Antibiotics and Endocrine Medications Overview

Gram staining

Procedure to categorize bacteria and determine what type of antibiotic to use.

Gram positive

Bacteria species that turn purple with gram staining.

Gram negative

Bacteria species that turn red with gram staining.

Community acquired infections

An infection that is acquired by a person who has not been hospitalized or had a medical procedure within the past year.

Health care associated infections

Infections contracted in a health care facility that occur more than 48 hours after admission.

Methicillin-resistant Staphylococcus aureus (MRSA)

Most common drug-resistant microorganism associated with health care associated infections.

Vancomycin-resistant Enterococcus (VRE)

Another drug-resistant microorganism associated with health care associated infections.

Disinfectants

Kills organisms and is used only on nonliving objects.

Antiseptic

Inhibits growth of microorganisms and is applied to living tissue.

Antibiotics

Meds used to treat bacterial infections.

Empiric therapy

Treatment of an infection before specific culture information has been reported or obtained.

Definitive therapy

Antibiotic therapy tailored to treat organism identified with cultures.

Prophylactic therapy

Treatment with antibiotics to prevent an infection, as in intra-abdominal surgery or after trauma.

Therapeutic response

Decrease in signs and symptoms of infection are noted.

Subtherapeutic response

Signs and symptoms of infection do not improve.

Allergic reactions

Penicillins and sulfonamides are two broad classes of antibiotics to which many people have allergic anaphylactic reactions.

Bactericidal

Antibiotics that kill bacteria.

Bacteriostatic

Antibiotics that inhibit growth of susceptible bacteria rather than killing them immediately.

Sulfonamides

One of the first groups of antibiotics, effective against both gram positive and gram negative bacteria.

Use of sulfonamides

Used for UTIs, certain pneumonias, upper respiratory infections, and outpatient MRSA infections.

Nursing implications for sulfonamides

Take with 2000-3000 mL of fluid per 24 hours and with food.

Lactam antibiotics

Includes penicillin, cephalosporins, carbapenems, and monobactams.

Penicillin

Enters bacteria via the cell wall and disrupts cell wall synthesis, leading to cell lysis.

Contraindications of penicillin

Includes allergy and increased risk of allergy to other lactam antibiotics.

Common adverse effects of Penicillin

Nausea, vomiting, diarrhea, abdominal pain.

Penicillin interactions

Includes nonsteroidal anti-inflammatory drugs, oral contraceptives, and warfarin.

Nursing implications for penicillin

Take oral doses with water, not juice, and monitor for allergic reaction for 30 mins after administration.

Cephalosporins

Semisynthetic antibiotics that are structurally and pharmacologically related to penicillins. Interfere with the cell wall building of bacteria when they divide.

Bacteria with weakened cell walls

Swell and burst as a result of the osmotic pressure within the wall.

Adverse effects of Cephalosporins

Mild diarrhea, abdominal cramps, rash, pruritus, redness, edema.

Sensitivity with penicillin

Potential sensitivity w/ penicillin's if allergies exist.

Disulfiram reaction

May cause a disulfiram reaction when taken w/ alcohol.

Macrolides

Erythromycin, Azithromycin, Clarithromycin.

Mechanism of action for macrolides

Prevent protein synthesis within bacterial cells.

Bacteriostatic

Considered bacteriostatic, the bacteria will eventually die.

Bactericidal

In high enough concentrations, may also be bactericidal.

Indications of Macrolides

Strep infections, mild to moderate upper and lower respiratory tract infections.

Adverse effects of Macrolides

GI effects, primarily with erythromycin (nausea, vomiting, diarrhea, hepatotoxicity, flatulence, jaundice, anorexia, heartburn, abnormal taste).

Nursing implications for Macrolides

These drugs are highly protein bound and will cause severe interactions with other protein-bound drugs.

Absorption of oral erythromycin

Enhanced when the medication is taken on an empty stomach.

Tetracyclines

Doxycycline hyclate (doxycin), minocycline hydrochloride (Minocin), tigecycline.

Tetracyclines mechanism

Bacteriostatic: inhibit bacterial growth and inhibit protein synthesis.

Chelation

Bind to Calcium, Magnesium and Aluminum ions to form insoluble complexes.

Oral absorption of tetracyclines

Dairy products, antacids, and iron salts reduce oral absorption.

Adverse effects of Tetracyclines

May stunt fetal skeletal development if taken during pregnancy.

Tooth discoloration

Should not be used in children younger than 8 years of age or in pregnant or lactating women because tooth discoloration will occur.

Nursing implications for Tetracyclines

Avoid milk products, iron preparations, antacids, and other dairy products.

Fluid intake for Tetracyclines

Take all medications with at least 180 mL of fluid, preferably water.

Photosensitivity

Avoid sunlight and tanning beds.

Thyroid gland

Secretes three hormones essential for proper regulation of metabolism: Thyroxine (T4), Tri-iodothyronine (T3), Calcitonin.

Hypothyroidism

Primary: abnormality in the thyroid gland itself. Secondary: results when the pituitary gland is dysfunctional and does not secrete thyroid-stimulating hormone (TSH). Tertiary: results when the hypothalamus gland does not secrete thyrotropin-releasing hormone, which, in turn, reduces TSH and thyroid hormone levels.

Congenital hypothyroidism

Hyposecretion of thyroid hormone during youth. Low metabolic rate, short stature, severely delayed sexual development, possible intellectual disabilities.

Goiter

Enlargement of the thyroid gland. Results from overstimulation by elevated levels of thyroid-stimulating hormone (TSH). TSH is elevated because there is little or no thyroid hormone in circulation.

S/S of hypothyroidism

Cold intolerance, unintentional weight gain, depression, dry brittle hair, and nails, fatigue.

Thyroid replacement drugs

Synthetic thyroid hormone (levothyroxine). (Synthroid®, Eltroxin®)-Synthetic thyroid hormone T4. Liothyronine (Cytomel®)-Synthetic thyroid hormone T3. Desiccated thyroid (Thyroid®)-Natural thyroid hormone T3 and T4.

Mechanism of action of Thyroid replacement drugs (TRD)

Thyroid preparations are given to replace what the thyroid gland cannot produce to achieve normal thyroid levels (euthyroid). Thyroid drugs work the same way as endogenous thyroid hormones.

Indications of TRD

Used to replace what the thyroid gland itself cannot produce to achieve euthyroid condition (levothyroxine). Indicated when there is a diagnosis of suspected hyperthyroidism (as in a thyroid-stimulating hormone– suppression test). Used for prevention or treatment of various types of goiters.

Goiter treatment

Indicated for prevention or treatment of various types of goiter.

Thyroid cancer treatment

Replacement hormonal therapy for patients whose thyroid glands have been surgically removed or destroyed by radioactive iodine in the treatment of thyroid cancer or hyperthyroidism.

Hypothyroidism of pregnancy

A condition where the thyroid gland does not produce enough thyroid hormones during pregnancy.

Adverse effects of TRD

Includes cardiac dysrhythmia, tachycardia, palpitations, angina, dysrhythmias, hypertension, insomnia, tremors, headache, anxiety, nausea, diarrhea, cramps, menstrual irregularities, weight loss, sweating, heat intolerance, and fever.

Hyperthyroidism

A condition caused by diseases such as Graves' disease, multinodular disease, and Plummer's disease (rare) also called toxic nodular disease, characterized by excessive thyroid hormone production. Affects multiple body systems, resulting in an overall increase in metabolism. Diarrhea, Flushing, Increased appetite, Muscle weakness, Sleep disorders, Altered menstrual flow. Fatigue, Palpitations, Nervousness, Heat intolerance, Irritability.

Thyroid storm

A severe and potentially life-threatening condition induced by stress or infection in patients with hyperthyroidism.

Radioactive iodine (I131)

A treatment for hyperthyroidism that works by destroying the thyroid gland through a process known as ablation. Surgery to remove all or part of the thyroid gland. Lifelong thyroid hormone replacement will be needed. As well Antithyroid drugs: thioamide derivatives, thiamazole (Tapazole®).

Antithyroid drugs

Medications used to treat hyperthyroidism and prevent surges in thyroid hormones post-surgery or during radioactive iodine treatment, which may cause liver and bone marrow toxicity.

Nursing implications for thyroid treatment

Includes assessing for drug allergies, contraindications, potential drug interactions, obtaining baseline vital signs and weight. Cautious use is advised for those with cardiac disease or hypertension and for pregnant women. During pregnancy, treatment for hypothyroidism should continue. Fetal growth may be retarded if maternal hypothyroidism is untreated during pregnancy and adjusting dosage every 4 weeks to maintain thyroid-stimulating hormone at the lower end of the normal range. Patients should take thyroid drugs daily in the morning to reduce insomnia risk, and follow the same dosage and brand with primary care provider approval. Drug might take several weeks to work.

Adverse Effects of Thyroid Meds

Thyroid drugs: cardiac dysrhythmia. Antithyroid drugs: leukopenia (manifested as fever, sore throat, lesions).

Diabetes

A chronic condition characterized by elevated blood glucose levels, classified into Type 1 and Type 2.

Signs and Symptoms of Diabetes

Elevated fasting blood glucose (higher than 7 mmol/L) or a hemoglobin A1c (HbA1c) level greater than or equal to 6.5%, polyuria, polydipsia, polyphagia, glycosuria, weight loss, fatigue, and blurred vision.

Type 1 Diabetes

A form of diabetes characterized by a lack of insulin production, requiring exogenous insulin for management. Fewer than 10% of all cases are type 1.

Type 2 Diabetes

The most common type of diabetes (90% of all cases), caused by insulin deficiency and insulin resistance, affecting many tissues. Reduced number of insulin receptors and Insulin receptors less responsive.

Comorbid conditions with Type 2 Diabetes

Includes obesity, coronary heart disease, dyslipidemia, hypertension, microalbuminemia (protein in the urine), and increased risk for thrombotic (blood clotting) events, collectively referred to as metabolic syndrome or cardiometabolic syndrome.

Gestational Diabetes

Hyperglycemia that develops during pregnancy, requiring insulin to prevent birth defects, usually subsiding after delivery. 30% of patients may develop type 2 diabetes within 10 to 15 years.

Nonpharmacological treatments for diabetes

For Type 1: Always requires insulin therapy; for Type 2: Weight loss, improved dietary habits, smoking cessation, reduced alcohol consumption, and regular physical exercise.

Pharmacological treatments for diabetes

For Type 1: Insulin therapy; for Type 2: Lifestyle change, oral drug therapy, and insulin when other treatments fail to provide glycemic control.

Types of antidiabetic drugs

Includes insulins, oral hypoglycemic drugs, and combinations of oral antihypoglycemic and insulin to control glucose levels.

Insulins

Substitutes for the endogenous hormone. Effects are the same as those of normal endogenous insulin, restoring the diabetic patient's ability to metabolize carbohydrates, fats, and proteins, and store glucose.

Human insulin

Insulin derived using recombinant DNA technologies, produced by bacteria and yeast, aimed at achieving tight glucose control. To reduce the incidence of long-term complications.

Rapid-acting insulin

Example: NovaRapid and Humalog, with an onset of action of 10 to 15 minutes, peak effect at 1 to 2 hours, and a duration of 3 to 5 hours. Patient must eat a meal after injection. May be given subcutaneously or via continuous subcutaneous infusion pump (but not intravenously).

Short acting insulin

Clear in appearance, includes regular insulin (Humulin R), with an onset of 30 minutes, peak of 2 to 3 hours, and duration of 6.5 hours.

Intermediate-Acting Insulins: Insulin isophane suspension (Humulin N)

Cloudy appearance; often combined with regular insulin (Humulin R). Onset: 1 to 3 hours, Peak: 5 to 8 hours, Duration: up to 18 hours.

Long-acting insulins

Insulin glargine (Lantus®); clear, colourless solution; constant level of insulin in the body; usually dosed once daily (at night) or every 12 hours; referred to as basal insulin. Onset: 90 minutes, Peak: none, Duration: 24 hours.

Insulin detemir (Levemir)

Duration of action is dose dependent; lower doses require twice-daily dosing; higher doses may be given once daily.

Fixed combination Insulins

Each contains two different insulins, fixed combinations; one intermediate-acting type and either one rapid-acting type (Humalog) or one short-acting type (Humulin).

Slide scale insulin dosing

Subcutaneous insulin is ordered in an amount that increases as the blood glucose increases; disadvantage: delays insulin administration until hyperglycemia occurs, resulting in large swings in glucose control. Recent research does not support sliding-scale use; nonetheless, sliding scale is still commonly used.

Basal Bolus insulin dosing

Preferred method of treatment for hospitalized patients with diabetes; mimics a healthy pancreas by delivering basal insulin constantly as a basal and then as needed as a bolus.

Oral antidiabetic drugs

Biguanide: metformin; first-line drug and the most used oral medication for the treatment of type 2 diabetes; not used for type 1 diabetes. If lifestyle modifications and the maximum tolerated metformin dose do not achieve the recommended A1c goals after 3 to 6 months, additional oral treatment should be given or insulin.

Metformin Adverse effects

Abdominal bloating, nausea, cramping, feeling of fullness, hypoglycemia, lactic acidosis.

Sulphonylureas

2nd generation (amaryl); adverse effects include hypoglycemia and weight gain.

Sodium glucose cotransporter 2 inhibitors

A decrease in blood glucose caused by an increase in renal glucose excretion; a new class (2014) of oral drugs for the treatment of type 2 diabetes. Work independently of insulin to prevent glucose reabsorption from the glomerular filtrate, resulting in a reduced renal threshold for glucose and glycosuria (excess glucose in urine).

Hypoglycemia

Abnormally low blood glucose level (below 4 mmol/L); mild cases can be treated with diet. Higher intake of protein and lower intake of carbohydrates—to prevent rebound postprandial hypoglycemia.

S/S of hypoglycemia

Adrenergic: anxiety, tremors, sensation of hunger, palpitations, sweating; CNS: difficulty concentrating, confusion, weakness, drowsiness, vision changes, difficulty speaking, dizziness, headache; Later signs: hypothermia, seizures, coma and death will occur if not treated.

Glucose elevating drugs

Oral forms of concentrated glucose (gel, liquid, or tablet form); 50% dextrose in water (D50W); glucagon.

Before giving drugs that alter glucose levels, obtain and document...

A thorough history, Vital signs, Blood glucose levels, HbA1c level, Potential complications and drug interactions.

Keep in mind that overall concerns for any patient with diabetes increase when the patient...

Under stress, Is pregnant or lactating, Has an infection, Has an illness or trauma.

Drawing up Insulin: Mixing Suspensions

Roll vials between hands instead of shaking them. Ensure correct storage of insulin vials. Only use insulin syringes, calibrated in units, to measure and give insulin. Ensure correct timing of insulin dose with meals.

When drawing up two types of insulin in one syringe…

Always withdraw the regular or rapid-acting (clear) insulin first. Provide thorough patient education regarding self- administration of insulin injections, including timing of doses, monitoring of blood glucose levels, and injection site rotations.

Adrenal Gland

Adrenal cortex and adrenal medulla; each portion has different functions and secretes different hormones. Feedback process of hormone regulation.

Adrenal medulla secretes catecholamines

Epinephrine and norepinephrine.

Adrenal cortex secretes corticosteroids

Glucocorticoids and mineralocorticoids (primarily aldosterone).