ATI RN Pharmacology for Nursing (8th Edition) Chapter 47 PDF

07/24/15 April 19, 2019 10:20 AM rm_rn_2019_pharm_chp47 CHAPTER 47 UNIT 12 MEDICATIONS FOR INFECTION THERAPEUTIC USES CHAPTER 47 Mycobacterial, Indicated for active and latent...

07/24/15 April 19, 2019 10:20 AM rm_rn_2019_pharm_chp47 CHAPTER 47 UNIT 12 MEDICATIONS FOR INFECTION THERAPEUTIC USES CHAPTER 47 Mycobacterial, Indicated for active and latent tuberculosis Fungal, and Latent: Isoniazid only daily for 9 months, or isoniazid with rifapentine once weekly for 3 months. Parasitic Infections (Contraindicated in children under age 2, clients who have HIV, pregnant clients, and clients resistant to either medication.) Mycobacterium tuberculosis is a slow-growing Active: Several antimycobacterial medications are used to treat a client who has active tuberculosis in order pathogen that necessitates long-term to decrease medication resistance. Treatment usually treatment. Long-term treatment increases the consists of a four-medication regimen often including isoniazid and rifampin. risk for toxicity, poor client adherence, and The initial phase (induction phase) focuses on development of medication-resistant strains. eliminating the active tubercle bacilli, which will result Treatment for tuberculosis requires the use of at in noninfectious sputum. The second phase (continuation phase) works toward eliminating any other pathogens least two medications to which the pathogen in the body. Length of treatment varies and can be as is susceptible. Isoniazid and rifampin are two short as 6 months for medication-sensitive tuberculosis (2 months for the initial phase and 4 to 7 months for effective antituberculosis medications. the continuation phase) or as long as 24 months for medication-resistant infections. Metronidazole is the medication of choice for parasitic infections. COMPLICATIONS Antifungal medications belong to a variety of Peripheral neuropathy chemical families and are used to treat systemic Tingling, numbness, burning, and pain resulting from and superficial mycoses. deficiency of pyridoxine, vitamin B6 NURSING ACTIONS: Administer 50 to 200 mg vitamin Antimycobacterial B6 daily. Prophylactic use of pyridoxine (vitamin B6) at 25 to 50 mg/day can decrease the risk of acquiring (selective antituberculosis) peripheral neuropathy. If peripheral neuropathy develops, it can be reversed by administering pyridoxine; however, SELECT PROTOTYPE MEDICATION: Isoniazid higher doses are required. OTHER MEDICATIONS CLIENT EDUCATION: Observe for manifestations and Pyrazinamide notify the provider if they occur. Ethambutol (bacteriostatic only to M. tuberculosis) Rifapentine Hepatotoxicity Anorexia, malaise, fatigue, nausea, and yellowish discoloration of skin and eyes PURPOSE NURSING ACTIONS Monitor liver function tests. EXPECTED PHARMACOLOGICAL ACTION Elevated liver function test results can result in the This medication is highly specific for mycobacteria. need to discontinue the medication. Isoniazid inhibits growth of mycobacteria by preventing CLIENT EDUCATION synthesis of mycolic acid in the cell wall. Observe for manifestations and notify the provider if they occur. Avoid consumption of alcohol. Hyperglycemia and decreased glucose control In clients who have diabetes mellitus NURSING ACTIONS Monitor blood glucose. Clients who have diabetes mellitus might require additional antidiabetic medication. RN PHARMACOLOGY FOR NURSING CHAPTER 47 MYCOBACTERIAL, FUNGAL, AND PARASITIC INFECTIONS 379 07/24/15 April 19, 2019 10:20 AM rm_rn_2019_pharm_chp47 07/24 CONTRAINDICATIONS/PRECAUTIONS THERAPEUTIC USES Isoniazid is contraindicated for clients who have Rifampin is a broad-spectrum antibiotic effective for liver disease. gram-positive and gram-negative bacteria. NURSING ACTIONS: Rifampin is given in combination with at least one other Use cautiously in older clients, and those who have antituberculosis medication to help prevent antibiotic diabetes mellitus or alcohol use disorder. resistance. Isoniazid, Pyrazinamide, Ethambutol, and Rifapentine are Pregnancy Risk Category C. COMPLICATIONS INTERACTIONS Discoloration of body fluids Isoniazid inhibits metabolism of phenytoin, leading CLIENT EDUCATION: There is an expected orange color of to buildup of medication and toxicity. Ataxia and urine, saliva, sweat, and tears. incoordination can indicate toxicity. NURSING ACTIONS: Monitor levels of phenytoin. Adjust Hepatotoxicity (jaundice, anorexia, and fatigue) dosage of phenytoin based on phenytoin levels. NURSING ACTIONS: Monitor liver function. Concurrent use of tyramine foods (aged cheeses, cured CLIENT EDUCATION meats), alcohol, rifampin, and pyrazinamide increases Monitor for manifestations of anorexia, fatigue, and the risk for hepatotoxicity. malaise, and notify the provider if they occur. NURSING ACTIONS: Monitor liver function. Avoid alcohol. CLIENT EDUCATION Avoid foods with high levels of tyramine. Mild GI discomfort Avoid alcohol consumption. Anorexia, nausea, and abdominal discomfort NURSING ACTIONS: Abdominal discomfort is mild and NURSING ADMINISTRATION usually does not require intervention. Usually administered orally. When given IM, warm to Pseudomembranous colitis room temperature to ensure that the solution is free of crystals, and inject deeply into a large muscle. CLIENT EDUCATION: Monitor and report fever, diarrhea, For active tuberculosis, direct observation therapy is abdominal pain, or bloody stool. Discontinue medication if done to ensure adherence. manifestations occur. CLIENT EDUCATION Consider using a second form of birth control (such as CONTRAINDICATIONS/PRECAUTIONS condom) if taking a hormonal contraceptive as various antibiotics can decrease their effectiveness. Rifampin is Pregnancy Risk Category B. Take isoniazid 1 hr before or 2 hr after meals, with a Use cautiously in clients who have liver dysfunction. full glass of water. If gastric discomfort occurs, take isoniazid with meals. Complete the prescribed course of antimicrobial therapy, INTERACTIONS even though manifestations can resolve before the full Rifampin accelerates metabolism of warfarin, oral course is completed. contraceptives, protease inhibitors, and non-nucleoside reverse transcriptase inhibitors (NNRTIs) for HIV, Broad-spectrum resulting in diminished effectiveness. NURSING ACTIONS antimycobacterial Increased dosages of HIV medications are often necessary. (antituberculosis) Monitor PT and INR. Advise clients to use a non-hormonal form of contraception. SELECT PROTOTYPE MEDICATION: Rifampin Concurrent use with isoniazid and pyrazinamide PURPOSE increases risk of hepatotoxicity. NURSING ACTIONS Instruct clients to avoid alcohol consumption. EXPECTED PHARMACOLOGICAL ACTION Monitor liver function. Rifampin is bactericidal as a result of inhibition of protein synthesis. 380 CHAPTER 47 MYCOBACTERIAL, FUNGAL, AND PARASITIC INFECTIONS CONTENT MASTERY SERIES 07/24/15 April 19, 2019 10:20 AM rm_rn_2019_pharm_chp47 NURSING ADMINISTRATION Darkening of urine Administer orally or by IV route. CLIENT EDUCATION: This is a harmless effect of Administer oral rifampin 1 hr before or 2 hr after meals metronidazole. with a full glass of water. Absorption is decreased if given with food. Neurotoxicity, CNS effects CLIENT EDUCATION Numbness of extremities, ataxia, and seizures Use a non-hormonal form of contraception. CLIENT EDUCATION Complete the prescribed course of antimicrobial therapy, Notify the provider if manifestations occur. even though manifestations can resolve before the full Stop metronidazole. course is completed. Pseudomembranous colitis NURSING EVALUATION OF NURSING ACTIONS: Discontinue medication. MEDICATION EFFECTIVENESS CLIENT EDUCATION: Monitor and report fever, diarrhea, Depending on therapeutic intent, effectiveness is abdominal pain, or bloody stool. evidenced by the following. Improvement of tuberculosis manifestations (clear breath sounds, no night sweats, increased appetite, and CONTRAINDICATIONS/PRECAUTIONS no afternoon rises of temperature). Metronidazole is a Pregnancy Risk Category B. Three negative sputum cultures for tuberculosis, Contraindicated in active CNS disorders, blood usually taking 3 to 6 months to achieve dyscrasias, and during lactation. Contraindicated in the first trimester of pregnancy and Antiprotozoals should be used with caution in clients who are in the second or third trimesters of pregnancy. Use cautiously in clients who have kidney, cardiac, SELECT PROTOTYPE MEDICATION: Metronidazole fungal, or candida infections or seizure disorders. Use cautiously in older adults. PURPOSE INTERACTIONS EXPECTED PHARMACOLOGICAL ACTION Alcohol causes a disulfiram‑like reaction (facial flushing, Metronidazole is a broad-spectrum antimicrobial with vomiting, dyspnea, tachycardia). bactericidal activity against anaerobic micro-organisms. CLIENT EDUCATION: Avoid alcohol consumption. Metronidazole inhibits inactivation of warfarin, THERAPEUTIC USES phenytoin, and lithium. NURSING ACTIONS: Monitor prothrombin time and INR, Treatment of protozoal infections (intestinal amebiasis, phenytoin and lithium levels. Adjust dosages accordingly. giardiasis, trichomoniasis) and obligate anaerobic bacteria (Bacteroides fragilis, antibiotic-induced Clostridium difficile, Gardnerella vaginalis) Prophylaxis for clients who will have surgical NURSING ADMINISTRATION procedures (vaginal, abdominal, colorectal surgery) and Administer by oral or IV route. are high-risk for anaerobic infection CLIENT EDUCATION Treatment of H. pylori in combination with tetracycline Complete the prescribed course of antimicrobial therapy, and bismuth subsalicylate in clients who have peptic even though manifestations can resolve before the full ulcer disease course is completed. Use condoms if using this medication for treatment of trichomoniasis. COMPLICATIONS Hormonal contraceptive effectiveness decreases with various antibiotics and therefore it is recommended to GI discomfort use a back-up method (a condom). Nausea, vomiting, dry mouth, and metallic taste If this medication is given to treat an STD, abstain from intercourse until the medication is finished, manifestations CLIENT EDUCATION: Observe for effects and to notify have resolved, and partners have been treated. the provider. Take the medication with meals to reduce adverse effects. RN PHARMACOLOGY FOR NURSING CHAPTER 47 MYCOBACTERIAL, FUNGAL, AND PARASITIC INFECTIONS 381 07/24/15 April 19, 2019 10:20 AM rm_rn_2019_pharm_chp47 07/24 NURSING EVALUATION OF Thrombophlebitis MEDICATION EFFECTIVENESS NURSING ACTIONS Depending on therapeutic intent, effectiveness is Observe infusion sites for of erythema, swelling, and pain. evidenced by improvement of manifestations. Rotate injection sites. Resolution of bloody mucoid diarrhea Administer in a large vein. Formed stools Negative stool results for amoeba and Giardia Nephrotoxicity Decrease or absence of watery vaginal/urethral discharge NURSING ACTIONS Negative blood cultures for anaerobic organisms in the Obtain baseline kidney function (BUN and creatinine) CNS, blood, bones and joints, and soft tissues and do weekly kidney function tests. Monitor I&O. Antifungals Infuse 1 L of 0.9% sodium chloride IV on the day of amphotericin B infusion. SELECT PROTOTYPE MEDICATIONS Amphotericin B (a polyene antibiotic for systemic mycoses) Electrolyte imbalance Ketoconazole (an azole for treating both superficial and NURSING ACTIONS systemic mycoses) Monitor electrolyte levels, especially potassium. OTHER MEDICATIONS Administer supplements for deficiencies. Flucytosine Nystatin Bone marrow suppression Miconazole NURSING ACTIONS: Obtain baseline CBC and hematocrit, Clotrimazole and monitor weekly. Terbinafine Fluconazole Griseofulvin KETOCONAZOLE PURPOSE Hepatotoxicity Anorexia, nausea, vomiting, jaundice, dark urine, and EXPECTED PHARMACOLOGICAL ACTION clay-colored stools Amphotericin B is an antifungal agent that acts on NURSING ACTIONS fungal cell membranes to cause cell death. Depending Obtain baseline liver function studies, and monitor liver on concentration, these agents can be fungistatic (slows function monthly. growth on the fungus) or fungicidal (destroys the fungus). If manifestations occur, notify the provider and discontinue the medication. THERAPEUTIC USES Effects on sex hormones Antifungals are the treatment of choice for systemic Male clients: Gynecomastia (enlargement of breast), fungal infection (candidiasis, aspergillosis, cryptococcosis, decreased libido, erectile dysfunction mucormycosis) and nonopportunistic mycoses, (blastomycosis, histoplasmosis, coccidioidomycosis). Female clients: Irregular menstrual flow Some antifungals treat superficial fungal infections: NURSING ACTIONS: Advise clients to observe for these dermatophytic infections (tinea pedis [ringworm of the effects and to notify the provider. foot] and tinea cruris [ringworm of the groin]); candida infections of the skin and mucous membranes; and fungal infections of the nails (onychomycosis). CONTRAINDICATIONS/PRECAUTIONS Antifungals are contraindicated in clients who have COMPLICATIONS impaired kidney function due to the risk for nephrotoxicity. Infusion reactions Use antifungals with caution in clients who have anemia, electrolyte imbalance, and bone marrow suppression. Fever, chills, rigors, and headache 1 to 3 hr after initiation Fluconazole is Pregnancy Risk Category C in high dose, NURSING ACTIONS and contraindicated during lactation. A test dose of 1 mg amphotericin B, infused slowly IV, Amphotericin B and terbinafine are Pregnancy Risk can assess client reaction. Category B. Pretreat with diphenhydramine and acetaminophen. Ketoconazole, flucytosine, nystatin, miconazole, and Administer meperidine, dantrolene, or hydrocortisone clotrimazole are Pregnancy Risk Category C. for rigors. Griseofulvin is Pregnancy Risk Category X. 382 CHAPTER 47 MYCOBACTERIAL, FUNGAL, AND PARASITIC INFECTIONS CONTENT MASTERY SERIES 07/24/15 April 19, 2019 10:20 AM rm_rn_2019_pharm_chp47 INTERACTIONS NURSING EVALUATION OF Aminoglycosides (gentamicin, streptomycin, MEDICATION EFFECTIVENESS cyclosporine) have additive nephrotoxic risk when used Depending on therapeutic intent, effectiveness is concurrently with antifungal medications. evidenced by the following. NURSING ACTIONS: Avoid use of these antimicrobials Improvement of findings of systemic fungal infections when clients are taking amphotericin B due to additive Improvement of findings of superficial infections (clear nephrotoxicity risk. mucus membranes, clear nails, and intact skin). Antifungal effects of flucytosine are potentiated with concurrent use of amphotericin B. NURSING ACTIONS: Potentiated flucytosine effects allow COMPLEMENTARY AND for a reduction in amphotericin B dosages. ALTERNATIVE THERAPIES By suppressing immune function (in response to long- Azole antibiotics increase levels of multiple medications, term use), echinacea can compromise drug therapy of including digoxin, warfarin, and sulfonylurea tuberculosis antidiabetic medications. Antibacterial and antifungal medications can kill the NURSING ACTIONS: If concurrent administration is bacteria and yeasts in probiotic products. Therefore, necessary, carefully monitor for toxicity. to help preserve probiotic activity, these preparations should be administered at least 2 hours after dosing with antibacterial or antifungal medications. NURSING ADMINISTRATION By eliminating intestinal flora, antibiotics may reduce Amphotericin B is highly toxic and should be reserved conversion of isoflavones to their active form, thus for severe life-threatening fungal infections. reducing potentially positive effects of soy. Infuse amphotericin B slowly over 2 to 4 hr IV. Rifampin and St. John’s Wort both induce CYP3A4 and Observe solutions for precipitation and discard if P-glycoprotein which can cause interactions precipitates are present. Use a filter to prevent infusion of undissolved crystals. Kidney injury is lessened with administration of 1 L of 0.9% sodium chloride IV on the day of amphotericin B infusion. Apply antifungals for topical use to treat superficial vulvovaginal candidiasis as vaginal suppository or cream. CLIENT EDUCATION Consider using a second form of birth control (such as Active Learning Scenario Key condom) if taking a hormonal contraceptive as various antibiotics can decrease their effectiveness. Using the ATI Active Learning Template: Medication Complete the prescribed course of antimicrobial therapy, THERAPEUTIC USES: A client who has latent tuberculosis has been even though manifestations might resolve before the infected by Mycobacterium tuberculosis and is at risk for (but has full course is completed. not yet developed) active tuberculosis. Some clients who have latent tuberculosis (those who are immunocompromised or who have recently immigrated to the U.S. from a country where active TB is common) can require treatment with isoniazid, with or without rifapentine, in order to prevent the onset of active TB. The client who has latent TB has a positive tuberculin test but a negative sputum culture and negative chest x-ray for TB. The client cannot infect others with tuberculosis unless the infection becomes active. Active Learning Scenario COMPLICATIONS Paresthesias in the extremities caused by vitamin B 6 deficiency A nurse in a public health department is teaching a client Hepatotoxicity who has latent tuberculosis (TB) and a new prescription for Hyperglycemia (if client has diabetes mellitus) isoniazid twice weekly for 6 months. What should the nurse NURSING INTERVENTIONS: The client who starts teach the client about this medication? Use the ATI Active isoniazid should have baseline liver function testing and Learning Template: Medication to complete this item. be tested periodically throughout treatment. CLIENT EDUCATION THERAPEUTIC USES: Describe the therapeutic Teach the client to watch for paresthesias, and to take use for isoniazid in this client. pyridoxine daily to reverse the effect if they occur. Teach the client about indications of hepatitis (anorexia, fatigue, COMPLICATIONS: List two adverse nausea, jaundice) and to notify the provider if these occur. effects the client should watch for. Teach the client to take isoniazid as prescribed, and not to stop until the entire course of treatment is completed. NURSING INTERVENTIONS: Describe one test The client who has latent tuberculosis does not feel ill. to monitor for clients taking isoniazid. The nurse should be sure that the client understands why it is important to continue with treatment. CLIENT EDUCATION: Describe two teaching NCLEX® Connection: Pharmacological and Parenteral Therapies, points for clients taking isoniazid. Medication Administration RN PHARMACOLOGY FOR NURSING CHAPTER 47 MYCOBACTERIAL, FUNGAL, AND PARASITIC INFECTIONS 383 07/24/15 April 19, 2019 10:20 AM rm_rn_2019_pharm_chp47 Application Exercises Application Exercises Key 1. A nurse is caring for a client who has diabetes 1. A. Ascorbic acid is given to clients who have a vitamin C deficiency. It is not a supplement administered mellitus, pulmonary tuberculosis, and a new to prevent an adverse effect of INH. prescription for isoniazid. Which of the following B. CORRECT: Pyridoxine is frequently prescribed supplements should the nurse expect to along with INH to prevent peripheral neuropathy for clients who have increased risk factors administer to prevent an adverse effect of INH? (diabetes mellitus or alcohol use disorder.) A. Ascorbic acid C. Folic acid is administered to clients who have hepatic disease and folic acid deficiency. It is not B. Pyridoxine administered to prevent an adverse effect of INH. D. Cyanocobalamin is administered to clients who have C. Folic acid malabsorption syndrome. It is not administered D. Cyanocobalamin to prevent an adverse effect of INH. NCLEX® Connection: Pharmacological and Parenteral Therapies, Expected Actions/Outcomes 2. A nurse is infusing IV amphotericin B to a client who has a systemic fungal infection. The nurse 2. A. Amphotericin B can cause hyperglycemia. should monitor the client for which of the following B. Amphotericin B can cause diarrhea. manifestations as an adverse effect of this medication? C. CORRECT: Amphotericin B can cause fever, chills, and nausea during the infusion. Pretreatment with diphenhydramine A. Hypoglycemia and acetaminophen can reduce these effects. B. Constipation D. Amphotericin B can cause hypokalemia. NCLEX® Connection: Pharmacological and Parenteral Therapies, C. Fever Adverse Effects/Contraindications/Interactions D. Hyperkalemia 3. A. Amphotericin B does not affect blood albumin levels. B. Amphotericin B does not cause pancreatitis. 3. A nurse is administering IV amphotericin B to a C. CORRECT: Hypokalemia is a serious adverse client who has a systemic fungal infection. The effect of amphotericin B. Monitor blood nurse should monitor which of the following potassium values for hypokalemia. D. CORRECT: Amphotericin B can cause bone marrow laboratory values? (Select all that apply.) suppression. Monitor CBC and platelet count periodically. A. Blood albumin E. CORRECT: Amphotericin B can cause nephrotoxicity. Monitor kidney function (with blood creatinine, B. Blood amylase BUN, and creatinine clearance). C. Blood potassium NCLEX® Connection: Pharmacological and Parenteral Therapies, Expected Actions/Outcomes D. Hematocrit E. Blood creatinine 4. A. A metallic taste in the mouth is an expected adverse effect of metronidazole and is nonurgent for the client to report to the provider. Another adverse effect is the priority to report. 4. A nurse is teaching a client who is beginning a course B. Nausea is an expected adverse effect of metronidazole of metronidazole to treat an infection. For which of and is nonurgent for the client to report to the provider. Another adverse effect is the priority to report. the following findings of an adverse effect should C. CORRECT: Using the urgent vs. nonurgent approach to the nurse instruct the client as a priority to stop client care, the priority adverse effect to report to the taking metronidazole and notify the provider? provider is ataxia, tremors, paresthesias of the extremities, and seizures, which are manifestations of CNS toxicity. A. Metallic taste D. Dark-colored urine is expected adverse effect of B. Nausea metronidazole and is nonurgent for the client to report to the provider. Another adverse effect is the priority to report. C. Ataxia NCLEX® Connection: Pharmacological and Parenteral Therapies, D. Dark-colored urine Adverse Effects/Contraindications/Interactions 5. A. Taking several antituberculosis medications concurrently 5. A nurse is teaching a client who has active tuberculosis does not decrease the chance of an allergic reaction about the treatment regimen. The client asks why to any of the individual medications. four different medications are necessary. Which of B. CORRECT: If the client took only one medication to treat active tuberculosis, resistance to the medication the following responses should the nurse make? would occur quickly. Taking three or four medications A. “Four medications decrease the risk decreases the possibility of resistance. for a severe allergic reaction.” C. Taking several antituberculosis medications concurrently does not minimize the chance of adverse effects to any B. “Four medications reduce the chance that of the medications. Risk for liver toxicity increases when the bacteria will become resistant.” more than one medication that causes liver toxicity is taken (isoniazid, rifampin, and pyrazinamide). C. “Four medications reduce the D. Taking several antituberculosis medications concurrently risk for adverse reactions” does not change the fact that the client will have a positive tuberculin skin test indefinitely. D. “Four medications decrease the chance of NCLEX® Connection: Pharmacological and Parenteral Therapies, having a positive tuberculin skin test.” Medication Administration 384 CHAPTER 47 MYCOBACTERIAL, FUNGAL, AND PARASITIC INFECTIONS CONTENT MASTERY SERIES