Antiviral Agents
Chapter 39
I Viruses
A. Viral replication
1. a virus cannot replicate on its own
2. it must attach to and enter a host cell
3. it then uses the host cell’s energy to synthesize protein, DNA and RNA
B. Viruses are difficult to kill because they live inside our cells
1. any drug that kills a virus may also kill our cells
C. Viral infections
1. a competent immune system is the best way to treat viruses
2. a well functioning immune system will eliminate or effectively destroy virus replication
D. Immunocompromised pts have frequent viral infections
1. CA pts, esp leukemia or lymphoma
2. transplant pts, due to pharmacologic therapy
3. AIDS pts, disease attacks immune system
II Antivirals
A. Viruses killed by current antiviral therapy (killed does not mean cured...suppressed)
1. cytomegalovirus (CMV)
2. hepatitis viruses
3. herpes viruses
4. HIV
5. influenza viruses
6. respiratory syncytial virus (RSV)
B. Key characteristics of anitviral drugs
1. able to enter the cells infected with virus
2. interfere with viral nucleic acid synthesis and/or regulation
3. some agents interfere with ability of virus to bind to cells
4. some agents stimulate the body’s immune system
C. Antiviral medications
1. Antiviral agents
a. used to treat infections caused by viruses other than HIV
2. antiretroviral agents
a. used to treat infections caused by HIV, the virus that causes AIDS
b. HAART (cocktail 10- 30 k/year)
i. highly active antiretroviral therapy
ii. includes at least 3 meds
iii. these meds work in different ways to reduce the viral load
c. side effects
i. numerous and vary with each agent
ii. drug therapy may need to be modified b/c of side effects
iii. goal is to find the regimen that will best control the infection with a tolerable side effect profile
iv. medication regimens change during the course of the illness
III Side effects (antivirals)
A. Zidovudine (given during labor to HIV pts)
1. bone marrow suppression
2. nausea
3. headache
4. foscarnet
5. headache, seizures, acute renal failure, nausea, vomiting, diarrhea, others
B. Ganciclovir
1. bone marrow toxicity
2. n/v, anorexia
IV HIV
A. Human immunodeficiency virus infection
B. ELISA (enzyme-linked immunosorbent assay)
1. detects HIV exposure based on presence of human antibodies to the virus in the blood
C. retrovirus
D. transmitted by:
1. sexual activity
2. intravenous drug use
3. perinatally from mother to child
E. 5 stages of HIV infection
1. primary infection
2. asymptomatic infection
3. persistent generalized lymphadenopathy
4. symptomatic stage
5. progression to full blown aids
V Opportunistic Infections
A. protozoal
1. toxoplasmosis of the brain, others
B. fungal
1. candiadiasis of the lungs, esophagus, trachea
2. PCP, others
C. Viral
1. CMV disease
2. HSV infection, others
D. Bacterial
1. various mycobacterial infections
E. Opportunistic neoplasias
1. Kaposi’s sarcoma
F. others
Friday, August 8, 2008
Antitubercular
Antitubercular Drugs
Chapter 40
I Tuberculosis
A. Caused by Mycobacterium tuberculosis
1. aerobic bacillus
2. passed from infected:
a. humans
b. cows (bovine)
c. birds (avian)
B. Common infection sites
1. lung (primary)
2. brain
3. bone
4. liver
5. kidney
C. infections
1. tubercle bacilli are conveyed by droplets
2. droplets are expelled by coughing or sneezing, then gain entry into the body by inhalation.
3. tubercle bacilli then spread to other body organs via blood and lymphatic systems
4. tubercle bacilli may become dormant, or walled off by calcified or fibrous tissue
II Antitubercular Agents *used in combination
A. First line
1. isoniazid (most frequently used)
2. ethambutol
3. pyrazinamide (PZA)
4. rafampin
5. streptomycin
B. second line agents (b/c of resistance)
1. capreomycin
2. cycloserine
3. ethionamide
4. kanamycin
5. para-aminosalicyclic acid (PAS)
III Mechanism of action (3 groups)
A. Protein wall synthesis inhibitors
1. streptomycin
2. kanamycin
3. capreomycin
4. rifampin
5. rifabutin
B. Cell wall synthesis inhibitors
1. cycloserine
2. ethionamide
3. isoniazid
a. drug of choice for TB
b. restistant strains of Mycobacterium emerging
c. metabolized in the liver through acetylation – watch for “slow acetylators”
d. used alone or in combination with other agents
e. indications
i. used for the prophylaxis or treatment of TB (for 6 months)
C. Other mechanisms of action
IV Antitubucular therapy
A. Effectiveness depends on:
1. type of infection
2. adequate dosing
3. sufficient duration of treatment
4. drug compliance
5. selection of an effective drug combination
6. resistance and compliance are a big problem
B. Problems
1. drug-resistant organisms
a. multidrug-resistant TB (MDR-TB)
2. drug toxicity
3. patient noncompliance
V Side Effects
A. INH (Isoniazid)
1. peripheral neuritis (inflammation of nerve endings)
2. hepatotoxicity
B. Ethambutol
1. retrobulbar neuritis
2. blindness
C. Rifampin
1. hepatitis
2. discoloration of urine (red/orange) and stools
VI Nursing Implications
A. Obtain a thorough medical history and assessment
B. perform liver function studies in pts who are to receive isoniazid or rifampin (esp in elderly pts or those who use alcohol daily)
C. Discontinue meds when liver enzymes rise to 4x higher than baseline.
SGOT = liver test. Watch tylenol consumption (or anything liver altering)
D. Assess for contraindications to the various agents, conditions for cautious use, and potential drug interactions
E. Patient education is critical
1. therapy may last up to 24 months
2. take meds exactly as ordered, at the same time everyday
3. emphasize the importance of strict compliance to regimen for improvement of condition or cure
4. remind pts that they are contagious during the initial period of their illness. Instruct in proper hygiene and prevention of the spread of infected droplets
5. emphasize to pts to take care of themselves, including adequate nutrition and rest
F. pts should not consume alcohol while on these meds or take other meds including OTC, unless they check with their physician
G. diabetic pts taking INH should monitor blood glucose levels b/c hyperglycemia may occur
H. INH and rifampin cause oral contraceptives to become ineffective; another form of birth control will be needed
I. Pts who are taking rifampin should be told that their urine, stool, salive, sputum, sweat, or tears may become reddish/orange; even contact lenses may be stained.
J. pyridoxine MUST be given with INH therapy to combat neuroligic side effects
K. Oral preparations may be given with meals to reduce GI upset, even though recommendations are to take them 1 hour before or 2 hours after meals.
L. Monitor for side effects
1. instruct pts on the side effects that should be reported to the physician immediately
2. these include fatigue, nausea, vomiting, numbness and tingling of the extremities, fever, loss of appetite, depression, jaundice
M. Monitor for therapeutic effects
1. decrease in symptoms of TB, such as cough and fever
2. lab studies (c&S tests) and CXR should confirm clinical findings
3. watch for lack of clinical response to therapy, indicating possible drug resistance
Antitubercular agents treat all forms of Mycobacterium
Chapter 40
I Tuberculosis
A. Caused by Mycobacterium tuberculosis
1. aerobic bacillus
2. passed from infected:
a. humans
b. cows (bovine)
c. birds (avian)
B. Common infection sites
1. lung (primary)
2. brain
3. bone
4. liver
5. kidney
C. infections
1. tubercle bacilli are conveyed by droplets
2. droplets are expelled by coughing or sneezing, then gain entry into the body by inhalation.
3. tubercle bacilli then spread to other body organs via blood and lymphatic systems
4. tubercle bacilli may become dormant, or walled off by calcified or fibrous tissue
II Antitubercular Agents *used in combination
A. First line
1. isoniazid (most frequently used)
2. ethambutol
3. pyrazinamide (PZA)
4. rafampin
5. streptomycin
B. second line agents (b/c of resistance)
1. capreomycin
2. cycloserine
3. ethionamide
4. kanamycin
5. para-aminosalicyclic acid (PAS)
III Mechanism of action (3 groups)
A. Protein wall synthesis inhibitors
1. streptomycin
2. kanamycin
3. capreomycin
4. rifampin
5. rifabutin
B. Cell wall synthesis inhibitors
1. cycloserine
2. ethionamide
3. isoniazid
a. drug of choice for TB
b. restistant strains of Mycobacterium emerging
c. metabolized in the liver through acetylation – watch for “slow acetylators”
d. used alone or in combination with other agents
e. indications
i. used for the prophylaxis or treatment of TB (for 6 months)
C. Other mechanisms of action
IV Antitubucular therapy
A. Effectiveness depends on:
1. type of infection
2. adequate dosing
3. sufficient duration of treatment
4. drug compliance
5. selection of an effective drug combination
6. resistance and compliance are a big problem
B. Problems
1. drug-resistant organisms
a. multidrug-resistant TB (MDR-TB)
2. drug toxicity
3. patient noncompliance
V Side Effects
A. INH (Isoniazid)
1. peripheral neuritis (inflammation of nerve endings)
2. hepatotoxicity
B. Ethambutol
1. retrobulbar neuritis
2. blindness
C. Rifampin
1. hepatitis
2. discoloration of urine (red/orange) and stools
VI Nursing Implications
A. Obtain a thorough medical history and assessment
B. perform liver function studies in pts who are to receive isoniazid or rifampin (esp in elderly pts or those who use alcohol daily)
C. Discontinue meds when liver enzymes rise to 4x higher than baseline.
SGOT = liver test. Watch tylenol consumption (or anything liver altering)
D. Assess for contraindications to the various agents, conditions for cautious use, and potential drug interactions
E. Patient education is critical
1. therapy may last up to 24 months
2. take meds exactly as ordered, at the same time everyday
3. emphasize the importance of strict compliance to regimen for improvement of condition or cure
4. remind pts that they are contagious during the initial period of their illness. Instruct in proper hygiene and prevention of the spread of infected droplets
5. emphasize to pts to take care of themselves, including adequate nutrition and rest
F. pts should not consume alcohol while on these meds or take other meds including OTC, unless they check with their physician
G. diabetic pts taking INH should monitor blood glucose levels b/c hyperglycemia may occur
H. INH and rifampin cause oral contraceptives to become ineffective; another form of birth control will be needed
I. Pts who are taking rifampin should be told that their urine, stool, salive, sputum, sweat, or tears may become reddish/orange; even contact lenses may be stained.
J. pyridoxine MUST be given with INH therapy to combat neuroligic side effects
K. Oral preparations may be given with meals to reduce GI upset, even though recommendations are to take them 1 hour before or 2 hours after meals.
L. Monitor for side effects
1. instruct pts on the side effects that should be reported to the physician immediately
2. these include fatigue, nausea, vomiting, numbness and tingling of the extremities, fever, loss of appetite, depression, jaundice
M. Monitor for therapeutic effects
1. decrease in symptoms of TB, such as cough and fever
2. lab studies (c&S tests) and CXR should confirm clinical findings
3. watch for lack of clinical response to therapy, indicating possible drug resistance
Antitubercular agents treat all forms of Mycobacterium
Antifungal
Antifungal Drugs
Chapter 41
Mechanism of action
Drug effects
Indications
I Fungal Infections
A. Fungi: very large and diverse group of microorganisms that include all yeasts and molds.
1. yeasts:
a. single celled fungi
b. reproduce by budding.
c. also used for baking and alcoholic beverages
2. molds:
a. multicellular.
b. Characterized by long, branching filaments called hyphae.
B. fungal infections aka mycoses (mycotic infections)
1. cutaneous
2. subcutaneous
3. superficial
4. systemic
a. usually occur in an immunocomprimised host
b. can be life threatening
5. diseases
a. Candida albicans
i. due to antibiotic therapy, antineoplastics, or immunosuppressants (corticosteroids)
ii. may result in overgrowth and systemic infections
b. in the mouth
i. oral candidiasis or thrush
ii. newborn infants and immunocompromised patients
iii. contagious
c. vaginal candidiasis
i. “yeast infection”
ii. pregnancy, diabetes mellitus, oral contraceptives, antibiotics
C. some fungi are part of the normal flora of the skin, mouth, intestines, and vagina.
II Antifungal agents:
A. drugs used to treat infections caused by fungi
B. systemic work in the blood stream
C. topical work on the skin
D. broken down into major groups based on their mechanisms of action
E. Agents
1. Polyenes
a. amphotericin B
b. nystatin
2. flucytosine
3. imidazoles
a. ketoconazole
b. muconazole
c. clotrimazole
d. fluconazole
4. griseofulvin
5. allylmine
a. terbinafine
III Mechanism of Action
A. polyenes (amphotericin B and nystatin)
1. bind to sterols in cell membrane lining
2. result: fungal death
3. do not bind to human cell membranes or kill human cells
B. flucytosine
1. aka 5-fluorocytosine (antimetabolite)
2. taken up by fungal cells and interferes with DNA synthesis
3. result: fungal cell death
C. imidazoles (...azoles)
1. inhibit an enzyme, resulting in cell membrane leaking
2. lead to altered cell membrane
3. result: fungal death
D. Griseofulvin
1. disrupts cell division
2. result: inhibited fungal mitosis (reproduction)
IV Indications (systemic and topical fungal infections)
A. Choice of agent depends on type and location of infection
B. Agent of choice for the treatment of many severe systemic fungal infections is amphotericin B
V Side Effects
A. Amphotericin B “shake and bake”
1. fever
2. headache
3. chills
4. malaise
5. hypotension
6. muscle and joint pain
7. lowered potassium and magnesium levels
8. dysrhythmias
9. nausea
10. anorexia
11. main concern is renal toxicity (b/c renally eliminated)
12. neurotoxicity: seizures and paresthesias
B. fluconazole
1. nausea, vomiting, diarrhea, stomach pain
2. increased liver function studies
C. flucytosine
1. n/v, anorexia, headache, dizziness, others
D. griseofulvin
1. rash, urticaria, headache, n/v, anorexia, others
VI Nursing Implications
A. Before beginning therapy, assess for hypersensitivity, possible contraindications, and conditions that require cautious use.
B. Obtain baseline VS, CBC, liver function studies, and ECG
C. Assess for other medcations used (prescribed and OTC) in order to avoid drug interactions.
D. Follow manufacturer’s directions carefully for reconstitution and admin.
E. Monitor VS’s op patients receiving IV infusions every 15 – 30 minutes
F. During IV infusions, monitor I & O and urinalysis findings to identify adverse renal effects.
G. Amphotericin B
a. to reduce the severity of the infusion-related reactions, pretreatment with an antipyretic (acetaminophin), antihistamines, and antiemetics may be given.
b. A test dose of 1mg per 20ml 5% dextrose in water infused over 30 min should be given.
c. use iv infusion pumps and the most distal veins possible
H. Tissue extravasation of fluconazole at the iv site may lead to tissue necrosis. Monitor the iv site carefully.
I. Oral forms of griseofulvin should be given with meals to decrease GI upset.
J. Monitor carefully for side/adverse effects
K. Monitor for therapeutic effects
1. easing for the sympotoms of infection
2. improved energy levels
3. normal vital signs, including temp
Questions
Are fungal infections are difficult to treat. True
Know that oral candidiasis is contagious.
How would we prevent side effects? Tylenol, steroid, antihistamine.
Chapter 41
Mechanism of action
Drug effects
Indications
I Fungal Infections
A. Fungi: very large and diverse group of microorganisms that include all yeasts and molds.
1. yeasts:
a. single celled fungi
b. reproduce by budding.
c. also used for baking and alcoholic beverages
2. molds:
a. multicellular.
b. Characterized by long, branching filaments called hyphae.
B. fungal infections aka mycoses (mycotic infections)
1. cutaneous
2. subcutaneous
3. superficial
4. systemic
a. usually occur in an immunocomprimised host
b. can be life threatening
5. diseases
a. Candida albicans
i. due to antibiotic therapy, antineoplastics, or immunosuppressants (corticosteroids)
ii. may result in overgrowth and systemic infections
b. in the mouth
i. oral candidiasis or thrush
ii. newborn infants and immunocompromised patients
iii. contagious
c. vaginal candidiasis
i. “yeast infection”
ii. pregnancy, diabetes mellitus, oral contraceptives, antibiotics
C. some fungi are part of the normal flora of the skin, mouth, intestines, and vagina.
II Antifungal agents:
A. drugs used to treat infections caused by fungi
B. systemic work in the blood stream
C. topical work on the skin
D. broken down into major groups based on their mechanisms of action
E. Agents
1. Polyenes
a. amphotericin B
b. nystatin
2. flucytosine
3. imidazoles
a. ketoconazole
b. muconazole
c. clotrimazole
d. fluconazole
4. griseofulvin
5. allylmine
a. terbinafine
III Mechanism of Action
A. polyenes (amphotericin B and nystatin)
1. bind to sterols in cell membrane lining
2. result: fungal death
3. do not bind to human cell membranes or kill human cells
B. flucytosine
1. aka 5-fluorocytosine (antimetabolite)
2. taken up by fungal cells and interferes with DNA synthesis
3. result: fungal cell death
C. imidazoles (...azoles)
1. inhibit an enzyme, resulting in cell membrane leaking
2. lead to altered cell membrane
3. result: fungal death
D. Griseofulvin
1. disrupts cell division
2. result: inhibited fungal mitosis (reproduction)
IV Indications (systemic and topical fungal infections)
A. Choice of agent depends on type and location of infection
B. Agent of choice for the treatment of many severe systemic fungal infections is amphotericin B
V Side Effects
A. Amphotericin B “shake and bake”
1. fever
2. headache
3. chills
4. malaise
5. hypotension
6. muscle and joint pain
7. lowered potassium and magnesium levels
8. dysrhythmias
9. nausea
10. anorexia
11. main concern is renal toxicity (b/c renally eliminated)
12. neurotoxicity: seizures and paresthesias
B. fluconazole
1. nausea, vomiting, diarrhea, stomach pain
2. increased liver function studies
C. flucytosine
1. n/v, anorexia, headache, dizziness, others
D. griseofulvin
1. rash, urticaria, headache, n/v, anorexia, others
VI Nursing Implications
A. Before beginning therapy, assess for hypersensitivity, possible contraindications, and conditions that require cautious use.
B. Obtain baseline VS, CBC, liver function studies, and ECG
C. Assess for other medcations used (prescribed and OTC) in order to avoid drug interactions.
D. Follow manufacturer’s directions carefully for reconstitution and admin.
E. Monitor VS’s op patients receiving IV infusions every 15 – 30 minutes
F. During IV infusions, monitor I & O and urinalysis findings to identify adverse renal effects.
G. Amphotericin B
a. to reduce the severity of the infusion-related reactions, pretreatment with an antipyretic (acetaminophin), antihistamines, and antiemetics may be given.
b. A test dose of 1mg per 20ml 5% dextrose in water infused over 30 min should be given.
c. use iv infusion pumps and the most distal veins possible
H. Tissue extravasation of fluconazole at the iv site may lead to tissue necrosis. Monitor the iv site carefully.
I. Oral forms of griseofulvin should be given with meals to decrease GI upset.
J. Monitor carefully for side/adverse effects
K. Monitor for therapeutic effects
1. easing for the sympotoms of infection
2. improved energy levels
3. normal vital signs, including temp
Questions
Are fungal infections are difficult to treat. True
Know that oral candidiasis is contagious.
How would we prevent side effects? Tylenol, steroid, antihistamine.
Antibiotics
Antibiotics
Chapter 37
Antibiotics
I Definition:
A. medications used to treat bacterial infections
B. Ideally, before beginning antibiotic therapy, the suspected areas of infection should be cultured to identify the causative organism and potential antibiotic susceptibilities
II Classes
A. Sulfonamides
B. Penicillins
C. Cephalosporins
D. Tetracyclines
E. Macrolides
F. Aminoglycosides
G. Quinolones
III Antibiotic Therapy
A. Empiric therapy: treatment of an infection before specific culture information has been reported or obtained
B. Prophylactic therapy: treatment with antibiotics to prevent an infection, as in intraabdominal surgery.
C. Therapeutic response:
Decrease in specific signs and symptoms of infection are noted (fever, elevated WBC, redness, inflammation, drainage, pain)
1. Streamline therapy: after results from C&S come back, change to the appropriate antibiotic. (narrow down) Broad spectrum causes resistance.
D. Subtherapeutic response:
Signs and symptoms of infection do not improve.
1. Superinfection: occurs when antibiotics reduce or completely eliminate the normal bacterial flora
2. antibiotic resistance:
3. host factors: age, allergy history, kidney and liver function, pregnancy, genetic characteristics, site of infection, host defenses
4. genetic host factors
a. G6PD deficiency
b. slow acetylator metabolic status
5. allergic reactions: especially to pcn (any “illins”) and sulfa drugs
IV Mechanism of Action
A. Interference with cell wall synthesis
B. Interference with protein synthesis
C. Interference with DNA replication
D. Acting as a metabolite to disrupt critical metabolic reactions inside the bacterial cell
E. Actions of Antibiotics
1. bactericidal: kill bacteria
2. bacteriostatic: inhibit growth of susceptible bacteria, rather than killing them immediately; will eventually lead to bacterial death
Sulfonamides
I Definition: one of the first groups of antibiotics.
II Drugs:
A. sulfadiazine
B. sulfamethoxazole: primary one used today in combination w/another antib.
C. sulfisoxazole
III Mechanism of Action
A. Bacteriostatic action
B. prevent synthesis of folic acid required for synthesis of purines and nucleic acid
C. Do not affect human cells or certain bacteria, they can use preformed folic acid
IV Indications
A. Treatment of UTI’s caused by susceptible strains of:
1. Enterobacter
2. Escherichia coli
3. Klebsiella
4. Proteus mirabilis
5. Proteus vulgaris
6. Staphylococcus aureus
B. Nocardiosis
C. Pneumocystis carinii pneumonia (PCP) co-trimoxazole This is a protozoa, not a bacteria. It is best treated by sulfonamides. Bactrim. Use high doses.
D. Upper respiratory tract infections
E. other uses
V Sulfanomides: Combination products
A. trimethoprim/sulfamethoxazole (Bactrm, Septra)
1. used to treat UTI’s, PCP, otitis media, others.
2. drink alot of water.
3. Don’t really use sulfa products alone anymore; we combine them so they work better.
VI Side effects:
Stevens-Johnson syndrome, epidermal necrolysis
Beta-Lactam Antibiotics
Penicillins
I Types
A. Natural penicillins
1. penicillin G
2. penicillin V potassium
B. Penicillinase-resistant penicillins (after natural became resistant we used these, didn’t last long)
1. cloxacillin
2. dicloxacillin
4. nafcillin
5. oxacillin
C. aminopenicillins (became resistant)
1. amoxicillin
2. ampicillin
3. bacampicillin
D. extended-spectrum penicillins
1. piperacillin
2. ticarcillin
3. carbenicillin
E. Can take monobactam if allergic to pcn, not cephalosporin or carbapenems.
II Facts
A. first introduced in the 1940’s, discovered by Fleming
B. bacteriacidal: inhibit cell wall synthesis
C. kill a wide variety of bacteria
D. also called beta lactams
E. bacteria produce enzymes called beta-lactamases which are capable of destroying penicillins. As a result, the medication is not effective. This is a method of resistance.
F. Chemicals have been developed to inhibit these enzymes. They bind with beta-lactamase and prevent the enzyme from breaking down the pcn.
1. clavulanic acid ( + ticarcillin = Timentin)
2. tazobactam (+ piperacillin = Zosyn)
3. sulbactam (+ampicillin = Unasyn)
4. clavulanic acid (+amoxicillin = Augmentin)
III Mechanism of Action
A. enter the bacteria via the cell wall
B. inside the cell they bind to penicillin binding protein
C. once bound, normal cell wall synthesis is disrupted
D. Result: bacteria cells die from lysis
IV Indications
A. prevention and treatment of infections caused by susceptible bacteria, such as:
1. gram + bacteria
2. Streptococcus, Enterococcus, Staphylococcus
V Adverse Effects
A. allergic reactions occur in 0.7% to 8% of cases
1. urticaria
2. pruritus
3. angioedema
B. 10% of allergic reactions are life threatening
1. 10% of these are fatal (All can be life threatening, all can be fatal)
VI Side effects
A. common: n/v, diarr, abd pain...others are less common
Beta-Lactam Antibiotics
Cephalospporins
I Types
A. 1st generation (good gram + coverage. Poor gram – coverage.)
1. cephalexin (Keflex) PO
2. cefazolin (Ancef and Kefzol) IV only
3. used for surgical prophylaxis, URI’s, otitis media
B. 2nd generation
1. good gram + coverage, better gram – than 1st generation
2. cefoxitin (Mefoxin) IV and IM
a. used prophylactically for abd or colorectal surgeries
b. kills anaerobes
3. cefuroxime (Kefurox and Ceftin) PO
a. surgical prophylaxis
b. does not kill anaerobes
C. 3rd generation
1. most potent group against gram negative, less active against gram +
2. ceftriaxone (Rocephin)
a. IV and IM
b. long ½ life
c. once a day dosing
d. easily passes meninges and diffused into CDF to treat CNS infections. Great for meningitis and shingles
e. NOT RENALLY ELIMINATED billiary/liver so can cause diarrhea.
f. covers all/most gram – and strepto pneumon, gonorrhea. (does not cover pseudomonas)
3. ceftazidime (ceptaz, fortaz, taxidime, tazicef)
a. IV and IM
b. excellent gram – coverage
c. used for difficult to treat organisms such as Pseudomonas
4. cefixime (Suprax) ONLY ORAL 3RD GENERATION AGENT
a. best of available oral cephalosporins against gram –
b. tablet and suspension
D. 4th generation
1. cefepime (Maxipime)
2. newest
3. broader spectrum esp against gram +
II Facts
A. semisynthetic derivatives from a fungus
B. structurally and pharmacologically related to pcn
C. Bacteriacidal
D. broad spectrum
E. divided into groups according to their antimicrobial activity
III Side effects
A. similar to pcn
Beta-Lactam Antibiotics
Carbapenems
I Facts
A. very broad spectrum antibacterial action
B. reserved for complicated body cavity and connective tissue infections
C. may cause drug induced seizure activity (imipenem-cilastatin...Primaxin)
D. used for treatment of bone, joint, skin, and soft tissue infections; many other uses
E. if allergic to pcn, allergic to this also
Beta-Lactam Antibiotics
Monobactams
I Facts
A. aztreonam (Azactam)
B. synthetic
C. primarily active against aerobic gram – bacteria (E. coli, Klebsiella, Pseudomonas)
D. If you are allergic to pcn you CAN take this
Macrolides
I Types
A. erythromycin (Emycin, EES)
B. azithromycin (Zithromax)
C. clarithromycin (Biaxin)
II Mechanism of Action
A. prevent protein synthesis within bacterial cells
B. bacteria will eventually die
C. bacteriastatic
D. all liver metabolized
III Indications (treat atypical organisms)
A. strep infections
B. mild to moderate URI
C. haemophilus influenzae
D. spirochetal infections
1. syphillis
2. lyme disease
E. gonorrhea, chlamydia, mycoplasma
IV Side effects
A. GI effects primarily with erythromycin
B. newer agents fewer side effects, better action
1. azithromycin
2. clarithromycin: bad metallid taste in mouth
Tetracyclines
I types
A. tetracyline: used for acne. Discolors teeth, crosses placenta & breastmilk
B. demeclocycline is also used to treat SIADH And pleural and pericardial effusions (symptoms of inappropriate ADH)
II Facts
A. natural and synthetic
B. obtained from cultures of streptomyces
C. bacteriostatic
D. inhibit protein synthesis
E. stop many essential function of the bacteria
F. Dairy products, antacids, and iron salts reduce absorption of tetras Has a strong affinity for calcium.
1. discoloration of permanent teeth and tooth enamel in fetuses and children
2. may retard fetal skeletal develop if taken during pregnancy
III Indications
A. wide spectrum
1. gram -, gram +, protozoa, mycoplasma, rickettsia, chlamydia, syphilis, lyme disease
IV Side effects
A. discoloration of permanent teeth and tooth enamel in fetuses and children
B. may retard fetal skeletal develop if taken during pregnancy
C. Alteration in intestinal flora may result in:
1. superinfection (overgrowth)
2. diarrhea
3. pseudomembranous colitis/bloody diarrhea
D. may also cause:
1. vaginal moniliasis
2. gastric upset
3. enterocolitis
4. maculopapular rash
Aminoglycosides
I Types (systemic)
A. gentamicin (Garamycin)
B. tobramycin
C. amikacin (Amikin)
II Facts
A. natural and semisynthetic
B. produced from streptomyces
C. poor oral absorption NO PO FORMS
D. very potent antibiotics with serious toxicities
E. Bacteriacidal
F. kills mostly gram –
G. Narrow therapeutic window. We must pull levels on this. Serious toxicities.
H. TOXIC TO KIDNEYS AND EARS
III Indications
A. kill gram -. Pseudomonas, e. coli, proteus, klebsiella, serratia
B. often used in combination with others for synergistic effect
C. narrow therapeutic window medications
D. All poorly absorbed through GI, the exception is neomycin.
1. given orally to decontaminate the gi tract before surgery
2. also used as an enema for this purpose
IV Side effects
A. cause serious toxicities
1. nephrotoxicity
2. ototoxicity: auditory impairment and vestibular 8th cranial nerve
B. must monitor drug levels to prevent toxicities
C. headache, paresthesia, dizziness, vertigo, skin rash, fever, superinfection
Quinolones
I Types
A. ciprofloxacin (cipro)
B. levofloxacin (levaquin)
II Facts
A. excellent oral absorption, as good as an IV
B. absorption reduced by antacids
C. first oral antibiotics effective against gram- bacteria (some +)
D. bactericidal
III Indications
A. Anthrax among others
IV Side effects
A. headache, dizziness, depression
B. n/v/d/constipation/
C. rash, photosensitvity
D. fever chills, blurred vision, tinnitus
Other
I Vancomycin (stands alone)
A. treatment of choice for MRSA and other gram +
B. monitor blood levels
C. ototoxicity and nephrotoxicity
D. should be infused over 90 minutes
E. Redman’s syndrome
Nursing implications
It is essential to obtain cultures from appropriate sites before beginning therapy.
Take exactly as prescribed and for the length of time prescribed.
Assess for superinfection.
Check the name of med carefully because of look/sound alikes
Take w/ 6-8 oz water
Most common side effects: n/v/d
Sulfonamides:
Take w/2000 ml fluid/day
Photosensitivity
Reduce contraceptives
Take w/food or milk to reduce upset
Penicillins
Allergic rxn for 30 min
Decreased w/caffeine, citrus, cola, tomato juice
Cephalosporins
Give w/food
No alcohol
Tetracyclines
Avoid dairy b/c of chelation
Photosensitivity
Aminoglycides
Nephrotoxicity....peak and trough levels
Ototoxicity...dizziness, tinnitus, hearing loss
Test Questions:
Penicillins can cause seizures if dosed too high. True.
(renally eliminated, if bad renal function...retain more drug.)
What was added to penicillins to prevent beta-lactamases from working?
Clavulanic acid, tazobactam, sulbactam.
Bacteriastatic
Macrolides
Tetracycline
sulfonamides
Bactericidal
Aminoglycosides
Quinolones
Pencillin
Cephalosporins
Carbapenems
Monobactams
vancomycin
Chapter 37
Antibiotics
I Definition:
A. medications used to treat bacterial infections
B. Ideally, before beginning antibiotic therapy, the suspected areas of infection should be cultured to identify the causative organism and potential antibiotic susceptibilities
II Classes
A. Sulfonamides
B. Penicillins
C. Cephalosporins
D. Tetracyclines
E. Macrolides
F. Aminoglycosides
G. Quinolones
III Antibiotic Therapy
A. Empiric therapy: treatment of an infection before specific culture information has been reported or obtained
B. Prophylactic therapy: treatment with antibiotics to prevent an infection, as in intraabdominal surgery.
C. Therapeutic response:
Decrease in specific signs and symptoms of infection are noted (fever, elevated WBC, redness, inflammation, drainage, pain)
1. Streamline therapy: after results from C&S come back, change to the appropriate antibiotic. (narrow down) Broad spectrum causes resistance.
D. Subtherapeutic response:
Signs and symptoms of infection do not improve.
1. Superinfection: occurs when antibiotics reduce or completely eliminate the normal bacterial flora
2. antibiotic resistance:
3. host factors: age, allergy history, kidney and liver function, pregnancy, genetic characteristics, site of infection, host defenses
4. genetic host factors
a. G6PD deficiency
b. slow acetylator metabolic status
5. allergic reactions: especially to pcn (any “illins”) and sulfa drugs
IV Mechanism of Action
A. Interference with cell wall synthesis
B. Interference with protein synthesis
C. Interference with DNA replication
D. Acting as a metabolite to disrupt critical metabolic reactions inside the bacterial cell
E. Actions of Antibiotics
1. bactericidal: kill bacteria
2. bacteriostatic: inhibit growth of susceptible bacteria, rather than killing them immediately; will eventually lead to bacterial death
Sulfonamides
I Definition: one of the first groups of antibiotics.
II Drugs:
A. sulfadiazine
B. sulfamethoxazole: primary one used today in combination w/another antib.
C. sulfisoxazole
III Mechanism of Action
A. Bacteriostatic action
B. prevent synthesis of folic acid required for synthesis of purines and nucleic acid
C. Do not affect human cells or certain bacteria, they can use preformed folic acid
IV Indications
A. Treatment of UTI’s caused by susceptible strains of:
1. Enterobacter
2. Escherichia coli
3. Klebsiella
4. Proteus mirabilis
5. Proteus vulgaris
6. Staphylococcus aureus
B. Nocardiosis
C. Pneumocystis carinii pneumonia (PCP) co-trimoxazole This is a protozoa, not a bacteria. It is best treated by sulfonamides. Bactrim. Use high doses.
D. Upper respiratory tract infections
E. other uses
V Sulfanomides: Combination products
A. trimethoprim/sulfamethoxazole (Bactrm, Septra)
1. used to treat UTI’s, PCP, otitis media, others.
2. drink alot of water.
3. Don’t really use sulfa products alone anymore; we combine them so they work better.
VI Side effects:
Stevens-Johnson syndrome, epidermal necrolysis
Beta-Lactam Antibiotics
Penicillins
I Types
A. Natural penicillins
1. penicillin G
2. penicillin V potassium
B. Penicillinase-resistant penicillins (after natural became resistant we used these, didn’t last long)
1. cloxacillin
2. dicloxacillin
4. nafcillin
5. oxacillin
C. aminopenicillins (became resistant)
1. amoxicillin
2. ampicillin
3. bacampicillin
D. extended-spectrum penicillins
1. piperacillin
2. ticarcillin
3. carbenicillin
E. Can take monobactam if allergic to pcn, not cephalosporin or carbapenems.
II Facts
A. first introduced in the 1940’s, discovered by Fleming
B. bacteriacidal: inhibit cell wall synthesis
C. kill a wide variety of bacteria
D. also called beta lactams
E. bacteria produce enzymes called beta-lactamases which are capable of destroying penicillins. As a result, the medication is not effective. This is a method of resistance.
F. Chemicals have been developed to inhibit these enzymes. They bind with beta-lactamase and prevent the enzyme from breaking down the pcn.
1. clavulanic acid ( + ticarcillin = Timentin)
2. tazobactam (+ piperacillin = Zosyn)
3. sulbactam (+ampicillin = Unasyn)
4. clavulanic acid (+amoxicillin = Augmentin)
III Mechanism of Action
A. enter the bacteria via the cell wall
B. inside the cell they bind to penicillin binding protein
C. once bound, normal cell wall synthesis is disrupted
D. Result: bacteria cells die from lysis
IV Indications
A. prevention and treatment of infections caused by susceptible bacteria, such as:
1. gram + bacteria
2. Streptococcus, Enterococcus, Staphylococcus
V Adverse Effects
A. allergic reactions occur in 0.7% to 8% of cases
1. urticaria
2. pruritus
3. angioedema
B. 10% of allergic reactions are life threatening
1. 10% of these are fatal (All can be life threatening, all can be fatal)
VI Side effects
A. common: n/v, diarr, abd pain...others are less common
Beta-Lactam Antibiotics
Cephalospporins
I Types
A. 1st generation (good gram + coverage. Poor gram – coverage.)
1. cephalexin (Keflex) PO
2. cefazolin (Ancef and Kefzol) IV only
3. used for surgical prophylaxis, URI’s, otitis media
B. 2nd generation
1. good gram + coverage, better gram – than 1st generation
2. cefoxitin (Mefoxin) IV and IM
a. used prophylactically for abd or colorectal surgeries
b. kills anaerobes
3. cefuroxime (Kefurox and Ceftin) PO
a. surgical prophylaxis
b. does not kill anaerobes
C. 3rd generation
1. most potent group against gram negative, less active against gram +
2. ceftriaxone (Rocephin)
a. IV and IM
b. long ½ life
c. once a day dosing
d. easily passes meninges and diffused into CDF to treat CNS infections. Great for meningitis and shingles
e. NOT RENALLY ELIMINATED billiary/liver so can cause diarrhea.
f. covers all/most gram – and strepto pneumon, gonorrhea. (does not cover pseudomonas)
3. ceftazidime (ceptaz, fortaz, taxidime, tazicef)
a. IV and IM
b. excellent gram – coverage
c. used for difficult to treat organisms such as Pseudomonas
4. cefixime (Suprax) ONLY ORAL 3RD GENERATION AGENT
a. best of available oral cephalosporins against gram –
b. tablet and suspension
D. 4th generation
1. cefepime (Maxipime)
2. newest
3. broader spectrum esp against gram +
II Facts
A. semisynthetic derivatives from a fungus
B. structurally and pharmacologically related to pcn
C. Bacteriacidal
D. broad spectrum
E. divided into groups according to their antimicrobial activity
III Side effects
A. similar to pcn
Beta-Lactam Antibiotics
Carbapenems
I Facts
A. very broad spectrum antibacterial action
B. reserved for complicated body cavity and connective tissue infections
C. may cause drug induced seizure activity (imipenem-cilastatin...Primaxin)
D. used for treatment of bone, joint, skin, and soft tissue infections; many other uses
E. if allergic to pcn, allergic to this also
Beta-Lactam Antibiotics
Monobactams
I Facts
A. aztreonam (Azactam)
B. synthetic
C. primarily active against aerobic gram – bacteria (E. coli, Klebsiella, Pseudomonas)
D. If you are allergic to pcn you CAN take this
Macrolides
I Types
A. erythromycin (Emycin, EES)
B. azithromycin (Zithromax)
C. clarithromycin (Biaxin)
II Mechanism of Action
A. prevent protein synthesis within bacterial cells
B. bacteria will eventually die
C. bacteriastatic
D. all liver metabolized
III Indications (treat atypical organisms)
A. strep infections
B. mild to moderate URI
C. haemophilus influenzae
D. spirochetal infections
1. syphillis
2. lyme disease
E. gonorrhea, chlamydia, mycoplasma
IV Side effects
A. GI effects primarily with erythromycin
B. newer agents fewer side effects, better action
1. azithromycin
2. clarithromycin: bad metallid taste in mouth
Tetracyclines
I types
A. tetracyline: used for acne. Discolors teeth, crosses placenta & breastmilk
B. demeclocycline is also used to treat SIADH And pleural and pericardial effusions (symptoms of inappropriate ADH)
II Facts
A. natural and synthetic
B. obtained from cultures of streptomyces
C. bacteriostatic
D. inhibit protein synthesis
E. stop many essential function of the bacteria
F. Dairy products, antacids, and iron salts reduce absorption of tetras Has a strong affinity for calcium.
1. discoloration of permanent teeth and tooth enamel in fetuses and children
2. may retard fetal skeletal develop if taken during pregnancy
III Indications
A. wide spectrum
1. gram -, gram +, protozoa, mycoplasma, rickettsia, chlamydia, syphilis, lyme disease
IV Side effects
A. discoloration of permanent teeth and tooth enamel in fetuses and children
B. may retard fetal skeletal develop if taken during pregnancy
C. Alteration in intestinal flora may result in:
1. superinfection (overgrowth)
2. diarrhea
3. pseudomembranous colitis/bloody diarrhea
D. may also cause:
1. vaginal moniliasis
2. gastric upset
3. enterocolitis
4. maculopapular rash
Aminoglycosides
I Types (systemic)
A. gentamicin (Garamycin)
B. tobramycin
C. amikacin (Amikin)
II Facts
A. natural and semisynthetic
B. produced from streptomyces
C. poor oral absorption NO PO FORMS
D. very potent antibiotics with serious toxicities
E. Bacteriacidal
F. kills mostly gram –
G. Narrow therapeutic window. We must pull levels on this. Serious toxicities.
H. TOXIC TO KIDNEYS AND EARS
III Indications
A. kill gram -. Pseudomonas, e. coli, proteus, klebsiella, serratia
B. often used in combination with others for synergistic effect
C. narrow therapeutic window medications
D. All poorly absorbed through GI, the exception is neomycin.
1. given orally to decontaminate the gi tract before surgery
2. also used as an enema for this purpose
IV Side effects
A. cause serious toxicities
1. nephrotoxicity
2. ototoxicity: auditory impairment and vestibular 8th cranial nerve
B. must monitor drug levels to prevent toxicities
C. headache, paresthesia, dizziness, vertigo, skin rash, fever, superinfection
Quinolones
I Types
A. ciprofloxacin (cipro)
B. levofloxacin (levaquin)
II Facts
A. excellent oral absorption, as good as an IV
B. absorption reduced by antacids
C. first oral antibiotics effective against gram- bacteria (some +)
D. bactericidal
III Indications
A. Anthrax among others
IV Side effects
A. headache, dizziness, depression
B. n/v/d/constipation/
C. rash, photosensitvity
D. fever chills, blurred vision, tinnitus
Other
I Vancomycin (stands alone)
A. treatment of choice for MRSA and other gram +
B. monitor blood levels
C. ototoxicity and nephrotoxicity
D. should be infused over 90 minutes
E. Redman’s syndrome
Nursing implications
It is essential to obtain cultures from appropriate sites before beginning therapy.
Take exactly as prescribed and for the length of time prescribed.
Assess for superinfection.
Check the name of med carefully because of look/sound alikes
Take w/ 6-8 oz water
Most common side effects: n/v/d
Sulfonamides:
Take w/2000 ml fluid/day
Photosensitivity
Reduce contraceptives
Take w/food or milk to reduce upset
Penicillins
Allergic rxn for 30 min
Decreased w/caffeine, citrus, cola, tomato juice
Cephalosporins
Give w/food
No alcohol
Tetracyclines
Avoid dairy b/c of chelation
Photosensitivity
Aminoglycides
Nephrotoxicity....peak and trough levels
Ototoxicity...dizziness, tinnitus, hearing loss
Test Questions:
Penicillins can cause seizures if dosed too high. True.
(renally eliminated, if bad renal function...retain more drug.)
What was added to penicillins to prevent beta-lactamases from working?
Clavulanic acid, tazobactam, sulbactam.
Bacteriastatic
Macrolides
Tetracycline
sulfonamides
Bactericidal
Aminoglycosides
Quinolones
Pencillin
Cephalosporins
Carbapenems
Monobactams
vancomycin
Nitrates Nitrites
Nitrates/Nitrites
I Available forms:
A. sublingual
B. buccal
C. chewable tables
D. oral capsules/tablets
E. iv
F. ointments
G. transdermal patches
H. translingual sprays (do not shake)
II Mechanism of action
A. cause vasodilation due to relaxation of smooth muscles
B. potent dilating effect on coronary arteries
C. used for prevention and treatment of angina
D. vasodilation results in reduced myocardial O2 demand
E. nitrates cause dilation of both large and small coronary vessels
F. result: O2 to ischemic myocardial tissue
G. nitrates alleviate coronary artery spasms
III Types
A. Nitroglycerin
1. prototypical nitrate
2. large first pass effect w/oral forms
3. Indications
a. used for symptomatic tx of ischemic heart conditions (angina)
b. IV form used for bp control in perioperative hpn, tx of hf, ischemic pain, pulmonary edema assoc w/ acute MI, and HPN emergencies
4. Dosages
a. Nitroglycerin SL (usuallly 0.4 mg) Place one under tongue every 5 minutes x 3 for chest pain. If still pain after 5 min call 911. Should be kept in original container. Once opened replace every 6 months. Side effect of headache should NOT deter use.
5. Nursing implications:
a. take prn nitrates at the first hint of anginal pain
b. the pt taking SL NTG should be lying down to prevent or decrease dizziness and fainting that may occur due to hypotension
c. make sure pts have a nitrate free period of 8-12 hours. Put on patch in am, take off @ night.
d. instruct pts in proper technique/guidelines for SL NTG
e. instruct pts in proper application of ointment and transdermal forms
f. “ “ site rotation & removal of old med daily
g. never chew or swallow the SL form
h. keep a fresh supply of NTG on hand
i. Burning sensation felt w/ SL = drug still potent
j. potency lost after bottle opened for 3 months
k. store in airtight, dark glass bottle w/a metal cap and not cotton filler to preserve potency
l. IV forms of NTG must be contained in glass & given w/infusion pumps
m. discard parenteral soln that is blue, green, or dark red
n. follow specific manuf instructions for Iv admin; use special IV tubing provided or non PVC tubing
B. Nitrates
1. types
a. Isosorbide dinitrate
i. Isordil
ii. Sorbitrate
iii. Dilatrate SR
b. Isosorbide mononitrate
i. Imdur
ii. Monoket
iii. ISMO
2. indications
a. acute relief of angina
b. prophylaxis in situations that may provoke angina
c. long term prophylaxis of angina
3. Side effects
a. headache: usually diminish in intensity and frequency after continued use
b. tachycardia
c. postural hypotension
d. tolerance may develop and need higher doses to be effective
I Available forms:
A. sublingual
B. buccal
C. chewable tables
D. oral capsules/tablets
E. iv
F. ointments
G. transdermal patches
H. translingual sprays (do not shake)
II Mechanism of action
A. cause vasodilation due to relaxation of smooth muscles
B. potent dilating effect on coronary arteries
C. used for prevention and treatment of angina
D. vasodilation results in reduced myocardial O2 demand
E. nitrates cause dilation of both large and small coronary vessels
F. result: O2 to ischemic myocardial tissue
G. nitrates alleviate coronary artery spasms
III Types
A. Nitroglycerin
1. prototypical nitrate
2. large first pass effect w/oral forms
3. Indications
a. used for symptomatic tx of ischemic heart conditions (angina)
b. IV form used for bp control in perioperative hpn, tx of hf, ischemic pain, pulmonary edema assoc w/ acute MI, and HPN emergencies
4. Dosages
a. Nitroglycerin SL (usuallly 0.4 mg) Place one under tongue every 5 minutes x 3 for chest pain. If still pain after 5 min call 911. Should be kept in original container. Once opened replace every 6 months. Side effect of headache should NOT deter use.
5. Nursing implications:
a. take prn nitrates at the first hint of anginal pain
b. the pt taking SL NTG should be lying down to prevent or decrease dizziness and fainting that may occur due to hypotension
c. make sure pts have a nitrate free period of 8-12 hours. Put on patch in am, take off @ night.
d. instruct pts in proper technique/guidelines for SL NTG
e. instruct pts in proper application of ointment and transdermal forms
f. “ “ site rotation & removal of old med daily
g. never chew or swallow the SL form
h. keep a fresh supply of NTG on hand
i. Burning sensation felt w/ SL = drug still potent
j. potency lost after bottle opened for 3 months
k. store in airtight, dark glass bottle w/a metal cap and not cotton filler to preserve potency
l. IV forms of NTG must be contained in glass & given w/infusion pumps
m. discard parenteral soln that is blue, green, or dark red
n. follow specific manuf instructions for Iv admin; use special IV tubing provided or non PVC tubing
B. Nitrates
1. types
a. Isosorbide dinitrate
i. Isordil
ii. Sorbitrate
iii. Dilatrate SR
b. Isosorbide mononitrate
i. Imdur
ii. Monoket
iii. ISMO
2. indications
a. acute relief of angina
b. prophylaxis in situations that may provoke angina
c. long term prophylaxis of angina
3. Side effects
a. headache: usually diminish in intensity and frequency after continued use
b. tachycardia
c. postural hypotension
d. tolerance may develop and need higher doses to be effective
Calcium Channel Blockers
Calcium Channel Blockers
I Types
A. verapamil (calan)
B. diltiazem (Cardizem)
C. nifedipine (Procardia)
II Mechanism of Action
A. Cause peripheral arterial vasodilation
B. reduce myocardial contractility (negative inotropic action)
C. result: decreased myocardial O2 demand
III Indications
A. First line agents for tx of angina, HPN and supraventricular tachy arryth
B. short term mgmt of atrial fibrillation and flutter
IV Side effects
A. very acceptable side effects and safety profile
B. may cause:
1. hypotension
2. palpitations
3. tachycardia or bradycardia
4. constipation
5. nausea
6. dyspnea
V Nursing implications
A. blood levels should be monitored to ensure they are therapeutic
B. oral CCBs should be taken before meals and as ordered
C. pts should be encouraged to limit caffeine intake
D. before administering, perform a complete health history to determine presence of conditions that may be contraindications for use or call for cautious use
E. obtain baseline VS, including respiratory patterns and rate
F. access for drug interactions
G. Pts should not take any meds including OTC w/o checking w/dr
H. pts should report blurred vision, persistent headache, dry mouth, dizziness, edema, fainting, weight gain of over 2 lbs/day or 5lbs/week, pulse over 60 and dyspnea
I. fainitng from vasodilation and hypotension w/ alcohol consumption & hot baths
J. teach pts to change positions slowly
K. keep records of angina attacks incl: precipitating factors, number of pills taken, and therapeutic effects
For all: monitor for adverse reactions & therapeutic effects
I Types
A. verapamil (calan)
B. diltiazem (Cardizem)
C. nifedipine (Procardia)
II Mechanism of Action
A. Cause peripheral arterial vasodilation
B. reduce myocardial contractility (negative inotropic action)
C. result: decreased myocardial O2 demand
III Indications
A. First line agents for tx of angina, HPN and supraventricular tachy arryth
B. short term mgmt of atrial fibrillation and flutter
IV Side effects
A. very acceptable side effects and safety profile
B. may cause:
1. hypotension
2. palpitations
3. tachycardia or bradycardia
4. constipation
5. nausea
6. dyspnea
V Nursing implications
A. blood levels should be monitored to ensure they are therapeutic
B. oral CCBs should be taken before meals and as ordered
C. pts should be encouraged to limit caffeine intake
D. before administering, perform a complete health history to determine presence of conditions that may be contraindications for use or call for cautious use
E. obtain baseline VS, including respiratory patterns and rate
F. access for drug interactions
G. Pts should not take any meds including OTC w/o checking w/dr
H. pts should report blurred vision, persistent headache, dry mouth, dizziness, edema, fainting, weight gain of over 2 lbs/day or 5lbs/week, pulse over 60 and dyspnea
I. fainitng from vasodilation and hypotension w/ alcohol consumption & hot baths
J. teach pts to change positions slowly
K. keep records of angina attacks incl: precipitating factors, number of pills taken, and therapeutic effects
For all: monitor for adverse reactions & therapeutic effects
Beta Blockers
Beta Blockers
I Available Forms
A. atenolol (Tenormin)
B. metoprolol (Lopressor)
C. propranolol (Inderal)
D. nadolol (Corgard)
II Mechanism of Action
A. decrease hr resulting in decreased myocardial O2 demand and increase O2 delivery to the heart
B. decrease myocardial contractility helps to conserve energy or decrease demand
C. blocks norepinephrine
III Indications
A. angina
B. anti HPN
C. cardioprotective effects, especially after MI
D. some used for migraine headaches
IV Side effects
A. cardiovascular
1. bradycardia
2. hypotension
3. 2nd or 3rd degree heart block
4. heart failure
B. metabolic
1. glucose
2. lipids
C. CNS
1. dizziness
2. fatigue
3. mental depression
4. lethargy
5. drowsiness
6. unusual dreams
D. other
1. impotence
2. wheezing
3. dyspnea w/ non-selective BB
V Nursing implications
A. monitor pulse rate daily and report any rate lower than 60 bpm
B. dizziness or fainting should also be reported
C. constipation is a common problem; instruct pts to take in adequate fluids and eat high fiber foods
D. never abruptly discontinue due to risk of rebound HPN crisis
E. inform pts that these meds are for long term prevention of angina, not immediate relief
I Available Forms
A. atenolol (Tenormin)
B. metoprolol (Lopressor)
C. propranolol (Inderal)
D. nadolol (Corgard)
II Mechanism of Action
A. decrease hr resulting in decreased myocardial O2 demand and increase O2 delivery to the heart
B. decrease myocardial contractility helps to conserve energy or decrease demand
C. blocks norepinephrine
III Indications
A. angina
B. anti HPN
C. cardioprotective effects, especially after MI
D. some used for migraine headaches
IV Side effects
A. cardiovascular
1. bradycardia
2. hypotension
3. 2nd or 3rd degree heart block
4. heart failure
B. metabolic
1. glucose
2. lipids
C. CNS
1. dizziness
2. fatigue
3. mental depression
4. lethargy
5. drowsiness
6. unusual dreams
D. other
1. impotence
2. wheezing
3. dyspnea w/ non-selective BB
V Nursing implications
A. monitor pulse rate daily and report any rate lower than 60 bpm
B. dizziness or fainting should also be reported
C. constipation is a common problem; instruct pts to take in adequate fluids and eat high fiber foods
D. never abruptly discontinue due to risk of rebound HPN crisis
E. inform pts that these meds are for long term prevention of angina, not immediate relief
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