ATI RN Pharmacology for Nursing (8th edition) PDF Adverse Effects, Interactions, and Contraindications

CHAPTER 5 UNIT 1 PHARMACOLOGICAL PRINCIPLES ADVERSE MEDICATION EFFECTS CHAPTER 5 Adverse Effects, These effects can be classified according to body systems. Interactions, and Central nervous system...

CHAPTER 5 UNIT 1 PHARMACOLOGICAL PRINCIPLES ADVERSE MEDICATION EFFECTS CHAPTER 5 Adverse Effects, These effects can be classified according to body systems. Interactions, and Central nervous system Contraindications Can result from central nervous system (CNS) stimulation (excitement) or CNS depression NURSING ACTIONS To ensure safe medication administration and If CNS stimulation is expected, clients can be at risk for seizures, and precautions should be taken. prevent errors, the nurse must know why a If CNS depression is likely, advise clients not to drive, medication is prescribed and its intended operate heavy machinery, or participate in other activities that can be dangerous. therapeutic effect. In addition, the nurse must Anticholinergic be aware of potential side/adverse effects, Effects that are a result of muscarinic receptor blockade. interactions, contraindications, and precautions. Most are seen in eyes, smooth muscle, exocrine glands, and the heart. Every medication has the potential to cause side CLIENT EDUCATION and adverse effects. Side effects occur when Manage these effects to minimize danger and the medication is given at a therapeutic dose. discomfort. Discontinuation of the medication is usually For example, dry mouth can be relieved by sipping on liquids; photophobia can be managed by use of not warranted. Adverse effects are undesired, sunglasses; and urinary retention can be reduced inadvertent, and unexpected severe responses by urinating before taking the medication. to the medication. Adverse effects can occur at Avoid activities that could lead to overheating, because there is a decreased ability to produce sweat to both therapeutic and higher-than-therapeutic cool the body. doses. Providers will discontinue the medication Cardiovascular immediately. Adverse effects are reported to Can involve blood vessels and the heart. the FDA using the MedWatch program. Antihypertensives can cause orthostatic hypotension. CLIENT EDUCATION: Monitor for indications of postural Medications are chemicals that affect the body. hypotension (lightheadedness, dizziness). If these occur, When more than one medication is given, there sit or lie down. Postural hypotension can be minimized by getting up and changing position slowly. is a potential for an interaction. In addition, Gastrointestinal (GI) medications can interact with foods, herbal Can result from local irritation of the GI tract. medicines, or other unconventional remedies. Stimulation of the vomiting center also results in adverse effects. Contraindications and precautions of specific CLIENT EDUCATION medications refer to client conditions that make NSAIDs can cause GI upset. Take these medications it unsafe or potentially harmful to administer with food. Opioid analgesics slow peristalsis and can cause nausea these medications. and sedation. Perform methods to avoid constipation and GI irritation, and promote safety. Response to medications differs for individuals Hematologic based on multiple factors (age, sex, disease Relatively common and potentially life-threatening with process, and ethnic/genetic variations). These some groups of medications. factors can be responsible for many expected NURSING ACTIONS: Bone marrow depression/suppression and unexpected adverse effects. is generally associated with anticancer medications and hemorrhagic disorders with anticoagulants and thrombolytics. CLIENT EDUCATION: Monitor for bleeding (bruising, discolored urine/stool, petechiae, bleeding gums). Notify the provider if these effects occur. RN PHARMACOLOGY FOR NURSING CHAPTER 5 ADVERSE EFFECTS, INTERACTIONS, AND CONTRAINDICATIONS 39  TOXICITY Rapid or immediate hypersensitivity An adverse medication effect that is considered severe Rapid or immediate hypersensitivity called atopic and can be life-threatening. allergy causes an overproduction of immune-globulin E It can be caused by an excessive dose, but it also can antibodies, resulting in acute inflammation, histamine occur at therapeutic dose levels. release, and vasoactive amines release (basophils, eosinophils, and mast cells). NURSING ACTIONS: Liver damage will occur with an Atopic allergies can result in hay fever, rhinosinusitis acetaminophen overdose. There is a greater risk of and can become severe. Severe reaction can result in liver damage with chronic alcohol use. The antidote, angioedema, anaphylaxis, or allergic asthma. This can acetylcysteine, can be used to minimize liver damage. occur by inhaling, ingesting, injection, or direct contact with an allergen. Hepatotoxicity Mild allergies (rash, hives, rhinosinusitis) is often Can occur with many medications. treated with diphenhydramine. Because most medications are metabolized in the liver, the liver is particularly vulnerable to drug-induced injury. Angioedema Damage to liver cells can impair metabolism of many A severe allergic reaction that affects deep tissues (blood medications, causing medication accumulation in the vessels, skin, subcutaneous tissue, mucous membranes). body and producing adverse effects. Generally, angioedema involves the lips, face, Many medications can alter normal values of liver oropharyngeal cavity, and neck, but can also affect the function tests with no obvious clinical indications of intestinal system and other parts of the body. liver dysfunction. NSAIDS and angiotensin-converting enzyme inhibitors NURSING ACTIONS (ACE inhibitors) are the most common medications that When two or more medications that are hepatotoxic are can cause angioedema and can occur within 24 hr or combined, the risk for liver damage is increased. anytime thereafter. Liver function tests are indicated when clients NURSING ACTIONS start a medication known to be hepatotoxic and Obtain a complete medical history to determine the type periodically thereafter. of medication the client is taking. Monitor clients for manifestations of hepatotoxicity Intervention is to apply oxygen, alleviate anxiety with (nausea, vomiting, jaundice, dark urine, abdominal reassurance, and if needed, maintain an open airway discomfort, and anorexia). Advise clients to monitor for with intubation or tracheostomy if laryngeal edema, these manifestations. stridor, and inability to swallow develops. Treatment is with corticosteroids, diphenhydramine, Nephrotoxicity and epinephrine depending on the severity of the Can occur with a number of medications, but it is primarily client’s condition. Monitor for recurrence when the result of certain antimicrobial agents and NSAIDs. medications wear off. Damage to the kidneys can interfere with medication excretion, leading to medication accumulation and Anaphylaxis and Allergic asthma adverse effects. Anaphylaxis is a life-threatening, immediate systemic NURSING ACTIONS: Aminoglycosides can injure cells in reaction caused from an allergic response to a the renal tubules of the kidneys. Monitor blood creatinine medication, dye, food, or insect bit or sting. Allergic and BUN, as well as peak and trough medication levels for asthma also has a rapid onset with similar causes. clients taking medication that is nephrotoxic (acyclovir, Manifestations of anaphylaxis can start with anxiety, aminoglycosides, cyclosporine, NSAIDs, amphotericin B). weakness, generalized itching and hives that progress to erythema and angioedema of the head and neck. Crackles, wheezing, decreased breath sounds, a feeling of a lump HYPERSENSITIVITY/ALLERGIES in the throat, hoarseness, and stridor can develop into Hypersensitivity and allergy are terms a life-threatening condition that results in respiratory used interchangeably. failure, hypoxemia, hypotension, tachycardia, and death. Occurs when an individual develops an immune Allergic asthma has similar manifestations that involve response to a medication. the pulmonary system that can become life-threatening. The individual has been previously exposed to the Allergic asthma is the production of an asthma response medication and has developed antibodies. following exposure to an allergen. Hypersensitivity or allergies can result in a mild reaction NURSING ACTIONS (itching, rash, watery eyes, sneezing, rhinosinusitis) or a Prevention and rapid intervention are vital to avoid a severe reaction resulting in anaphylaxis. fatal outcome. If the allergy is known, the client should wear a medical alert bracelet. The client should have available at all time injectable epinephrine. Stop the medication immediately if that is the antigen and notify the Rapid Response team. 40 CHAPTER 5 ADVERSE EFFECTS, INTERACTIONS, AND CONTRAINDICATIONS CONTENT MASTERY SERIES  Establish an airway to maintain ventilation. Administer Increased adverse effects bronchodilators if needed. NURSING ACTIONS: Clients can take two medications that Treat with epinephrine IM or IV to constrict blood vessels, have the same adverse effect. Taking these medications improve cardiac contraction, and promote bronchodilation together increases the risk of potentiating these of the pulmonary system, every 5 to 15 minutes as needed. findings. Diazepam and hydrocodone bitartrate 5 mg/ Administer diphenhydramine, an antihistamine, to acetaminophen 500 mg both have CNS depressant effects. decrease manifestations of the angioedema and urticaria. When these medications are used together, clients have an Continue to administer oxygen, obtain arterial blood increased risk for CNS depression. gases, plan for the client to receive inhaled beta- adrenergic agonist or bronchodilators (albuterol, Decreased therapeutic effects metaproterenol) every 2 to 4 hr. Administer corticosteroids for late recurrence NURSING ACTIONS: One medication can increase the of manifestations. metabolism or block the effects of a second medication Monitor hemodynamics; watch for fluid overload from and therefore decrease the blood level and effectiveness of too rapid of IV fluid infusions, and pulmonary status. the second medication. For example: Phenytoin increases hepatic EXTRAPYRAMIDAL SYMPTOMS (EPSs) medication-metabolizing enzymes that affect warfarin and thereby decreases the Abnormal body movements that can include involuntary blood level and the effect of warfarin. fine-motor tremors, rigidity, uncontrollable restlessness, and acute dystonias (spastic movements and/or muscle Decreased side/adverse effects rigidity affecting the head, neck, eyes, face, tongue, back, and limbs). NURSING ACTIONS: One medication can be given to Can occur within a few hours or take months to develop. counteract the side/adverse effects of another medication. Ondansetron hydrochloride, an antiemetic, can be NURSING ACTIONS administered to counteract the side effects of nausea and EPSs are more often associated with medications vomiting for clients receiving chemotherapy. affecting the CNS (those used to treat mental health disorders). Increased blood levels, leading to toxicity Most EPSs can be treated with anticholinergic medications NURSING ACTIONS: One medication can decrease the metabolism of a second medication and therefore IMMUNOSUPPRESSION increase the blood level of the second medication. Decreased or absent immune response. This can lead to toxicity. Fluconazole inhibits hepatic medication-metabolizing enzymes that affect aripiprazole NURSING ACTIONS and thereby increases blood levels of this medication. Immunosuppressant medications (glucocorticoids) can mask the usual manifestations of infection (fever). Monitor clients taking an immunosuppressant (a 5.1 Over-the-counter (OTC) glucocorticoid) for delayed wound healing and subtle medication interactions manifestations of infection (sore throat). INTERACTIONS CLIENT EDUCATION: Avoid contact with anyone who has a Ingredients in OTC medications or herbal supplements can interact with other OTC or prescription medications. communicable disease. Inactive ingredients (dyes, alcohol, or preservatives) can cause adverse reactions. Potential for overdose exists because of the use of INTERACTIONS several preparations (including prescription medications and herbal supplements) with similar ingredients. NURSING IMPLICATIONS DRUG-DRUG INTERACTIONS Obtain a complete medication history and include any prescription medications, OTC medications, illicit drug Increased therapeutic effects use, as well as herbal and other dietary supplements. Instruct clients to follow the manufacturer’s NURSING ACTIONS: Some medications can be given recommendation for dosage. together to potentiate their action and increase therapeutic effects. INTERACTION Interactions of certain prescription and OTC CLIENTS EDUCATION: If with asthma, use albuterol, a medications can interfere with therapeutic effects. beta2-adrenergic agonist inhaler, 5 min prior to using NURSING IMPLICATIONS: Advise clients to use caution and triamcinolone acetonide, a glucocorticoid inhaler, to to check with the provider before using any OTC preparations increase the absorption of triamcinolone acetonide. (antacids, laxatives, decongestants, herbal supplements, or cough syrups). For example, antacids can interfere with the absorption of ranitidine and other medications. Advise client to follow provider and pharmacist guidelines for separating administration of antacids and other medications. RN PHARMACOLOGY FOR NURSING CHAPTER 5 ADVERSE EFFECTS, INTERACTIONS, AND CONTRAINDICATIONS 41  MEDICATION-FOOD INTERACTIONS PREGNANCY RISK CATEGORIES Food can alter medication absorption and/or can contain The U.S. Food and Drug Administration (FDA) has assigned substances that react with certain medications. categories to medications according to the risks they pose to a fetus. Although this classification system is still in EXAMPLES widespread use, new medications that have received FDA Consuming foods with tyramine while taking approval since mid-2015 and those yet to receive approval monoamine oxidase inhibitors (MAOIs) can lead to FDA approval have or will have labeling detailing the risks hypertensive crisis. Clients taking MAOIs should in three sections: pregnancy, lactation, and females and be aware of foods containing tyramine (cheese and males of reproductive potential. Medications approved processed meats) and avoid them. prior to mid-2015 will be updated accordingly, and should Vitamin K can decrease the therapeutic effects of be in compliance by 2020. The following are the previous warfarin and place clients at risk for developing pregnancy risk categories. blood clots. Clients taking warfarin should include a consistent amount of vitamin K in their diet. CATEGORY A: There is no evidence of risk to fetus during Tetracycline can interact with a chelating agent (milk), pregnancy based on adequate and well-controlled studies. and form an insoluble, unabsorbable compound. Instruct CATEGORY B: There is no evidence of risk to animal clients not to take tetracycline within 2 hr of consuming fetuses based on studies, but there are no adequate and dairy products. well-controlled studies in pregnant clients. Grapefruit juice seems to act by inhibiting medication metabolism in the small bowel, thus increasing the CATEGORY C: Adverse effects have been demonstrated on amount of medication available for absorption of certain animal fetuses. There are no adequate and well-controlled oral medications. This increases either the therapeutic studies in pregnant clients, but use of the medication effects or the adverse reactions. Instruct clients to not during pregnancy can be warranted based on the drink grapefruit juice if they are taking such potential benefits. a medication. CATEGORY D: Adverse effects have been demonstrated Food often decreases the rate of medication absorption. on human fetuses based on data from investigational However, some foods increase the rate of absorption of or marketing experience, but use of the medication certain medications. during pregnancy can be warranted based on the potential benefits. CONTRAINDICATIONS CATEGORY X: Adverse effects have been demonstrated on AND PRECAUTIONS animal and human fetuses based on studies and data from investigational or marketing experience. The use of the A specific medication can be contraindicated for a client medication is contraindicated during pregnancy because based on the client’s condition. For example, penicillins the risks outweigh the potential benefits. are contraindicated for a client who has an allergy to this medication. Precautions should be taken for a client who is more likely to have an adverse reaction than another client. Morphine depresses respiratory function, so it should be used with caution for clients who have asthma or impaired respiratory function. 42 CHAPTER 5 ADVERSE EFFECTS, INTERACTIONS, AND CONTRAINDICATIONS CONTENT MASTERY SERIES  Application Exercises 1. A nurse in a clinic is caring for a group of clients. 3. A nurse is providing discharge instructions The nurse should contact the provider about a for a client who has a new prescription for an potential contraindication to a medication for which antihypertensive medication. Which of the of the following clients? (Select all that apply.) following statements should the nurse give? A. A client at 8 weeks of gestation who A. “Be sure to limit your potassium intake asks for an influenza immunization while taking the medication.” B. A client who takes prednisone and B. “You should check your blood pressure every has a possible fungal infection 8 hours while taking this medication.” C. A client who has chronic liver disease and C. “Your medication dosage will be increased is taking hydrocodone/acetaminophen if you develop tachycardia.” D. A client who has peptic ulcer disease, D. “Change positions slowly when you takes sucralfate, and has started move from sitting to standing.” taking OTC aluminum hydroxide E. A client who has a prosthetic heart valve, takes warfarin, and reports a suspected pregnancy 4. A nurse is reviewing a client’s health record and notes that the client experienced permanent extrapyramidal effects caused by a previous medication. The nurse 2. A nurse is preparing to administer an IM dose of should recognize that the medication affected penicillin to a client who has a new prescription. which of the following systems in the client? The client states when they took penicillin 3 A. Cardiovascular years ago, they developed a rash. Which of the B. Immune following actions should the nurse take? C. Central nervous A. Administer the prescribed dose. D. Gastrointestinal B. Withhold the medication. C. Ask the provider to change the prescription to an oral form. 5. A nurse is caring for a client who is taking oral oxycodone. The client is also taking ibuprofen in D. Administer an oral antihistamine at the same time. three recommended doses daily. The nurse should identify that an interaction between these two medications will cause which of the following findings? A. A decrease in blood levels of ibuprofen, possibly leading to a need for increased doses of this medication B. A decrease in blood levels of oxycodone, possibly leading to a need for increased doses of this medication C. An increase in the expected therapeutic effect of both medications D. An increase in expected adverse effects for both medications Active Learning Scenario A nurse is planning care for a client who is receiving gentamicin IV bolus twice daily. The client has a history of musculoskeletal pain and takes naproxen daily for relief. What information should the nurse include in the client’s plan of care? Use the ATI Active Learning Template: Medication to complete this item. THERAPEUTIC USES: Describe the use of gentamicin. COMPLICATIONS: Describe two adverse effects. NURSING INTERVENTIONS Describe two laboratory findings to monitor. Describe two nursing actions. RN PHARMACOLOGY FOR NURSING CHAPTER 5 ADVERSE EFFECTS, INTERACTIONS, AND CONTRAINDICATIONS 43  Application Exercises Key Active Learning Scenario Key 1. A. The influenza vaccine is recommended for all Using the ATI Active Learning Template: Medication clients older than 6 months of age and is not THERAPEUTIC USES: Gentamicin is a narrow-spectrum contraindicated for pregnant clients. aminoglycoside antibiotic prescribed to treat B. CORRECT: Glucocorticoids should not be taken by a serious infections caused by aerobic bacilli. client who has a possible systemic fungal infection. Recognize a contraindication and notify the provider. COMPLICATIONS C. CORRECT: Acetaminophen is contraindicated Gentamicin can injure cells of the proximal renal tubules. due to toxicity for a client who has a liver disorder. Naproxen and other NSAIDs can cause renal insufficiency. Notify the provider, who can prescribe a medication The glomerular filtration rate of the kidneys decreases with advanced that does not contain acetaminophen. age, making this client at increased risk for nephrotoxicity. D. There is no contraindication for a client who has peptic ulcer disease and takes sucralfate and also starts taking NURSING INTERVENTIONS OTC aluminum hydroxide. Ensure that the client takes Laboratory Findings to Monitor the two medications 30 min apart and verify that the BUN ◯ provider knows what medications the client is taking. Blood creatinine ◯ E. CORRECT: Warfarin is a Pregnancy Category X medication, Peak and trough levels of gentamicin ◯ which can cause severe birth defects to the fetus. Notify Specific gravity of urine ◯ the provider about the suspected pregnancy. Urinalysis ◯ NCLEX® Connection: Pharmacological and Parenteral Therapies, Nursing Actions Adverse Effects/Contraindications/Side Effects/Interactions Monitor intake and output. ◯ Notify the provider of low urinary output. ◯ 2. A. Administering the intramuscular penicillin in the Ensure that the client is adequately hydrated, ◯ prescribed dosage could cause a severe reaction and monitor for fluid overload. and is not the appropriate action. Assess for manifestations of ototoxicity. ◯ B. CORRECT: Withhold the medication and notify the provider NCLEX® Connection: Pharmacological and Parenteral Therapies, of the client’s previous reaction to penicillin so that an Adverse Effects/Contraindications/Side Effects Interactions alternative antibiotic can be prescribed. Allergic reactions to penicillin can range from mild to severe anaphylaxis, and prior sensitization should be reported to the provider. C. Administering the penicillin orally rather than intramuscularly would not prevent a reaction and is not the appropriate nursing action. D. Giving the penicillin along with an oral antihistamine would not prevent a reaction from occurring and is not the appropriate nursing action. NCLEX® Connection: Pharmacological and Parenteral Therapies, Adverse Effects/Contraindications/Side Effects/Interactions 3. A. Potassium can lower blood pressure, so clients who have hypertension should eat plenty of fruits and vegetables. B. Clients should check their blood pressure daily on a regular basis when taking an antihypertensive medication, but every 8 hr is unnecessary. C. Tachycardia is an adverse effect that would not warrant an increase in a dose of medication. D. CORRECT: Orthostatic hypotension is a common adverse effect of antihypertensive medications. The client should move slowly to a sitting or standing position and should be taught to sit or lie down if lightheadedness or dizziness occurs. NCLEX® Connection: Pharmacological and Parenteral Therapies, Adverse Effects/Contraindications/Side Effects/Interactions 4. A. Medications affecting the cardiovascular system generally do not cause extrapyramidal effects. B. Medications affecting the immune system generally do not cause extrapyramidal effects. C. CORRECT: Realize that extrapyramidal effects are movement disorders that can be caused by a number of central nervous system medications (typical antipsychotic medications). D. Medications affecting the gastrointestinal system generally do not cause extrapyramidal effects. NCLEX® Connection: Pharmacological and Parenteral Therapies, Adverse Effects/Contraindications/Side Effects/Interactions 5. A. Taking these medications together does not cause a decrease in blood levels of ibuprofen. B. Taking these medications together does not cause a decrease in blood levels of oxycodone. C. CORRECT: These medications work together to increase the pain-relieving effects of both medications. Oxycodone is a narcotic analgesic, and ibuprofen is an NSAID. They work by different mechanisms, but pain is better relieved when they are taken together. D. Adverse effects of oxycodone and ibuprofen are not increased when the medications are taken together. NCLEX® Connection: Pharmacological and Parenteral Therapies, Adverse Effects/Contraindications/Side Effects/Interactions 44 CHAPTER 5 ADVERSE EFFECTS, INTERACTIONS, AND CONTRAINDICATIONS CONTENT MASTERY SERIES