170 B Exam 3 Study Guide PDF

# 170 B Exam 3 Study Guide ## Exam 3 Exam 3 will cover material from Weeks 5-8. It will include content from Sherpath lessons, EAQs, and PowerPoint slides. There will be 45 questions totaling 82 points. Some questions will have multiple parts. **Please review any OSMOSIS videos for medications.*...

# 170 B Exam 3 Study Guide ## Exam 3 Exam 3 will cover material from Weeks 5-8. It will include content from Sherpath lessons, EAQs, and PowerPoint slides. There will be 45 questions totaling 82 points. Some questions will have multiple parts. **Please review any OSMOSIS videos for medications.** ## Key Topics - IV Sites/Access (SG#3) - Signs of cellulitis (SG#4) - First generation cephalosporins used to treat (SG#14) - TMP-SMX (Bactrim) (SG#24) - Antihistamines treat (SG#19) - Surgical Care Improvement Project (SCIP) (SG#28) - Epidural Catheter (SG#31 & 32) - VTE (SG#39) - Smoking and Vaping complications (SG#40) - Valacyclovir MOA (SG#1 & 2) - Hypotonic intravenous (IV) (SG#7) - RN interventions for IV potassium (SG#8) - Crystalloid solutions adverse effect (SG#9) - Treatment for genital herpes (SG#11) - Nursing considerations when providing IV antivirals (SG#43) - Adverse reaction of giving a intravenous bolus (SG#12) - Skin discomfort (SG#17) - MOA of Cephalosporins (SG#13) - IV Antibiotics, what to monitor for? (SG#13) - What is a Macrolide? (SG#22) - What are Macrolides side effects? (SG#23) - Tetracyclines (SG#16) - Second generation of second-generation antihistamines (SG#21) - Dr Favorite Antiemetic? (SG#37) - Promethazine (SG#36) - National safety goals for surgery (SG#29) ## Mechanism of Action of Valacyclovir Valacyclovir is metabolized to acyclovir in the body. It acts as a guanosine analogue that inhibits viral DNA polymerase and prevents replication of HSV and VZV. Valacyclovir gets incorporated into the growing viral DNA chain and causes chain termination. This mechanism of action allows valacyclovir to suppress active viral infections and reduce symptom severity. ## Side Effects of Valacyclovir - Headache - Nausea - Vomiting - Diarrhea - Abdominal pain - Dizziness - Rash - Increased liver enzymes - Kidney problems - Confusion - Agitation - Seizures - Coma - Blood disorders like thrombocytopenia ## Valganciclovir - Hematologic toxicity - Impaired fertility - Carcinogenesis - Fetal toxicity ## Contraindications **Acyclovir & Valacyclovir:** - Pregnancy - Breastfeeding - Electrolyte imbalance - Dehydration - Zidovudine & Aminoglycosides: Increased risk of neurologic side effects and nephrotoxicity ## Sites Safe for IV Insertion Avoid areas of: - Joint flexion - The same side of a mastectomy - Dialysis shunt or AV fistulas - Areas that present signs or symptoms of infection - Extensive scarring, burns, or surgeries - CVA paralysis side - Extremities that have previous recent infiltration, extravasation, or phlebitis - Site distal to previous puncture ## Finding a Vein - Go by feel not by sight - Use warm compresses - Let arm hang downward - Avoid areas of joint flexion - Start distally and work upward ## Never Choose Veins: - In extremities on the same side of a mastectomy - Any extremity that has dialysis shunts or AV fistulas - Present signs/symptoms of infection - Areas with extensive scarring, burns, or surgeries - CVA paralysis side - Extremities that have previous recent infiltration, extravasation, or phlebitis - Site distal to previous puncture ## Tourniquet Place 6-8 inches above the intended site. - Massage vein prn - Clench fist prn - Use heat prn Bevel goes face up always, insertion always toward heart. **Never tie a tourniquet in a knot.** ## Extension Tubing Connects to the patient's IV catheter to make a saline lock with a cap on the end. ## IV Fluids - Expand intravascular volume - Correct imbalances of fluids and electrolytes - Compensate for an ongoing problem that is affecting pt's fluid and electrolytes ## Fluid Overload Can cause CHF. - Excessive fluid accumulation in the body increases the workload on the heart. This can weaken the heart muscle and lead to CHF. ## D5W (Dextrose 5% in Water) A form of glucose (sugar) injected into a vein through an IV to replace lost fluids and provide carbohydrates. It is used to treat: - Low blood sugar (hypoglycemia) - Insulin shock - Dehydration (fluid loss) - Nutritional support to patients who are unable to eat because of illness, injury, or other medical conditions. ## IV Flow Rates - Gravity flow (check rate hourly, do not try to catch up if running slow) - Volume control pump - Sigma pump - Alaris pump ## Clinical Findings of Cellulitis Inflammation of the loose connective tissue around the insertion site. It is caused by poor aseptic technique. Red swollen areas spreads from the insertion site outwardly in a diffuse circular pattern. - Warmth - Tenderness - Swelling is present ### Key Signs: - Erythema (redness) of the skin - Warmth over the affected area - Swelling/edema - Pain or tenderness - Possible fever ## Reasons Why IV Meds are Administered - Helps maintain/restore fluid volume and electrolyte balance - Nourishes and provides patient calories - Medication administration - To transfuse blood products - To provide avenue for diagnostic lab testing. ## Antidotes for Drugs Reviewed in Class - Heparin ⇄ Protamine sulfate - Acetaminophen ⇄ Acetylcysteine (mucomyst) - Opioids ⇄ Naloxone (Narcan) - Warfarin ⇄ Vitamin K (phytonadione) - Benzodiazepine ⇄ Flumazenil ## Hypotonic Intravenous (IV) Fluids - Pull body water into the cells (net inflow = cell expands) - Used to treat conditions where there is an excess of sodium or solutes in the extracellular fluid, leading to movement of water out of cells ### Clinical Problems Targeted by Hypotonic Fluids - Hypernatremia - Hypertonic dehydration - Hypovolemia - Acute kidney injury - Hyperglycemic emergencies - Hyperosmolar Hyperglycemic Nonketotic Syndrome (HHNS) - Chronic Heart Failure - Diabetic ketoacidosis (DKA) ### Commonly Ordered Hypotonic Fluids: - 0.45% normal saline - 0.33% normal saline - 0.225% normal saline ### Contraindicated In: - Dehydration - Trauma and ICP (intracranial pressure) ## RN Interventions for IV Potassium Replacement - Verify the order, concentration, rate, and compatibility with other IV fluids. Double-check calculations. - Assess the patient's kidney function and urine output before administration to prevent potassium toxicity. - Monitor cardiac rhythm continuously during infusion. Do not exceed 10 mEq/hr for non-monitored patients. - Inspect IV site hourly for signs of extravasation or phlebitis. - Educate patients on S/S of hyperkalemia, such as muscle weakness and arrhythmias. - Never give potassium as an IV push or bolus due to the risk of cardiac arrest. Must dilute with 0.9% NS. - Document intake, output, potassium levels, and patient response. - Use an infusion pump for precise control of potassium infusion rate. **Must dilute because it burns. Must run it as two primary lines at the same time.** ## Crystalloid Solutions Adverse Effect ### S/S Of Pulmonary: - Dyspnea - Tachypnea - Crackles in the lungs - Restlessness - Hypertension Crystalloids supply water and sodium to maintain the osmotic gradient between the extravascular and intravascular compartments. The most commonly used crystalloids are normal saline (0.9% NaCl) and lactated Ringer's solution. ### Unwanted Effects: - Leakage out of the plasma into the tissues and cells may result in edema anywhere in the body. - Peripheral edema and pulmonary edema are two common examples. - Dilute the proteins that are in the plasma, which further reduces the colloid oncotic pressure. - Large volumes of fluid are usually required; therefore, prolonged infusions may cause fluid overload. - Short-lived effects. ### Main Adverse Effects: - Edema (peripheral, pulmonary) due to the leakage of fluid from blood vessels into tissues - Dilution of plasma proteins, reducing oncotic pressure - Fluid overload from large volume infusions required for effectiveness - Short-lived effects, requiring prolonged infusions that can lead to fluid overload - Electrolyte imbalances if not properly balanced solutions ## RN Would Expect to Decrease IV Therapy - Infiltration or extravasation at the IV site due to improper placement (S/S: swelling, discomfort, burning, tightness, cool skin, blanching) - Phlebitis, inflammation of the vein - Fluid overload symptoms like edema, crackles, jugular venous distention - Electrolyte imbalances like hyperkalemia or hypokalemia - Improvement in the patient's condition making IV therapy unnecessary - Patient refusal or inability to continue IV therapy - Cellulitis from contamination during insertion resulting in a bacterial infection of the skin and soft tissue around the IV site (S/S: redness, warmth, swelling, and pain) - Air embolus (Occurs when air enters the bloodstream through the IV line (S/S: dyspnea, chest pain, hypotension, tachycardia, decreased LOC) ## Treatment for Genital Herpes - There is no cure. - Antiviral medications help manage outbreaks and reduce transmission risk. **For Initial Outbreaks** - Acyclovir (must drink lots of water, also treats varicella) - Valacyclovir - Famciclovir **Intravenous Acyclovir** - May be needed for severe cases. **Episodic Therapy** - Taking antivirals at the first sign of an outbreak can speed healing if started promptly. **Suppressive Therapy** - Daily antiviral medication reduces outbreak frequency but does not eliminate viral shedding. **Patient Education** - Transmission prevention - Trigger avoidance - Emotional support ## Administration of an Intravenous Bolus **Hypertonic** - 5%, 3% D5NS, de1/2NS, D5LR, D10W. **Used for:** - Cerebral edema - Hyponatremia - Metabolic alkalosis - Hypovolemia - Maintenance of fluids **Monitor for:** - Fluid overload **MAO** - Vessels become more concentrated than cells; therefore, cells will shrink. **Hypotonic MAO** - Vessels become less concentrated than cells, therefore, cells will swell. **Contraindications:** - ICP - Burns - Dehydration - Trauma **Examples:** - 0.45%, 0.33%, 0.225%,D5W **Used for:** - Hypernatremia - Dehydrated cells - DKA - Hyperglycemic stage **Adverse Effects:** - Fluid overload - Edema - Fluid in lungs - Crackles in lungs. ## Adverse Reaction of Giving a Intravenous Bolus - Fluid overload (shortness of breath, jugular venous distension, and crackles on lung auscultation) - Catheter dislodgement or infiltration - Phlebitis, extravasation, or anaphylaxis ### Be vigilant for: - Adverse reactions, especially with certain medications or blood products. - Closely observe the patient's overall response and make necessary adjustments. ## Cephalosporins ### MOA - Semisynthetic antibiotics that work by interfering with bacterial cell wall synthesis. - Inhibit cell wall formation and causes bacterial cell death. - Bind to penicillin-binding proteins inside bacteria. ### Common Side Effects: - Headache - Vomiting - Dizziness - Diarrhea - Nausea - Mild diarrhea - Abdominal cramps - Skin rash at injection site - SJS - Anaphylaxis - Disrupt GI flora #### Cross-sensitivity with penicillin allergies: - Can occur in 1-4% of patients. - Caution is advised in those with a history of several penicillin reaction ### Serious Side Effects: - Seizures (particularly in clients with renal impairment, acute kidney injury, or renal failure) - Hyperkalemia - Hematologic issues: Anemia, neutropenia, and thrombocytopenia. - Meningitis, pneumonia, uti, sepsis. ### Monitoring IV Antibiotics: - The IV site for signs of: - Phlebitis (redness, swelling, warmth, pain along the vein) - Infiltration (swelling, coolness, slowed/stopped flow, lack of blood return) - Extravasation (leakage into surrounding tissues) - Dislodgement or accidental removal of the IV catheter #### When monitoring IV antibiotics it is important to be alert for the following: - Hypersensitivity reactions (wheezing. shortness of breath, swelling, itching, or rash which could indicate an allergic reaction). **MOA of Cephalosporins** Mechanism of action: - Inhibit bacterial cell wall synthesis. - Bind to and inactivate penicillin-binding proteins (PBPs). - Disrupt the structural integrity of the cell wall. - Leads to osmotic instability and eventual cell lysis and death. * Belong to Beta-Lactam antibiotics: - Disrupt synthesis of peptidoglycan layer - Weaken bacterial cell wall - Kill bacteria ## First Generation Cephalosporins ### Used to treat infections: - Cephalexin(PO) - Cefadroxil(OP IV) - Cefazolin(IV IM) ### Primarily used to treat infections: - Gram-positive bacteria (Staphylococcus and Streptococcus species) - Common indications: Skin and soft tissue infections, surgical prophylaxis, respiratory tract infections, urinary tract infections, and bone/joint infections caused by susceptible organisms. ### Examples of first-generation cephalosporins: - Cefazolin - Cephalexin - Cefadroxil ## Cefazolin Intravenously - Monitor the insertion site closely for signs of extravasation, such as redness, puffiness, or blanching. - Monitor: Vital signs and urine output, as well as for signs of a hypersensitivity reaction (an unusual rash or blister, throat tightness, difficulty swallowing, or shortness of breath). ## First Generation Cephalosporins - Treat infection caused by gram-positive bacteria. - Have excellent activity against Staphylococcus and Streptococcus species. - Common uses include: - Skin and soft tissue infections - Surgical prophylaxis - Respiratory tract infections - Urinary tract infections - Bone and joint infections ## Potential Severe Adverse Effects of Cephalosporins: - Anaphylactic reactions - Stevens-Johnson syndrome - Exfoliative dermatitis - Seizures ## Penicillins (Class) - Inhibit bacterial cell wall synthesis, causing cell lysis and death. - Bind to penicillin-binding proteins, interfering with peptidoglycan cross-linking in cell walls. - Active against gram-positive organisms like Streptococcus and some gram-negatives. - Oral and parenteral routes available. - Assess for penicillin allergies. - Monitor kidney function, electrolytes like potassium. - Common adverse effects: Gastrointestinal upset, rash, fever, superinfections - Narrow vs broad-spectrum - choose the narrowest effective agent - Combination therapy used for some resistant organisms - Crucial to complete full course to prevent resistance ## Penicillins Are Used to Treat a Wide Range of Infections: - Streptococcal infections, such as pharyngitis, tonsillitis, scarlet fever, and endocarditis - Pneumococcal infections - Staphylococcal infections - Diphtheria - Anthrax - Syphilis ## Classification of Penicillins - **Basic Penicillins:** Penicillin V, Penicillin G, Penicillin G Benzathine - For common gram-positive bacteria long acting. - Not working well against gram-negative bacteria - Used to treat: - Upper respiratory infections, otitis media, pneumonia, rheumatic fever, erysipelas, skin and soft-tissue infections, and STIs like gonorrhea and syphilis. - **Broad-spectrum (aminopenicillins):** Amoxicillin, ampicillin - More effective against a wide variety of gram-negative bacteria. - Useful to treat: - Respiratory, gastrointestinal, genitourinary, and skin infections. **Amoxicillin:** - Useful for gonorrhea **Ampicillin:** - Useful for more serious infections that require an intravenous administration (meningitis, endocarditis, and septicemia). **Broad-spectrum penicillins should not be combined with allopurinol since it increases the risk of developing a skin rash.** - **Penicillinase-resistant (antistaphylococcal penicillins):** Dicloxacillin, Nafcillin, Oxacillin - Created to fight bacteria like Staphylococcus aureus, which often have the beta-lactamase enzyme making them resistant to other penicillins. - Decrease the effectiveness of live virus vaccines, so they shouldn't be given together. - **Extended-spectrum (antipseudomonal penicillins):** Piperacillin (IV) - More gram-negative coverage. - Effective against Pseudomonas aeruginosa. - Often administered in combination with beta-lactamase inhibitors, such as tazobactam. ### Common Side Effects of Penicillin Antibiotics - Allergic reactions (Urticaria, pruritus, and angioedema) - More Severe Reactions: - Maculopapular rashes - Eosinophilia - Stevens-Johnson syndrome - Exfoliative dermatitis - Anaphylaxis - Gastrointestinal side effects: Nausea, vomiting, and diarrhea - High amounts of sodium or potassium may need dose adjustments in patients with renal dysfunction to avoid electrolyte imbalances. - Increased risk for cross-reactivity to cephalosporins and other beta-lactam antibiotics. ## Tetracyclines and Glycylcyclines Side Effects **Examples:** - Doxycycline, Minocycline, tetracycline, Demeclocycline, oxytetracycline - Avoid tetracycline in pregnancy, childhood, younger than 8 years, and monitor for GI, vaginal, and blood related side effects: - Photosensitivity (monitor for) - Thrombocytopenia - Hemolytic anemia - Coagulation issues **NOT to be used with warfarin or theophylline due to increased effects and toxicity.** ### Common Side Effects - Headache - Dizziness ### Gastrointestinal Issues: - Abdominal pain - Nausea - Vomiting - Diarrhea - Esophageal irritation ### Photosensitivity: - Increased risk of sunburn ### Skin Reactions: - Skin rash - Injection site reactions ### Hypersensitivity Reactions (Severe): - Exfoliative dermatitis - Stevens-Johnson syndrome - Anaphylaxis ### Superinfections: - Fungal Overgrowth: Candida albicans (oral thrush) - Bacterial Overgrowth: C. difficile infection (CDI) causing severe diarrhea ### Teeth and Bone Effects: - Tooth discoloration: Permanent yellow or brown staining - Affects deciduous teeth if taken during pregnancy after 4 months of gestation - Affects permanent teeth in children under 8 years - Bone accumulation: Delayed bone growth in children. - Metabolic Concerns: Nephorotoxicity **While both classes share the same side effect profile, tetracyclines boxed warning for mortality risk is a significant distinction, limiting its use. Oral tetracyclines are more likely to cause esophageal irritation compared to glycylcyclines.** ### Tetracyclines Specific About It? - Yellow teeth - Need to name a them as well. - Tetracyclines accumulate in teeth during pregnancy after the 4th month of gestation. - Tetracyclines are contraindicated for children younger than 8 years. ## Tetracyclines (Broad-Spectrum Antibiotics) Treat a wide variety of bacterial infections. - CNS (Meningitis, community-acquired pneumonia) - Respiratory (Pneumonia) - Gastrointestinal (Cholera) - Skin (Acne) - Genitourinary (Chlamydia, syphilis) - Rare (Rocky Mountain spotted fever, Lyme disease, anthrax, tularemia) ## Patient Assessment of Itching - Onset - Location - Progression - Associated symptoms - Potential triggers - Relieving factors - Medication history ## Skin Discomfort - **Location**: Is the itching localized or generalized over the body? - **Duration**: How long has the itching been occurring? Is it constant or intermittent? - **Characteristics**: Describe the sensation (mild tickle, intense burning/stinging, etc.) - **Visible skin changes**: Look for rashes, dryness, lesions that may contribute to itching. - **Aggravating/relieving factors**: Does anything make the itching better or worse? - **Impact on daily life**: Does the itching disrupt sleep, work, or activities? - **Underlying conditions**: Rule out causes like allergies, kidney or liver disease. - **Medications**: Certain drugs can cause itching as a side effect. ## Cefazolin - First-generation cephalosporin antibiotic used to treat various bacterial infections. - **Spectrum of activity**: Effective against gram-positive organisms like Staphylococcus aureus and Streptococcus species. Limited coverage for gram-negative bacteria. - **Route of administration**: Parenteral (intravenous or intramuscular) only as it is not absorbed orally. - **Common uses**: - Surgical prophylaxis to prevent postoperative wound infections - Treatment of skin tissue infections, respiratory tract infections, urinary tract infections caused by susceptible organisms - Bones and joint infections - **Dosing:** Typical adult dose is 1-2 grams IV every 8 hours, adjusted for renal function. - Given 30-60 minutes before surgical incision for prophylaxis. - **Adverse effects**: Generally well-tolerated but can cause: - Hypersensitivity reactions - GI upset - Injection site reactions - Blood dyscrasias - **Contraindications**: - Hypersensitivity to cephalosporins - Severe renal impairment (without dosage adjustment) - Infants less than 1 month - **Precautions**: Should be taken during pregnancy and breastfeeding, as well as with elderly clients. - Use with caution in clients with anemia or coagulation disorders. - Additional precautions should be taken when administering cephalosporins to clients with gastrointestinal diseases, as well as those with renal disease or on dialysis. - **While your client is receiving the medication cefazolin intravenously, be sure to monitor the insertion site closely for signs of extravasation, such as redness, puffiness, or blanching. In addition, monitor their vital signs and urine output, as well as for signs of a hypersensitivity reaction, including an unusual rash or blister, throat tightness, difficulty swallowing, or shortness of breath.** ## Conditions Antihistamines Treat - Allergic rhinitis (hay fever) and nasal allergies - Urticaria (hives) and other allergic reactions - Pruritus (itchy skin) - Symptoms of the common cold like sneezing and runny nose - Motion sickness - Vertigo - Insomnia - Parkinson's disease (due to their anticholinergic effects) ## Antihistamines - Block histamine receptors, preventing histamine's effects: Itching, nasal congestion, runny nose, and smooth muscle constriction. - Provide symptomatic relief; they do not cure the underlying condition or viral infection. ## Malignant Hyperthermia (MH) - Inherited disorder triggered by certain anesthetic agents: - Volatile gases (halothane, isoflurane) and the depolarizing muscle relaxant succinylcholine. - Causes a hypermetabolic crisis with uncontrolled skeletal muscle contractions. - Rapidly increasing body temperature, acidosis, and rhabdomyolysis ### Mechanism - Begins in skeletal muscles exposed to the drugs. - Increased calcium levels in muscle cells and increased muscle metabolism. - Serum calcium and potassium levels are increased, as is the metabolic rate, leading to acidosis, cardiac dysrhythmias, and high body temperature. ### Initial/Early Signs Increased end-tidal carbon dioxide ### Late Symptoms - Increased temperature (as high as 111.2 °F) ### Key Clinical Features - Muscle rigidity of the jaw and upper chest - Tachycardia - Tachypnea - Hypoxemia - Hypercarbia - Unstable blood pressure - Profuse sweating ### If Untreated: - Rapidly progress to multi-organ failure and death ### Symptoms - Dysrhythmias - Hypotension - Skin mottling - Cyanosis - Myoglobinuria (muscle proteins in the urine due to rhabdomyolysis) ### The Most Sensitive Indication - Unexpected rise in the end-tidal carbon dioxide level with a decrease in oxygen saturation and tachycardia. ## Malignant Hyperthermia (MH) Treatment: - Dantrolene (direct-acting skeletal muscle relaxant) stops the uncontrolled muscle contractions - Supportive care: Cooling measures, hyperventilation, correction of acidosis and electrolyte imbalances. - All facilities providing general anesthesia must stock dantrolene for emergency management. - Proper screening of patients for MH susceptibility. - Avoiding triggering agents, preparedness with dantrolene, and close monitoring are crucial. - **Patients with muscular dystrophies or a family history of MH are at higher risk. Understanding MH pathophysiology, presentation, treatment, and preventive measures is essential for perioperative patient safety.** ## Second Generation Antihistamines - Essentially the same as **non-sedating antihistamines.** - Loratadine - Cetirizine - Fexofenadine - Less likely to cause sedation and have fewer central nervous system effects compared to older antihistamines. - Do not readily cross the blood-brain barrier. - Longer duration of action, allowing for once-daily dosing to improve adherence. - Some sedation can still occur at higher doses ## Drug Interactions **Drug** - Fexofenadine - Loratadine - Diphenhydramine, Cetirizine **Interacting Drug** - Erythromycin and other CYP450 inhibitors - Phenytoin - Ketoconazole, Cimetidine, Erythromycin - Alcohol, MAOIs, CNS depressants **Mechanism** - Inhibit metabolism - Increased metabolism - Inhibit metabolism - Additive effects **Result** - Increased fexofenadine levels - Decreased fexofenadine levels - Increased loratadine levels - Increased CNS depression ## Second Generation Antihistamines - Effective relief of allergy: - Rhinitis and urticaria - Minimal drowsiness or impairment of cognitive function. - Longer duration of action, allowing for convenient once-daily dosing to improve adherence. ## Macrolides - Treat a wide range of infections caused by mild to moderate bacteria. - Respiratory - Gastrointestinal - Genitourinary ### Macrolide Antibiotics: - Erythromycin (pill/IV) - Azithromycin (pill/ophthalmic eye drops) - Clarithromycin (pill) - Oral to treat mild to moderate bacterial infections: - Respiratory - Gastrointestinal - Genitourinary tracts - Erythromycin can also be given intravenously, and azithromycin has an ophthalmic formulation to treat bacterial conjunctivitis. # What kind of antibiotic is a macrolide? - Broad spectrum - Active against most gram-positive bacteria - Moderately active against some gram-negative bacteria - Inhibits protein synthesis. - Bacteriostatic effect - Stop bacterial growth ## Macrolide Antibiotics to Their Specific Side Effects - **Erythromycin**: can cause esophagitis. - **Azithromycin**: can rarely cause thrombocytopenia - **Clarithromycin**: can cause abnormal taste and pancreatitis. ### Common Side Effects: - Headaches - Skin rash - Gastrointestinal disturbances: - Diarrhea - Nausea - Abdominal Pain - Vomiting ### Rare Side Effects: - Clostridioides difficile infection (CDI) - Vaginitis - Candidiasis - Ototoxicity - Hearing loss (used for prolonged time) ### More Serious Side Effects: - Prolonged QT interval - Ventricular arrhythmias: - Torsade de pointes - Hepatotoxicity - Hepatitis - Seizures - Hypersensitivity reactions: - Stevens-Johnson syndrome - Toxic epidermal necrolysis - Angioedema ## TMP-SMX (Brand Name: Bactrim) - **Most commonly used to treat:** - Acute and simple UTIs - Acute otitis media - Travelers' diarrhea - Shigellosis - **Also effective in treating:** - Pneumonia and sinus infections caused by Streptococcus pneumoniae and Haemophilus influenzae. - **First line therapy for the treatment of:** - UTIs - Pneumonia and sinus infections - Prevention of Pneumocystis jirovecii infections - Effective against Methicillin-Resistant Staphylococcus aureus, or MRSA ### Administration - Most often given orally - For serious infections and Pneumocystis jirovecii pneumonia, it can be administered intravenously. ### Sulfonamides can also be used alone - Sulfadiazine orally to treat infection: - Toxoplasma gondii - Silver sulfadiazine (administered topically in clients with second and third-degree burns to help prevent and treat wound sepsis) ### MOA - Inhibit the synthesis of folate, folic acid or vitamin B9, which is necessary for the synthesis of DNA and RNA. - Interfere with bacterial DNA and RNA synthesis. - Ultimately kills the bacteria. ### TMP-SMX Treats: - UTIs - Ear (otitis media) - PNA - MRSA - Respiratory tract infections - Opportunistic infections in HIV/AIDS patients, especially Pneumocystis jirovecii pneumonia - Infections caused by Stenotrophomonas maltophilia. - Outpatient Staphylococcus aureus infections, including MRSA ## Trimethoprim-Sulfamethoxazole (TMP-SMX)/Bactrim Side Effects ### Common: - Nausea - Vomiting - Abdominal pain - Skin rash - Dermatitis - Urticaria - Photosensitivity - Crystalluria - Hyperkalemia - Blood dyscrasias - C-diff ### Rare: - SJ- syndrome - Toxic epidermal necrolysis - Erythema multiforme - Systemic lupus erythematosus - Anaphylactic reaction ## Contraindications for Ondansetron (Zofran) - Known hypersensitivity or allergy to ondansetron - Congenital long QT syndrome or risk of QT prolongation - Use in the first trimester of pregnancy due to potential risk of cleft palate - Severe hepatic impairment (may require dose adjustment) - Alcohol ### Use Cautiously in: - Electrolyte abnormalities (hypokalemia, hypomagnesemia) - Bradyarrhythmias or conduction disturbances - Concurrent use of other QT prolonging medications - Phenylketonuria (orally disintegrating tablets contain phenylalanine) - Report: Palpitations, confusion, flushing ### Proper screening: - For contraindications and drug interactions is important before administering ondansetron to ensure safe use, especially in high-risk patients. ## MoA of Promethazine - Phenothiazine derivative that acts as a nonselective antagonist of multiple receptors in the body. ### Primary Mechanism: - Antihistaminic effects: Promethazine competitively antagonizes H1 histamine receptors, preventing the binding and effects of histamine. - This accounts for its antiemetic, sedative, and antipruritic properties. ### Anticholinergic Effects: - Blocks the muscarinic actions of acetylcholine in the brain and periphery. - Causes: - Sedation - Reduced secretions - Decreases Gl motility ### Anti-dopaminergic Effects: - Promethazine blocks dopamine D2 receptors in the chemoreceptor trigger in the brain. - Contributes to its potent antiemetic action/ ## Surgical Care Improvement Project (SCIP) - Initiated in 2006 to reduce surgical complications. - Focuses on: - Proper administration of prophylactic antibiotics to prevent surgical site infections. - Timely discontinuation of urinary catheters after surgery to reduce catheter-associated urinary tract infections. - Appropriate venous thromboembolism (VTE) prophylaxis to prevent deep vein thrombosis and pulmonary embolism. ### SCIP aims: - Standardize and improve surgical care by promoting evidence-based practices. - Following SCIP guidelines has become the standard of care to enhance patient safety and outcomes in the surgical setting. - Understanding and adhering to these core measures is essential for nursing practice. ## National Patient Safety Goals Related to Safety and Preoperative Care of Perioperative Patients - Having the correct procedure done on the correct patient and at the correct place on the patient’s body - Marking the correct site of surgery on the patient’s body where surgery will take place. - Pausing before surgery to make sure that mistakes are not being made ### Prevent Mistakes in Surgery: - Make sure that the correct surgery is done on the correct patient and at the correct place on the patient’s body. - Mark the correct place on the patient’s body where the surgery is to be done. - **Pause before the surgery to make sure that a mistake is not being made.** ### Three Preoperative Verification Principles: - **Make sure that all relevant documents** (e.g., consent forms, allergies, medical history, physical assessment findings) and **the results of laboratory tests and diagnostic studies are available before the start of the procedure and that the type of surgery scheduled is consistent with the patient’s expectations.** **Mark the operative site** with indelible ink to mark: - Left and right distinction - Multiple structures (e.g., fingers), and levels of the spine - **A “time-out”** just before starting the procedure for final verification of: - The correct patient, - Procedure, - Site, - Any implants. # The marking and “time-out” most commonly occur in the holding area, just before the patient enters the OR - The individual who is performing the surgery and who is accountable for it must personally mark the site and involve the patient if possible. - All members of the surgical/procedure team perform the time-out. - If the patient refuses a mark, document this on the procedure checklist. ## Purpose of Team Stepps - System designed by the Department of Defense (DOD) and the Agency for Healthcare Research and Quality (AHRQ) - Facilitate effective communication, teamwork, and collaboration among healthcare providers to enhance patient safety and quality of care. - Promotes a culture of safety by standardizing communication techniques, fostering mutual respect, and optimizing team performance during patient care situations. - Aims to reduce medical errors and preventable patient harm by improving interprofessional teamwork and creating a safer healthcare environment. ## Safety Concerns of Epidural Catheter - Headache - Hypotension - Infection ### The Epidural Catheter: - May be left in place after surgery to assist with pain control. - Nurses must take care to ensure that the catheter does not become kinked or dislodged. ### Placement: - May be inadvertently pushed too far, puncturing the dural membrane and causing cerebrospinal fluid to leak into the epidural space. - Can result in hypotension, headache, or infection. ### Respiratory Depression - Can occur if the anesthetic agent moves higher in the epidural or subarachnoid space. ### Hypotension - Can occur when regional anesthesia causes widespread vasodilation. ### Epidural Hematoma: - Assess pain level in the back. Notify the anesthesia provider immediately if the patient feels pressure or increasing back pain while coughing or straining. - Hypotension, notify anesthesia provider if systolic blood pressure remains more than 10 mmHg below patients baseline. - Infection (meningitis), notify immediately if temp above 101 (38.3 °C), inability to move the neck, or acute confusion. ### Potential Complications of Epidural Catheters: - Hypotension - Headaches (spinal headache) - Infection ## Infection: - Lack of aseptic technique or handling the medication or catheter can lead to infection at the insertion site