NSG 251 Exam 3 Blueprint

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May 24, 2024

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NSG 251: Pharmacology and Dosage with Lab Exam 3: Test Blueprint FALL 2022 Exam 3 40 questions worth 2 points each Testing Date Exam 3 is scheduled for Week 7. See Communication Course Calendar Module 3 Outcomes: Drugs that Act on the Immune System After completing this module, you will be able to: Cancer and Antineoplastic Therapy  Explain the role of antineoplastic therapy in the treatment of cancer.  Develop a nursing plan of care using nursing process for a patient receiving chemotherapy. Biologic and Disease-Modifying Antirheumatic Drug (DMARD) Therapy  Describe the mechanism of action, therapeutic purpose, cautions, contraindications, common adverse and toxic effects of biologic response-modifying and antirheumatic drugs: o Filgrastim Indications/therapeutic purpose  Prevent or reduce febrile neutropenia in patients receiving myelosuppressive antineoplastics for NONMYELOID (bone marrow) malignancies  reduce the incidence, duration, and severity of infection  Contraindications/interactions  Allergy  Do NOT give in the presence of more than 10% myeloid blasts (these are immature tumor cells in the bone marrow) as malignant growth may be stimulated  Effect is antagonized when administered with myelosuppressive chemotherapy agents  Adverse effects  Mild to moderate bone pain 1

 Administration/teaching  Do not give within 24 hours of administration of myelosuppressive chemotherapy but give promptly after this time frame to prevent the WBC nadir from dropping too low  Must be given prior to a patient developing an infection  Assess for manifestations of infection, teach patient to report sore throat, vomiting, diarrhea, fever of 100.5 or greater to HCP  discontinue when the absolute neutrophil count rises above 10,000 cells/mm3  administer analgesics as required for pain  pregnancy should be discouraged during treatment of cancer, use appropriate contraceptives o monoclonal antibodies (general)/biosimilars indications/therapeutic purpose  treatment of cancer  autoimmune disorders  organ transplantation contraindications/interactions  allergy  active infection and HIV  tumor necrosis factor antagonists are contraindicated in patients with active TB or other serious infections: FDA: BOX WARNING: increase risk of serious infection or lymphoma or other malignancies  specific interactions vary by drug  adverse effects  classic “allergic response” 2

 flulike symptoms including fever, dyspnea, chills  nausea, vomiting, diarrhea, abdominal pain  depression, insomnia, headache, fatigue  hypertension administration/teaching  generic name ends in “mab”  if a patient has hypersensitivity, premedicate with acetaminophen and diphenhydramine  Assess/report symptoms of infection: sore throat, vomiting, diarrhea, fever  teach infection control such as handwashing, avoiding contact with sick persons, avoid crowds – appropriate masking, clean environment  screen for TB prior to starting therapy  monitor CBC prior to and during therapy o methotrexate indications/therapeutic purpose  anticancer drug (breast, head &neck, and lung cancers) commonly used for the treatment of RA at much lower doses than needed to treat cancer  antiinflammatory, analgesic, antiarthritic, with immune modulating effects to slow or stop progression of RA  may also be used to treat psoriasis  contraindications/interactions  allergies  liver disease  Peptic ulcer disease 3

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 Ulcerative colitis  Interactions with penicillin, phenytoin, probenecid, sulfa, theophylline  Do not take wit NSAIDs adverse effects  bone marrow suppression  liver damage if taken for a long period of time  may cause lung damage  may cause GI ulcers  rash  Photosensitivity  administration/teaching  administer WEEKLY  usually given orally but can be given by injection  do not drink alcohol while taking this medication  monitor liver enzymes: assess/have patient report: nausea, extreme fatigue, anorexia, pain in the right upper quadrant of the abdomen, yellowing of the skin/eyes, clay-colored stools  monitor CBC  Develop a nursing plan of care using nursing process for a patient receiving biologic response- modifying and antirheumatic drugs. Immunosuppressant Therapy  Describe the mechanism of action, therapeutic purpose, cautions, contraindications, common adverse and toxic effects of immunosuppressants: o Mycophenolate Therapeutic Purpose/Indications  Prevent T cell proliferation and treat rejection 4

 Contraindications/interactions  Allergy  Kidney disease  Liver disease  INTERACTION: antacids, iron, rifampin: decrease in immune suppression effect  INTERACTION: oral contraceptives: possible pregnancy Adverse effects  FDA: BOX WARNING: risk of congenital anomalies and spontaneous miscarriage, high risk for infection, risk for lymphoma, skin cancer  FDA: BOX WARNING: risk for progressive multifocal leukoencephalopathy  A viral infection that targets cells in the CNS that make myelin (nerve insulator/speed conductor). Affects only the immunocompromised (by disease or medications). Manifestations include clumsiness, progressive weakness, visual/speech/and personality changes with high risk of death of 30-50% in the first few months following diagnosis of the viral infection Adverse effects  BP up and down  Edema  Chest pain  Headache  Insomnia  Nausea, vomiting, diarrhea  Dyspnea 5

 Rash  Hyperglycemia  Thrombocytopenia  Leukopenia  Anemia  Liver and kidney impairment o Tacrolimus Therapeutic Purpose/Indications  Prevent T cell proliferation and treat rejection  Contraindications/interactions  Allergy  Decreased renal function  INTERACTIONS: gentamicin and amphotericin: risk renal failure  INTERACTION: fluconazole and calcium channel blockers: increased tacrolimus effect (beware toxicity)  INTERACTION: rifampin, antiepileptic drugs, St. John’s wort: decreased tacrolimus effect  DO NOT TAKE WITH CYCLOSPORINE Adverse effects  Renal and Liver toxicity  Pancytopenia (low RBCs, low WBCs, and platelets)  Diabetes  Hypercholesterolemia  Edema, Variable BP 6

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 Atrial fibrillation, Tachycardia  Thrombosis  Headache  Tremors, Depression, Neuropathy  Acute renal failure  Nausea, vomiting, constipation  Develop a nursing plan of care using nursing process for a patient receiving immunosuppressants. Immunization  Develop a nursing plan of care using nursing process for patient receiving toxoids and vaccines. Module 4 Outcomes: Gastrointestinal and Anemia Medications After completing this module, you will be able to: Acid-Controlling Drugs  Describe the mechanism of action, therapeutic purpose, cautions, contraindications, common adverse and toxic effects, and significant drug interactions for medications used to treat acid reflux and peptic ulcer disease: o Antacids May be single ingredient or combinations of: o Sodium o Calcium o Aluminum o Magnesium o AND may contain the anti-gas agent simethicone  Alkaline substances that neutralize HCl, antacids do NOT affect HCl production or secretion Therapeutic purpose/indications  Symptomatic relief of stomach pain and reflux “heartburn” Contraindications/interactions  Allergy 7

 Renal failure: DO NOT USE ANY MAGNESIUM BASED PRODUCT  Caution: Electrolyte disturbances: hypercalcemia  Caution: bowel obstruction: magnesium  Interactions: common mechanisms o Adsorption and chelation: other drugs are bound to or chemically inactivated reducing or preventing their therapeutic effects o Increased stomach pH: increases absorption of basic drugs (benzodiazepines, sympathomimetics, valproic acid) and decreases absorption of acid drugs (allopurinol, thyroid hormones, digoxin, antihistamines, corticosteroids, digoxin, aspirin, isoniazid) o DO NOT GIVE WITH quinolone antibiotics: blocks antimicrobial effect Adverse effects  Magnesium: diarrhea  Aluminum and calcium: constipation  Calcium: kidney stones  Systemic alkalosis with OVER USE of any antacid, especially sodium bicarbonate (baking soda)  Calcium can cause acid rebound  Chronic high dose calcium antacids can cause milk-alkali syndrome  Hypercalcemia, headache, nausea, and alkalosis  Aluminum antacids can lead to hypercalcemia and hypophosphatemia  Calcium antacids can cause gas and belching Administration/teaching  Conduct an appropriate history and physical exam with focus of GI tract disorders, 8

bowel pattern, GI related pain  Review current medications and review any available labs  Assess for HTN, heart failure, presence of edema: antacids are high in sodium  Long-term self-medication with antacids may be masking manifestation of a serious underlying condition (such as a bleeding ulcer, or cancer): encourage occasional use only, if continued use is necessary, advise patient to see their HCP after 2 weeks of use  Separate antacids by 2 hours from other meds  Pregnancy category A  Many antacids are high in sodium: read labels if the patient is on a sodium restriction  Calcium based antacids may also be used a source of calcium (as for osteoporosis treatment, prevention)  Liquid antacids must be shaken prior to dosing  Assess/report: prolonged constipation/diarrhea, increasing abdominal pain/distension, hematemesis or black tarry stools o H2 blockers Such as cimetidine Therapeutic purpose/indications  decreases acid secretion in the treatment of GERD, PUD, esophagitis  Control of upper GI bleeding  Prophylaxis of stress ulcers Contraindications/interactions  Allergy  Caution: liver/kidney: may need dose adjustment 9

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 Interactions: cimetidine has A TON of interactions with other medications: always look at the patient’s medication profile prior to administration  Recommendation to switch to famotidine (Pepcid) which has very few drug interactions  Adverse effects  Good safety profile  Confusion and disorientation may occur in the older adult  Cimetidine may cause impotence and gynecomastia  Hypotension with IV administration, especially if infused too quickly  Headache  Diarrhea  thromboc Administration/teaching  Conduct an appropriate history and physical exam with focus of GI tract disorders, bowel pattern, GI related pain  Assess/report: bruising, fatigue, diarrhea, black tarry stools, sore throat, or rash to the HCP  Monitor for mental status changes  Monitor renal and liver labs  Take cimetidine with food  Smoking decreases effectiveness of H2 blockers: encourage patient to reduce use or quit  H2 blockers should be taken 1 to 2 hours BEFORE an antacid  Cimetidine may also be used, with other drugs, to treat allergic reactionsytopenia 10

o proton pump inhibitors  Several in this class, all end in “prazole”  omeprazole Therapeutic purpose/indications  Helps to prevent and first line therapy for esophagitis, GERD (poorly responsive to other treatments such as H2 blockers), short term treatment of active gastric/duodenal ulcers, NSAID induced ulcers, and stress ulcer prophylaxis. Long term maintenance of healing of erosive esophagitis, and pathologic hypersecretory states  Contraindications/interactions  Allergy  Interaction: increase serum levels of diazepam and phenytoin  Interaction: increase risk of bleeding with warfarin  Interferes with absorption of digoxin, ampicillin, and iron  Slowed absorption when given with sucralfate  Food slows absorption  Adverse effects  Over prescribing of PPIs may be linked to GI tract infections due to loss of normal acid mediated microbial protection: FDA: BOX WARNING: C. difficile  Osteoporosis from inhibition of stomach acid necessary for calcium absorption, also PPIs may speed up bone demineralization: FDA: BOX WARNING: wrist, hip, and spine fractures, pneumonia, and 11

magnesium depletion  Possible link between PPIs and dementia  Administration/teaching  Complete appropriate history and physical exam, focusing on GI:  Ability to swallow (some capsules are LARGE) Some capsules can be opened and given with small amount of applesauce: check prior to administration  Joints ROM, muscle strength, history of fractures without trauma  All PPIs can be used with antibiotics to treat H. pylori infection  Can be given orally or capsules opened/diluted in water and given per NG or PEG  NOTE: pantoprazole granules must be given through a NG tube larger than 16 French – clogging will occur with smaller tubes  Some PPIs come in IV formulation  Give on an empty stomach 30-60 minutes before meals to enhance absorption  For patients with GERD: teach to avoid black pepper, caffeine, alcohol, harsh spices, and extremes in food temperature o sucralfate mucosal protectant Therapeutic purpose/indications  Treatment of active stress ulcers  Long term management of PUD  Esophageal erosion Provides thin lining of protection over ulcers 12

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Contraindications/interactions  Allergy  May interfere with absorption of other drugs: separate from other meds by 2 hours  Hypoglycemia may occur in the diabetic patient  Adverse effects  Nausea, constipation  Administration/teaching  Complete appropriate history and physical exam, focusing on GI  Local acting drug  Take on an empty stomach, separated from antacids by at least 30 minutes prior to or after the dose of sucralfate  Requires up to 4 doses per day  Teach patient importance of adhering to dose schedule  Take before meals and at bedtime  Monitor blood glucose response to sucralfate administration  For patients with difficulty swallowing (tablet is big) it can be given as a slurry  Place uncrushed tablet in plastic medicine cup and add 30 mL of warm water: the tablet will rapidly dissolve – then have patient drink it  Recent research and ED practice: sucralfate is being used to limit erosive esophagitis in children who swallow button batteries!, and dry mouth o simethicone o treatment of H. pylori infection  Develop a nursing plan of care using nursing process for a patient receiving medications for acid reflux and peptic ulcer disease. 13

Bowel Medications for Diarrhea and Constipation  Describe the mechanism of action, therapeutic purpose, cautions, contraindications, common adverse and toxic effects, and significant drug interactions for medications used to treat diarrhea and constipation: o Loperamide Therapeutic purpose/Indications  Decreases number of stools and their water content to treat acute diarrhea Opiod (cause unknown, traveler’s diarrhea, and to reduce ileostomy drainage  Contraindications/Interactions  Allergy  Do not give to patients with ulcerative colitis, pseudomembranous colitis, GI bleeding/obstruction/perforation  Interactions with other CNS depressants and alcohol and antihistamines Adverse effects  Dizziness, drowsiness fatigue  Nausea, dry mouth, vomiting, constipation  Administration/Teaching  Available OTC and by prescription  Give without regard to food but with adequate fluid intake  Teach to take exactly as prescribed and never exceed maximum tablets per day (overdose may cause dangerous changes in heart rhythm)  Use caution when driving a car or operating machinery  Do not give to children under the age of 2 o Probiotics  Therapeutic purpose/Indications 14

 Suppress growth of diarrhea-causing bacteria  Reestablish normal flora in the GI tract  Reduction in abdominal pain and cramping  Contraindications/Interactions  Allergy  Use cautiously severe illness and compromised immune systems  Adverse effects  Infection  Administration/Teaching  Take exactly as directed  Encourage natural sources such as yogurt, fermented milk, miso, tempeh, and soy beverages  Self-medication with probiotics for prolonged diarrhea may delay diagnosis and treatment of an underlying disease or disorder o Psyllium Therapeutic purpose/Indications  Management of acute and chronic constipation  Irritable bowel syndrome  Diverticulitis  Contraindications/Interactions  Allergy  Do not use in patients with nausea, vomiting, or abdominal pain  GI strictures (narrowing of the GI lumen)  Adverse effects 15

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 Few if any systemic effects, action limited to the GI tract  Impaction/blockage  Gas formation  Administration/Teaching  Available OTC  MUST be taken with ample water to prevent esophageal obstruction or fecal impaction  Approved and safe for long term use  Assess swallowing  If taking the powder version: mix with water (per directions) and drink immediately. Follow with an additional glass of water o Docusate Therapeutic purpose/Indications  Softens the stool to ease passage of stool WITHOUT straining  Treat constipation  Soften fecal impaction  Prevent opioid-induced constipation  Contraindications/Interactions  Allergy  Intestinal obstruction  Fecal impaction  Nausea/vomiting  Adverse effects  Rash 16

 Decreased absorption of vitamins  Administration/Teaching  Has NO stimulant properties  Teach patient to increase fluid intake to enhance softening of stool o Lactulose  Therapeutic purpose/Indications  Acidic environment reduces serum ammonia levels by converting ammonia to ammonium (water soluble) which is then excreted in the stool  Lactulose is used to control serum ammonia levels in patients with cirrhosis of the liver.  Protein converts to ammonia which is converted to Blood Urea Nitrogen (BUN) by the liver and excreted in the urine by the kidney. Patients with cirrhosis or hepatitis cannot make this conversion and ammonia levels rise causing hepatic encephalopathy. Manifestations of rising ammonia levels include anxiety, loss of balance/coordination/concentration, flapping hand tremor (asterixis), personality changes, muscle twitches, reduced alertness, altered sleep, slurred speech. If levels rise too high, hepatic coma and death follow  Contraindications/Interactions  Allergy  Contraindicated in persons on a low lactose diet  Adverse effects  Abdominal bloating 17

 Rectal irritation  Administration/Teaching  Older adults are less tolerant of this drug and other hyperosmotic laxatives o Magnesium Laxatives  Therapeutic purpose/Indications  Relief of constipation  Bowel prep prior to a diagnostic procedure  Removal of unabsorbed poisons from the GI tract  Contraindications/Interactions  allergy  Renal insufficiency and renal failure  Abdominal pain, nausea, vomiting, obstruction, rectal bleeding  Adverse effects  Magnesium toxicity (with renal insufficiency)  Cramping, diarrhea  Thirst  Electrolyte imbalances Administration/Teaching May cause dehydration Do not give or take with renal impairment Assess for electrolyte imbalance Very potent: nurses often think of it as “dynamite in a bottle” Magnesium citrate is more palatable chilled 18

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Drink extra fluids o Bisacodyl  Therapeutic purpose/Indications  Treatment of constipation  Evacuation of the bowel prior to diagnostic procedures or surgical procedures  Contraindications/Interactions  Allergy  Adverse effects  LAXATIVE DEPENDENCE  Nutrient malabsorption  Electrolyte imbalance  Abdominal cramping and pain  thirst  Administration/Teaching  The action of this drug is proportional to the dose  Assess for electrolyte imbalance  Teach for OCCASIONAL USE, if really needed.  Take on an empty stomach  Do not take with milk, antacids, or juices  Do not chew or crush tablets  Bisacodyl also is frequently given as a suppository: teach patient to try to retain the suppository for at least 15 to 30 minutes prior to attempting a BM  Discontinue if patient experiences severe abdominal pain 19

 Develop a nursing plan of care using nursing process for a patient receiving medications for diarrhea and constipation. Antiemetic and Antinausea Drugs  Describe the mechanism of action, therapeutic purpose, cautions, contraindications, common adverse and toxic effects, and significant drug interactions for medications used to treat nausea and vomiting: o Scopolamine Therapeutic purpose/Indications  Motion sickness  Post-operative Nausea and vomiting  Contraindications/Interactions  Allergy to scopolamine or atropine  Contraindicated in patients with narrow-angle glaucoma  INTERACTION: anticholinergics have added drying effect when given with antihistamines and antidepressants Adverse effects Dizziness, drowsiness Tachycardia Blurred vision, dilated pupils Difficult urination Constipation erythema Administration/teaching  Comes in oral, injectable, and transdermal formulas  Transdermal patch is placed on the mastoid process. Each patch is effective for 72 hours. Clean skin and dry prior to applying. 20

o Wear gloves to apply and remove  Teach patient NOT TO TOUCH the patch with fingers (if the active drug is touched and the eyes rubbed: pupil dilation will occur)  Teach patient to apply in advance of activities that produce motion sickness  Teach patient to carefully remove patch, folding the patch with medication inside and then wash hands  Rotate placement right to left  Older adults may experience confusion, agitation, and hypotension  Teach to avoid tasks that require mental clarity or motor skills (due to sedative effect) o Promethazine Therapeutic purpose/Indications  Intractable hiccups  Nausea and vomiting  Contraindications/Interactions  allergy  do NOT use in children under 2 yeas  INTERACTION: increased CNS depression when antidopaminergics are given with opioids, hypnotics, alcohol Adverse effects Sedation is most common side effect Orthostatic hypotension, tachycardia Extrapyramidal symptoms Tardive dyskinesia Blurred vision, dry eyes 21

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Urinary retention Dry mouth, anorexia, constipation  Administration/teaching  Preferred route is oral or IM, rectal, and IV use is not preferred but is commonly used  If giving IV: drug must be given via a vein only. Accidental arterial injection causes extensive tissue damage that may lead to amputation. Dilute in at least 10 mL and given via an infusing IV from the port farthest away from the patient  Assess IV access frequently; discontinue use is burning occurs  Assess hydration status carefully (turgor, tongue furrows) as may lead to excess drop in blood pressure  Assess ROM and muscle function: assess for abnormal involuntary muscle twitches that could be associated with extrapyramidal symptoms  Verify drug name carefully as a common sound alike drug  Teach patient to avoid use with other CNS depressants and alcohol and limit caffeine  Avoid driving or using machinery due to sedative effect o Metoclopramide Therapeutic purpose/Indications  Stimulates peristalsis and gastric emptying  nausea and vomiting  GERD (Gastroesophageal Reflux Disease)  Contraindications/Interactions  allergy 22

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 Contraindicated in patients with seizure disorders, pheochromocytoma, breast cancer, GI obstruction  INTERACTION: metoclopramide and alcohol increase CNS depression  INTERACTION: motility effects of metoclopramide are decreased with anticholinergics and opioids  Adverse effects  Hypotension  Supraventricular tachycardia  Sedation, fatigue  Dry mouth, diarrhea  Administration/teaching  FDA advisory: potential for tardive dyskinesia with long-term use, educate patient properly  Assess for extrapyramidal reactions: report to HCP immediately if occur  Take 30 minutes before meals and at bedtime  Administer IV forms over proper time frame per manufacturer's guidelines  IV forms are good for only 48 hours, then dispose of. IV forms are sensitive to the light o Ondansetron Therapeutic purpose/Indications  Postoperative nausea and vomiting  Nausea and vomiting associated with chemotherapy  Hyperemesis gravidarum  Contraindications/Interactions 23

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 allergy  No significant interactions Adverse effects  Headache  Diarrhea  Rash  Bronchospasm  FDA: BOX WARNING: Prolonged QT interval  Administration/teaching  To prevent post-operative nausea and vomiting: a dose is typically given 30 minutes before the end of surgery  To prevent nausea and vomiting associated with cancer treatment: give dose 30 -60 minutes before chemotherapy  Assess for signs of dehydration prior to use o Potassium • Serum level: 3.5-5 mEq/L • Potassium must be provided in the daily diet as it is not stored and excess is excreted  Hypokalemia o Causes Decreased intake Shift of potassium into cells from the blood Insulin administration Ion shift secondary to alkalosis Increased renal excretion 24

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Licorice (natural “European”) Low magnesium levels Excess loses Chronic diarrhea, bowel diversion, laxative abuse Featured Drug: potassium: Part 1  Hypokalemia o Causes Vomiting and gastric suction potassium loss due to metabolic alkalosis and low fluid volume stimulate aldosterone. Aldosterone saves sodium and water and excretes potassium GI drainage tubes medications beta 2 agonists (adrenergic agonists): albuterol corticosteroids diuretics laxative abuse o Manifestations Muscle weakness (especially of large muscles) Hypotension Lethargy/confusion Paralytic ileus Neuropathy hypoventilation 25

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Cardiac dysrhythmias ST segment and T wave depression Prominent U waves Premature ventricular beats (PVCs) Tachyarrhythmias Heart block Ventricular fibrillation Diagnosis Serum potassium level Serum magnesium level Acid/base ECG 24-hour urine for potassium excretion CBC o Treatment Diet modification to increase intake of potassium rich foods Treat excessive losses Oral supplementation IV supplementation  Therapeutic purpose/Indications  Treatment of or prevention of potassium depletion  Contraindications/Interactions  Allergy  Hyperkalemia 26

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 Renal disease  Acute dehydration  Untreated Addison’s disease  Hemolytic disease  Conditions of tissue breakdown such as trauma, burns  NOTE: low potassium levels in patients taking digoxin can lead to digoxin toxicity  INTERACTIONS: concurrent use of potassium supplements while taking potassium sparing diuretics, and ACE inhibitors: hyperkalemia  Adverse effects  Nausea, vomiting, and diarrhea  IV potassium can cause phlebitis  Administration/teaching  Assess manifestations and factors for hypokalemia, assess GI function and history of stomach issues  Always check MOST current potassium levels prior to administering ANY potassium supplements  IV potassium must be infused via a pump and over the proper time frame:  depending on the site of IV access  Never exceed 10 mEq/hour via peripheral line » Never exceed 20 mEq/hour via central line  ECG monitoring is required  NEVER ADD ADDITIONAL POTASSIUM TO A LITER IV BAG!  Peripheral fluids: no more than 20-40 mEq/L  Central fluids: no more than 60 mEq/L o Agitate IV fluids that contain potassium prior to spiking and priming the IV 27

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Potassium Replacement: Part 2  Administration/teaching  ONLY give IV potassium when adequate kidney function is present  Patients receiving 20 mEq/hr or more MUST be placed on a cardiac monitor  Potassium MUST BE DILUTED with NORMAL SALINE ONLY  Potassium can NEVER EVER be given IV push: will lead to sudden cardiac arrest  TOO MUCH potassium or TOO rapid infusion can lead to dangerous hyperkalemia and ventricular fibrillation  Treatment of hyperkalemia:  High elevations:  Dextrose and insulin drip  Sodium bicarbonate  Calcium gluconate or chloride  Sodium polystyrene sulfonate (Kayexalate)  Hemodialysis o Minor elevations: diet restrictions  Oral supplements can cause nausea and stomach irritation: give with food  Educate patient on foods that are naturally high in potassium Potassium Replacement: Part 3 Administration/teaching  ONLY give IV potassium when adequate kidney function is present  Patients receiving 20 mEq/hr or more MUST be placed on a cardiac monitor  Potassium MUST BE DILUTED with NORMAL SALINE ONLY  Potassium can NEVER EVER be given IV push: will lead to sudden cardiac arrest  TOO MUCH potassium or TOO rapid infusion can lead to dangerous hyperkalemia and 28

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ventricular fibrillation  Treatment of hyperkalemia:  High elevations:  Dextrose and insulin drip  Sodium bicarbonate  Calcium gluconate or chloride  Sodium polystyrene sulfonate (Kayexalate)  Hemodialysis o Minor elevations: diet restrictions  Oral supplements can cause nausea and stomach irritation: give with food  Educate patient on foods that are naturally high in potassium  Develop a nursing plan of care using nursing process for a patient receiving medications for nausea and vomiting.  Describe the proper administration of potassium by oral and intravenous routes. Anemia Drugs  Describe the mechanism of action, therapeutic purpose, cautions, contraindications, common adverse and toxic effects, and significant drug interactions for medications used to treat anemia: o folic acid Therapeutic purpose/Indication  Prevent and treat folic acid deficiency  Prevention of neural tube disorders: spina bifida and anencephaly  Contraindications/interactions  Allergy  DO NOT give folic acid for anemia until the cause of the anemia is known, otherwise blood counts may normalize masking symptoms  NOTE: oral contraceptives, sulfonamides, methotrexate can all cause folic acid deficiency 29

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Adverse effects  Rare  Yellow discoloration of urine  Administration/teaching  Encourage folic acid foods:  Spinach, kale, brussels sprouts, cabbage, broccoli, asparagus, beets  Beans and legumes  Oranges and orange juice  Whole grains  eggs  Pork, shellfish, liver  Fortified cereals  Take folic acid supplements/and encourage folic acid foods starting at least 1 month prior to becoming pregnant o vitamin B12 Therapeutic purpose/Indication  Treatment of vitamin B12 deficiency:  Pernicious anemia secondary to loss of intrinsic factor  From malabsorption, such as gastric bypass  Strict vegan diet and/or alcoholism Contraindications/interactions  Allergy  Hereditary optic nerve atrophy (Leber’s Disease)  INTERACTION: decrease oral B12 absorption when taken with anticonvulsants, 30

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aminoglycoside antibiotics, long-acting potassium preparations  Adverse effects  B12 is nontoxic and LARGE doses must be consumed to produce adverse effects:  Thrombosis  Flushing  Optic nerve atrophy  Diarrhea  Pruritus, rash  hypokalemia Administration/teaching  Monitor serum blood levels  Oral forms of Vitamin B12 require presence of intrinsic factor  Give with food  Encourage food sources of B12:  Liver  Beef  lamb  Mackerel, cams, crab, tuna, oysters, octopus, trout, sardines, salmon  Milk  Swiss cheese  B12 fortified foods: cereal, yogurt, soy milk  Given by deep IM injection (to treat megaloblastic pernicious anemia)  Preferred route  Also comes in an intranasal gel and a sublingual tablet 31

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o epoetin alfa  Therapeutic purpose/Indication  Treatment of anemia associated with chronic renal failure  Treatment of anemia associated with chemotherapy  Treatment of anemia associated with HAART therapy  Contraindications/interactions  Allergy  Caution when given with uncontrolled hypertension  Caution when hemoglobin levels are above 10 g/dL (cancer patients) or above 11 g/dL (renal patients)  These drugs may increase tumor growth and increase risk of thrombosis (clots)  Frequently given with oral or IV iron Featured Drug: epoetin alfa: Part 1 Mechanism of action  Biosynthetic form of the hormone erythropoietin Adverse effects  Hypertension  Fever, Headache  Pruritus, rash  Nausea/vomiting  Arthralgia  Injection site reaction  FDA: BOX WARNING: elevated hemoglobin levels above 11 g/dL: clots leading to myocardial infarction, stroke, and death  Administration/teaching 32

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 This medication is ineffective without adequate body iron stores and bone marrow function  Given by either subcutaneous injection or via IV  Teach/demo/return demo proper subcutaneous injection  Monitor CBC (especially hemoglobin)  Monitor blood pressure o ferrous sulfate Therapeutic purpose/Indication  Correct symptoms of iron deficiency anemia  Prevention of iron deficiency anemia  Contraindications/interactions  Allergy  Hemochromatosis (iron overload)  Do not give to patients with ulcerative colitis, peptic ulcer disease, hemolytic anemia, cirrhosis, gastritis  INTERACTIONS: decreased iron absorption with antacids and calcium  INTERACTIONS: decrease absorption of antibiotics such as tetracycline and quinolones Adverse effects  Nausea, constipation, black tarry stools, diarrhea  Temporary discoloration of tooth enamel (liquid formulations)  Administration/teaching  Complete a nutritional assessment  Assess for manifestations of iron deficiency anemia  For females between puberty and menopause: complete a history of menstrual cycles, assess for excessive or dysfunctional bleeding, pregnancy status 33

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 Monitor for iron toxicity  Vomiting, diarrhea, abdominal pain, drowsiness, tachypnea, hypotension, seizures, coma  Monitor serum iron levels, bilirubin, and levels of folate and B12  Monitor RBC, hemoglobin, hematocrit, and reticulocyte counts o iron dextran Therapeutic purpose/Indication  Iron deficiency anemia  Contraindications/interactions  Allergy  Adverse effects  Anaphylactic reactions Administration/teaching  For IM or IV use  Give test dose before injection of a full dose: allow 1 hour between test dose and administering the remaining medication  For IM: may cause staining of the skin: give deep IM by Z-track. Change needle prior to administering the drug  For IV: assess patency of the line prior to drug administration, flush line with normal saline prior to administration, give over the proper time interval. Premedication with diphenhydramine and acetaminophen may be ordered  Develop a nursing plan of care using nursing process for a patient receiving medications for anemia. 34

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Topics and Tips and Questions to Ponder During your Studies: For Example: Do You Know…  What is the difference between cell-cycle specific and cell-cycle nonspecific antineoplastics? Specific cell cycle will only identify and kill a cell that’s in a certain phase (mitosis) of reproduction. Nonspecific cell cycle kills cell no matter what phase the cell is in.  Discuss the RN role of giving chemo Look at patient’s chart and obtain any relevant information. Look at order to know what type of chemo you’re going to give. Observe IV site and make sure it is secured and not infected. Look at patient’s labs. Look at complete blood cell count (*white-line of protection* and red) and platelet count. Educate patient. Administer pre-meds just in case pt experiences side effects. Confirm drug and dosage with another set of eyes. Put on PPE. Administer chemo through pump. Dispose of used items in closed container.  What is a nadir? When a person with cancer reaches their “nadir” following each chemotherapy cycle, it means that the person's blood cell counts are the lowest they will be during that treatment cycle. It is temporary. As the drug is removed from the body, the blood cell count will normalize.  What is an absolute granulocyte count? How is it calculated? A look at the number of white blood cells (first responders) a person has. <500 indicates a problem.  When should chemotherapy be delayed? When vital signs are off, if neutrophil count is <500, if patient has an infection, if patient is dehydrated, if side effects have harmed lungs or kidneys. Give chemo even if patient is allergic, pre-load medication in system that would reduce the likelihood of an allergic reaction (Benadryl), line should be secure, so chemo does not leak. If drug leaks, cells will be killed and tissue will began to die  What is extravasation? What is the proper course of action? Extravasation is the unintentional leakage of vesicant fluids or medications from the vein into the surrounding tissue which could cause amputation. When it happens, turn off chemo. Keep primary fluid bag running. Some chemo has an antidote and tissue damage will occur. You can also place heat/ice on site or elevate the site.  What are the most common side effects of chemo? 35

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Cells that go through mitosis are going to be harmed first when doing chemo (hair, bone marrow) diarrhea, colon issues, issues with GI tract, sores, lowering of red blood cells, decrease in platelet count, neutropenia  What are common patient management issues in chemo patients and how can they be treated? Women and men given chemo after puberty have fertility issues. Chemo also penetrates the CNS and produce chemo (fog) brain. Hair usually falls out.  What are chemotherapy precautions? Cut hair off, don’t wash or comb hair often, stay on top of drugs, eliminate highly fat foods, spicy foods, caffeine, smoking. Practice good hygiene. Weigh patient on regular basis. Keep mouth clean. Oxygen provides energy so provide oxygen if needed, iron supplements as well. Let patient rest Never let patient out of bed without protective footwear. No razors, flossing. Place patient in private room, keep visitors away. Must wear PPE if people do come around. Only eat cooked foods, no fresh or raw foods. Bank sperm for men upon first treatment so men can father children if they want. Women should use birth control or put off treatment until baby is born.  What is a “biologic drug”? A drug based on an original live substance (bacteria, virus, animal/plant cell). They help to better the immune system and increase blood cell count.  What reasons are immune modulating drugs used? Drugs control your immune system against tumor. They attack malignant cells. It can turn down or amplify the immune system. Biologic drugs are modulating drugs. Stimulates the bone marrow to produce blood cells.  What are the 3 colony stimulating factors to produce blood cells?  Why are hematopoietic drugs used with chemotherapy? Hematopoietic drugs stimulate the growth of blood cells and platelet count. Filgrastim (neupogen) forces stem cells in the bone marrow to produce new WBCs; protects against infection; allows chemo to continue on schedule; can’t give to pts with bone cancer; makes bones ache; watch for infection; not pregnancy friendly. Another drug (Epogen alpha) stimulates the bone marrow to produce red blood cells (make sure a person has enough iron first; the more red blood cells, the thicker the blood is).  What are monoclonal antibodies? What are they used for? When are they contraindicated? Manipulates cells’s genetics and produce antibodies. Can be harvested and injected into patient. Every monoclonal antibody is the same. They are used to treat cancer, autoimmune disorders, and organ transplant. Kills off damaged cells. Contraindications are allergy, active infection, HIV, tumor necrosis, lymphoma. 36

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 What are common adverse effects? What screening and teaching should be done? Adverse reactions are allergic response, flulike sx, depression, fatigue, hypertension. Screen pt for infection, TB, HIV, cancer before administering treatment. Pt should report anything suspicious.  What is the difference between a monoclonal antibody drug and a biosimilar drug? Biosimilar drug is a cheap knockoff of monoclonal antibody. Bio(similar)=similar to another drug.  What are the DMARDS? When are they contraindicated? What should be ruled out before starting therapy? Treats rheumatoid arthritis. Immune suppressive. Anti-inflammatory, decrease pain, slow progression of disease, slow progression of disease. Screen before treating.  What adverse effects and administration/teaching are associated with methotrexate? Used for chemotherapy; anti-inflammatory, anti-arthritis (does not cure), immune suppressive, Screen before administering. Not bone marrow friendly. Causes ulcers and light sensitivity (will burn), nausea. Not liver friendly.  Why are immune suppressants used after organ transplant? What education should be completed? Very specific; Blocks T cells; Immune system collapses. Don’t drink with grapefruit juice. No vaccinations, infectious control procedures.  What protocols does a nurse follow when giving an immunization? When should a vaccine be withheld? Have to have confirmed consent from pt, immunization pamphlet must be given to pt. cannot give immunization against patient’s will, document immunization well into system. Store properly. Many vaccines use chicken eggs so screen people for allergies against eggs. Allergy against horse serum needs to be tested; technis uses horse serum. Cannot immunize for rubella if patient is pregnant, especially in first trimester.  What are the most common side effects of vaccines? Pain, fever, rash, edema serum sickness  What is the difference between an active and a passive immunization medication? Active is forever. Passive only provides a small window of protection  What is the difference between a vaccine and a toxoid? Toxoid comes from horses. Vaccines comes from bacteria.  How are antacids used in the treatment of GERD and PUD? How do calcium, magnesium, and aluminum in effectiveness and adverse effects? Anatacids are first type of drugs developed for ulcers, heart burn. Increase mucous protection. Alkaline, neutralize stomach acid. Magnesium mellows the muscles. Mg is very good of getting rid of heart burn, can cause diarrhea, can cause respiratory depression and toxicity in people with kidney disease. Aluminum is not the best of 37

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neutralizing, causes constipation. Calcium makes you feel better instantly, stimulates more acid production, can make people feel gassy and bloated.  How should antacids be given in relation to other meds? Should be separated from other medications by 2 hours. If liquid, shake before taking. If chewable, drink water with it. Can contain a lot of salt. For ulcer disease, antacids are given after the meal.  What is the difference between H2 receptor antagonists and proton pump inhibitors? H2 blockers only decrease acid production can cause altered mental status and growth of breast tissue. Proton pump inhibitors turn the mechanism off that creates hydrochloric acid.  What interactions, adverse effects and administration and teaching should be done is a patient is on an H2 blocker such as cimetidine?  How do PPI’s work and what adverse effects and teaching should be done?  Lack of acid production from PPIs causes food not to be broken down as easily and calcium is not retained in the body (bone problems). Acid is a normal retardant to the overgrowth of unwanted bacteria in the colon so C.Diff and other colon infections are common. PPIs are not as common as H2 blockers now.  How does sucralfate work? What teaching/administration issues need addressed? Alterations in esophagus/stomach. Dissolves in liquid and turns into sticky paste. Acts as a protective layer over ulcers. Needs to given before meals and bedtime.  What is H. pylori and what is the treatment protocol? Bacterial infection that causes ulcers in GI tract. #1 cause of ulcers in GI tract.  When should antidiarrheal medications be withheld? Why? If bacterial infection, fungal infection in colon. We want the patient to have diarrhea so infections comes out.  What teaching should be enforced if a patient is taking loperamide (Imodium)? Anti-diarrheal. Opioid. Can stop heart. 4 doses in a 24 hour period is enforced. Drug can make you sleepy.  What are the purposes for use of constipation drugs? What teaching should be done regarding laxative use? Scerosis, spinal cord injuries, to bring ammonia levels down, constipation.  How does psyllium work? What teaching is required? It is a laxative. Load up on fluid, fiber, and walking  What reasons would docusate be prescribed? Stool softener; decreases level of constipation.  How is lactulose used in the management of cirrhosis of the liver? Lactulose is a laxative. Lactulose is used to loosen bowels control (decrease) serum ammonia levels in patients with cirrhosis of the liver. It treats decreased comprehension and increases mental status. 38

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 What are the purposes for prescribing magnesium salts? When are these drugs contraindicated? What adverse effects do they produce? Promotes peristalsis and a bowel movement. cannot give to pt with renal problems. Could cause watery stool, cramping, and loss of electrolytes. Make sure no obstruction is in bowel tract.  What is laxative dependence? Which laxative can cause this? Laxative dependence= bowel movements don’t work unless drug is in system. Bisacodyl (stimulate laxative); causes contractions; fasts method to empty colon.  What interventions should be implemented to minimize nausea? No strong smells, no unpleaseant surroundings, small meals, small sips of water, carbonated beverages, nausea meds  When is scopolamine contraindicated? How should this drug be administered? What teaching needs to be done? For motion sickness; comes in a patch (transdermal) goes behind ear. Anti-cogulant. Related to atropy (drug); takes about a day to dissolve into skin; leave on for 72 hours; can make you tired  What are adverse effects associated with promethazine? What routes can it be administered and what cautions should be taken? What teaching should be done? Powerful anti-nauseant; IV has to be diluted with fluid and has to be pushed over the course of minutes; can make vision blurry, knock patient out. No alcohol or any other drug that makes people sleepy, no allergy medicine. Fall risk pt!  A patient on long-term metoclopramide should be monitored for what adverse effects? Reglan; helps reduce nausea. Can cause low blood pressure, sleepiness, tachycardia  What adverse effects, and administration/teaching concerns are associated with ondansetron? Zofran; developed to treat nausea associated with chemotherapy; provides immediate relief from nausea and vomiting; oral/IV;  What are contraindications to the administration of potassium? How is IV potassium administered safely? What teaching should be done for patients on oral supplements? Safer to give as food replacement. Oral potassium is upsetting to stomach so eat when taking it. Has to be diluted with normal saline. Do not push potassium alone. Hates veins. Cannot infuse faster than 10 units/hour.  What is the therapeutic purpose of epoetin alfa? What labs should be monitored? What supplement is required? What teaching should be done for a patient self-administering this drug? Regulates RBC; hemoglobin cannot go over 10-11 to prevent blood clots  What are adverse effects of ferrous sulfate? What teaching should be done? 39

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Viral deficiency. Will cause nausea, constipation, heart burn, black stool. Needs to be given with acidic beverage. Pt has to sit up for a while after taking it. Diet should be altered to include food that contains iron (chicken/vegetable/supplement)  How is iron dextran properly administered by the IV or IM route? Brown in color. Can cause anaphylaxis. Give a small dose first before administering entire dose. Make sure that IV line is good so brown iron stain is not left underneath pt’s skin. Have to be administered in Z tract method. Helps RBC count.  What are the therapeutic purposes for folic acid supplementation? What teaching should be done? Given to women who want to become pregnant. Helps brain and spinal cord develop. Water soluble.  Mega doses of cyanocobalamin (Vit B12) can cause what adverse effects? What teaching should be done? RBC production; can cause vision problems and clotting disturbances. Vegans must be on a B12 supplement for iron and RBC. People with anemia have to be injected with B12. 40

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NSG 251 Exam 3 Blueprint

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