures such
=mitotane =nilutamide hormones and central nervous system as staying in a cool environment.
=tamoxifen hormone (CNS) effects; skin to ■ Perform hygiene and skin care
=toremifene modulators. evaluate for lesions; hair and use measures to reduce stress
=triptorelin pamoate and hair distribution to to help cope with menopausal
monitor for adverse drug effects.
effects; blood pressure, ■ You may need to have periodic
pulse, and perfusion to blood tests to monitor the effects of
evaluate the status of the this drug on your body.
cardiovascular system and
monitor for adverse drug
effects; and bowel sounds
and mucous membrane
status to monitor for
gastrointestinal (GI)
effects.
■ Monitor the results of
laboratory tests such as
complete blood count with
differential to identify bone
marrow suppression and
toxic drug effects, serum
calcium levels to evaluate
for hypercalcemia, and
renal and liver function
tests to determine the need
for possible dose
adjustment to evaluate

CANCER CELL–SPECIFIC AGENTS
The goal of much of the current antineoplastic drug research is
directed at finding drugs that are cancer cell specific. These
drugs would not have the devastating effects on healthy cells
in the body and would be more effective against particular
cancer cells.
Three groups of drugs are available for cancer cell–specific
actions:
protein tyrosine kinase inhibitors, an epidermal growth
factor inhibitor, and a proteasome inhibitor
a. PROTEIN TYROSINE KINASE INHIBITORS
The protein kinase inhibitors act on specific enzymes that are
needed for protein building by specific tumor cells. Blocking
of these enzymes inhibits tumor cell growth and division.
Each drug that has been developed inhibits a very specific
protein kinase and acts on very specific tumors.
=They do not affect healthy human cells, so the patient does
not experience the numerous adverse effects associated with
antineoplastic chemotherapy.
=Imatinib (Gleevec), the first drug approved in this class, is
given orally and is approved to treat chronic myelocytic
leukemia (CML). Patients who have CML and who have been
switched to imatinib after traditional chemotherapy have been
amazed at how good they feel and how much they have
recovered from the numerous adverse effects of the traditional
chemotherapy. Long-term effects are not yet known because
the drug is relatively new.
=The protein tyrosine kinase inhibitors that are available
include everolimus (Afi nitor), gefitinib (Iressa), imatinib
(Gleevec), lapatinib (Tykerb), nilotinib (Tasigna), pazopanib
(Vorient), sorafenib (Nexavar), sunitinib (Sutent), and
temsirolimus (Torisel).
toxic drug effects. See the
Critical Thinking Scenario
for a full discussion of
assessing and evaluating
antineoplastic therapy for a
patient with breast cancer.
Imatinib is an oral antineoplastic drug is a protein tyrosine
kinase inhibitor that selectively inhibits the Bcr-Abl tyrosine
kinase created by the Philadelphia chromosome abnormality
in CML. Blocking this enzyme inhibits proliferation and
induces cell division in Bcr-Abl–positive cell lines, as well as
in new leukemic cells, thereby inhibiting tumor growth in
CML patients in blast crisis. It also inhibits a specific receptor
site in gastrointestinal stromal tumor patients. Because of its
specific effects on these tumor cells, it is not associated with
adverse effects on normal human cells. Gefitinib, lapatinib,
nilotinib, pazopanib, sorafenib, sunitinib, and temsirolimus
work by inhibiting various kinases in the cancer cell
Imatinib is slowly absorbed from the GI tract, reaching peak
levels in 2 to 4 hours. It is extensively metabolized in the liver,
with a half-life of 18 and then 40 hours. Gefi tinib is slowly
absorbed from the GI tract, reaching peak levels in 3 to 7
hours. It is metabolized in the liver with a half-life of 48
hours. Lapatinib, given orally, is absorbed from the GI tract,
reaching peak levels in 1 to 1.5 hours. Lapatinib is
metabolized in the liver, with a half-life of 24 hours. Nilotinib,
given orally, reach peak levels in 3 hours after GI absorption.
Most of the drug is excreted unchanged in the stool with a
half-life of 17 hours. Pazopanib is given orally, reaching peak
levels in 2 to 4 hours; it is metabolized in the liver and
excreted in the feces, with a half-life of 30/9 hours. Sorafenib
is well absorbed from the GI tract after oral administration,
reaching peak levels in 1 to 2 hours. Most of the drug is
excreted unchanged in the stool with a half-life of 24 to 48
hours. Sunitinib, given orally, is slowly absorbed from the GI
tract, reaching peak levels in 6 to 12 hours. After metabolism
in the liver, it has a half-life of 40 to 60 hours and then 80 to
110 hours for its active metabolite. Temsirolimus, only
available for IV use, reaches peak levels at the end of the
infusion. It is metabolized in the liver and primarily excreted
 in the feces with a half-life of 17 hours and then 55 hours for
its active metabolite. Erlotinib is well absorbed orally from the
GI tract, reaching peak levels in 4 hours. It is metabolized in
the liver with a half-life of 36 hours. Bortezomib, given IV,
reaches peak effects at the end of the infusion. It is
metabolized in the liver and has a half-life of 40 to 193 hours.
b. EPIDERMAL GROWTH FACTOR INHIBITOR
In late 2004, the U.S. Food and Drug Administration (FDA)
approved erlotinib (Tarceva), a drug that inhibits cell
epidermal growth factor receptors. This growth factor is found
on normal and cancerous cells but is more abundant on rapidly
growing cells.

c. PROTEASOME INHIBITOR
In 2003, the FDA approved bortezomib (Velcade) for the
treatment of multiple myeloma in patients whose disease had
progressed after two other standard therapies. This drug
inhibits proteasome in human cells, a large protein complex
that works to maintain cell homeostasis and protein
production. Without it, the cell loses homeostasis and dies.
This drug was shown to delay growth in selected tumors.