NUR130 Med Surge Medications (Exam 1)

0.9% Sodium Chloride (Normal Saline)

Isotonic Crystalloid Solution

Mechanism of Action: Provides isotonic hydration by expanding extracellular fluid (ECF) volume without shifting fluid between compartments.

Indications: Hydration, ECF expansion, blood product transfusions, fluid resuscitation, shock management.

Side Effects/Adverse Effects: Rapid infusion may cause hypernatremia, fluid volume excess (FVE), and electrolyte depletion. Long-term use provides no calories.

Nursing Considerations: Monitor for signs of FVE (edema, crackles, dyspnea). Assess electrolyte levels, especially sodium. Monitor intake and output. Avoid long-term use without nutritional support.

Patient Education: Report swelling, difficulty breathing, or weight gain. Explain this provides hydration but not nutrition.

Antidotes/Interactions: No specific antidote. Diuretics may be needed if FVE develops.

Rationale: Normal saline is isotonic and commonly used for hydration and volume expansion, but rapid or prolonged infusion can lead to fluid overload and hypernatremia.

Lactated Ringer's Solution (LR)

Isotonic Balanced Electrolyte Solution

Mechanism of Action: Provides isotonic hydration with balanced electrolytes similar to plasma. Lactate is metabolized in the liver to bicarbonate, acting as a buffering agent.

Indications: Hydration, electrolyte replacement, fluid resuscitation, treatment of burns and trauma.

Side Effects/Adverse Effects: Fluid overload, excess electrolytes, metabolic acidosis with long-term therapy.

Nursing Considerations: Contraindicated in patients with liver disease (cannot metabolize lactate). Monitor for FVE (weight gain, edema, crackles). Assess electrolyte levels. Monitor intake and output. Does not provide adequate electrolytes for maintenance therapy in patients with no oral intake.

Patient Education: Report swelling, difficulty breathing, or weight gain. Not suitable if you have liver problems.

Antidotes/Interactions: No specific antidote. Avoid in liver disease due to impaired lactate metabolism.

Rationale: LR is similar to plasma in electrolyte content and is useful for fluid replacement, but lactate metabolism requires normal liver function.

Dextrose 5% in Water (D5W)

Isotonic/Hypotonic Crystalloid Solution

Mechanism of Action: Initially isotonic, but dextrose is rapidly metabolized to CO₂ and water, making the remaining solution hypotonic. Provides hydration, some calories, and increases blood glucose.

Indications: Hydration, hypoglycemia correction (in higher concentrations), medication dilution, provision of minimal calories.

Side Effects/Adverse Effects: Rapid infusion may cause hyperglycemia leading to osmotic diuresis and fluid/electrolyte imbalance. Vein irritation due to acidic pH (3.4-4). Long-term use may cause electrolyte depletion, fluid overload, water intoxication, pulmonary edema.

Nursing Considerations: Monitor blood glucose levels. Assess IV site for infiltration or phlebitis (solution is irritating). Monitor for signs of FVE and hyponatremia. Assess intake and output. Solutions >10% dextrose should be given via central line (except 50% dextrose for hypoglycemia via peripheral line).

Patient Education: Report IV site pain, redness, or swelling. May cause temporary increase in blood sugar.

Antidotes/Interactions: Insulin may be needed if hyperglycemia develops.

Rationale: D5W becomes hypotonic after dextrose metabolism and can cause vein irritation; monitoring glucose and IV site is essential.

3% Sodium Chloride

Hypertonic Saline Solution

Mechanism of Action: Hypertonic solution that increases serum sodium levels and draws fluid from interstitial and intracellular spaces into the vascular space.

Indications: Treatment of severe hyponatremia or hypochloremia, SIADH, cerebral edema (reduces intracranial pressure).

Side Effects/Adverse Effects: Osmotic demyelination syndrome if sodium corrected too rapidly (permanent brain damage). Hypernatremia, FVE, circulatory overload, vein irritation, thrombosis if given peripherally.

Nursing Considerations: Monitor serum sodium levels closely—increase should not exceed 10-12 mEq/L in first 24 hours or 18 mEq/L in 48 hours. Administer via central line when possible. Monitor neurological status. Maintain accurate intake and output. Assess for signs of FVE (crackles, dyspnea, edema). Monitor vital signs frequently.

Patient Education: This is a strong salt solution to correct dangerously low sodium. Report confusion, headache, seizures, or breathing difficulty immediately.

Antidotes/Interactions: Discontinue or slow infusion if sodium rises too rapidly. Diuretics for FVE.

Rationale: 3% saline treats severe hyponatremia but requires careful monitoring to prevent rapid overcorrection and osmotic demyelination syndrome.

Albumin (5% and 25%)

Colloid Solution/Volume Expander

Mechanism of Action: Increases oncotic pressure, pulling fluid from interstitial space into blood vessels, thereby expanding plasma volume. 5% solution is isotonic (expands volume equal to amount infused). 25% solution is hypertonic (draws additional fluid into vascular space).

Indications: Hypovolemia, shock, burns, hepatic failure, ascites, hypoalbuminemia.

Side Effects/Adverse Effects: Circulatory overload (pulls fluid into ECF), fluid volume excess, allergic reactions, hypertension, pulmonary edema.

Nursing Considerations: Monitor vital signs and urine output frequently. Assess for signs/symptoms of FVE (crackles, dyspnea, JVD, edema, hypertension). Monitor hemodynamic parameters if available. Use 25% albumin for burns, hepatic failure, and ascites. Use 5% for hypovolemia. Assess for allergic reactions.

Patient Education: Report difficulty breathing, chest tightness, rapid heartbeat, or swelling. This medication helps restore blood volume.

Antidotes/Interactions: Discontinue infusion if circulatory overload occurs. Diuretics may be needed for FVE.

Rationale: Albumin is a colloid that effectively expands plasma volume but requires close monitoring for fluid overload due to its oncotic effect.

0.45% Sodium Chloride (1/2 Normal Saline)
Hypotonic Crystalloid Solution

Mechanism of Action: Hypotonic solution that dilutes extracellular fluid (ECF), lowering serum osmolality. Water moves from ECF into cells, causing cells to swell and providing cellular hydration.

Indications: Hypernatremia treatment, maintenance fluid therapy (normal daily losses are hypotonic), cellular rehydration.

Side Effects/Adverse Effects: Can deplete ECF and lower blood pressure. Potential for cellular swelling and cerebral edema. Hyponatremia if given excessively.

Nursing Considerations: Monitor for changes in mentation that may signal cerebral edema. Not ideal for fluid replacement as it can deplete ECF. Monitor serum sodium and osmolality. Assess neurological status frequently. Monitor vital signs and intake/output.

Patient Education: Report confusion, headache, or altered mental status immediately. This solution provides hydration and helps correct high sodium levels.

Antidotes/Interactions: Discontinue if cerebral edema develops. May require hypertonic saline if severe hyponatremia occurs.

Rationale: As a hypotonic solution, 1/2 normal saline is useful for hypernatremia but requires careful monitoring for cerebral edema.

Dextrose 5% in 0.9% Sodium Chloride (D5NS)
Hypertonic Crystalloid Solution

Mechanism of Action: Initially hypertonic; dextrose is metabolized providing calories while the remaining normal saline expands ECF volume and provides sodium.

Indications: Fluid replacement when both calories and sodium are needed, temporary treatment of circulatory insufficiency and shock, hypoglycemia with dehydration.

Side Effects/Adverse Effects: Hyperglycemia, hypernatremia, fluid volume excess, electrolyte imbalances, vein irritation.

Nursing Considerations: Monitor blood glucose levels regularly. Assess serum sodium and electrolytes. Monitor for signs of FVE (edema, crackles, dyspnea). Assess IV site for infiltration or phlebitis. Monitor intake and output. Provides approximately 170 calories per liter from dextrose.

Patient Education: Report IV site pain, swelling, or redness. Report difficulty breathing or excessive swelling. May temporarily raise blood sugar.

Antidotes/Interactions: Insulin may be needed for hyperglycemia. Diuretics for fluid overload.

Rationale: D5NS provides both hydration and minimal calories but requires monitoring for hyperglycemia and hypernatremia.

Dextrose 5% in Lactated Ringer's Solution (D5LR)
Hypertonic Balanced Electrolyte Solution

Mechanism of Action: Provides isotonic hydration with balanced electrolytes plus calories from dextrose. Lactate is metabolized to bicarbonate in the liver.

Indications: Hydration with electrolyte replacement and minimal caloric support, fluid resuscitation, treatment of burns and trauma.

Side Effects/Adverse Effects: Fluid overload, metabolic acidosis with long-term use, hyperglycemia, excess electrolytes.

Nursing Considerations: Contraindicated in liver disease (cannot metabolize lactate). Monitor blood glucose. Assess for FVE. Monitor electrolytes. Does not provide adequate electrolytes for maintenance in patients with no oral intake. Assess IV site. Monitor intake and output.

Patient Education: Report swelling, breathing difficulty, or weight gain. Not suitable if you have liver problems. May temporarily increase blood sugar.

Antidotes/Interactions: Avoid in liver disease. Insulin for hyperglycemia. Diuretics for fluid overload.

Rationale: D5LR provides hydration, electrolytes, and minimal calories but requires normal liver function to metabolize lactate.

Potassium Chloride (KCl)
Electrolyte Supplement

Mechanism of Action: Replaces potassium, an essential electrolyte for cardiac function, muscle contraction, and nerve impulse transmission.

Indications: Hypokalemia treatment and prevention, maintenance of normal potassium levels.

Side Effects/Adverse Effects: Phlebitis and infiltration causing tissue necrosis and sloughing. Hyperkalemia if given too rapidly. Cardiac dysrhythmias. Nausea, vomiting, diarrhea with oral forms.

Nursing Considerations: IV infusion rates should not exceed 10 mEq/hr unless patient is in critical care with continuous ECG monitoring and central line access. Must be given by infusion pump. Assess IV sites at least hourly for phlebitis and infiltration. Never give IV push. Monitor serum potassium levels. Assess cardiac rhythm. Monitor renal function. Encourage dietary potassium intake for mild cases.

Patient Education: Report IV site pain, burning, or swelling immediately. Eat potassium-rich foods (bananas, oranges, potatoes). Report muscle weakness, palpitations, or irregular heartbeat.

Antidotes/Interactions: Calcium gluconate for severe hyperkalemia with cardiac changes. ACE inhibitors and potassium-sparing diuretics increase hyperkalemia risk.

Rationale: KCl is irritating to veins and requires careful administration with hourly IV site assessment to prevent tissue damage.

Magnesium Sulfate
Electrolyte Supplement

Mechanism of Action: Replaces magnesium, essential for neuromuscular function, cardiac rhythm, and numerous enzyme systems. Acts as a CNS depressant and smooth muscle relaxant.

Indications: Severe hypomagnesemia, hypomagnesemia with hypocalcemia, seizure prevention in preeclampsia/eclampsia, torsades de pointes treatment.

Side Effects/Adverse Effects: Respiratory depression, cardiac arrest, hypotension, depressed deep tendon reflexes, flushing, sweating. Toxicity signs: loss of patellar reflex, respiratory rate <12/min.

Nursing Considerations: Monitor respiratory rate, deep tendon reflexes, and urine output closely. Have calcium gluconate available as antidote. Monitor serum magnesium levels (therapeutic: 4-6 mEq/L for eclampsia). Continuous cardiac monitoring for IV administration. Assess blood pressure frequently. Use infusion pump for IV administration. For mild deficiency, give oral supplements and increase dietary magnesium.

Patient Education: Report muscle weakness, difficulty breathing, or extreme drowsiness. Eat magnesium-rich foods (nuts, whole grains, leafy greens). May cause flushing or warmth during IV infusion.

Antidotes/Interactions: Calcium gluconate is the antidote for magnesium toxicity. CNS depressants potentiate effects.

Rationale: Magnesium sulfate requires close monitoring due to risk of respiratory depression; calcium gluconate reverses toxicity.

Calcium Gluconate

Electrolyte Supplement

Mechanism of Action: Replaces calcium, essential for cardiac function, muscle contraction, nerve transmission, and bone health. Raises the threshold at which dysrhythmias occur, temporarily stabilizing the myocardium in hyperkalemia.

Indications: Symptomatic hypocalcemia (including tetany and significant ECG changes), hyperkalemia with cardiac changes (life-threatening dysrhythmias), calcium supplementation.

Side Effects/Adverse Effects: Bradycardia, hypotension, cardiac dysrhythmias, tissue necrosis if extravasation occurs. Less irritating than calcium chloride when given IV.

Nursing Considerations: Monitor ECG during IV administration. Administer slowly (not to exceed 0.5-2 mL/min). Assess IV site frequently for infiltration—can cause severe tissue damage. Monitor serum calcium levels. Monitor vital signs and cardiac rhythm. Closely assess patients post-thyroid or neck surgery for hypocalcemia signs. Treat pain and anxiety to prevent hyperventilation-induced tetany. Contains 4.65 mEq Ca++/g (less than calcium chloride).

Patient Education: Report IV site pain, burning, tingling, or numbness immediately. Report muscle cramps, spasms, or numbness around mouth. Maintain diet high in calcium-rich foods and take vitamin D supplementation as prescribed.

Antidotes/Interactions: No specific antidote. Loop diuretics increase calcium loss; thiazide diuretics may be used to decrease urinary calcium excretion.

Rationale: Calcium gluconate is the preferred IV calcium for treating symptomatic hypocalcemia and stabilizing the myocardium in hyperkalemia, but requires slow administration and careful IV site monitoring.

Sodium Polystyrene Sulfonate (Kayexalate)

Cation-Exchange Resin

Mechanism of Action: Cation-exchange resin that exchanges sodium ions for potassium ions in the GI tract, binding potassium and promoting its evacuation through the bowel.

Indications: Hyperkalemia treatment in stage 4 CKD, acute hyperkalemia (non-emergent).

Side Effects/Adverse Effects: Diarrhea (due to osmotic laxative action), sodium and water retention, hypokalemia, hypomagnesemia, hypocalcemia, constipation, fecal impaction, intestinal necrosis (rare but serious).

Nursing Considerations: Inform patient to expect diarrhea. Monitor for sodium and water retention (edema, weight gain, hypertension). Monitor serum potassium, sodium, magnesium, and calcium levels. Assess bowel sounds and bowel movements. Not for emergency treatment—dialysis is preferred for life-threatening hyperkalemia with ECG changes (peaked T waves, widened QRS complexes). May take several hours to days for effect.

Patient Education: Expect loose stools or diarrhea. Report swelling, weight gain, or difficulty breathing. Take as prescribed even if feeling well. Avoid potassium-rich foods while on this medication.

Antidotes/Interactions: No specific antidote. May bind other medications in the GI tract, reducing absorption.

Rationale: Kayexalate lowers potassium by exchanging it for sodium in the bowel but causes diarrhea and requires monitoring for sodium retention and electrolyte imbalances.

Sodium Zirconium Cyclosilicate (Lokelma)

Potassium Binder

Mechanism of Action: Oral potassium binder that selectively traps potassium ions in the GI tract in exchange for sodium and hydrogen ions, increasing fecal potassium excretion.

Indications: Long-term treatment of hyperkalemia in patients with CKD.

Side Effects/Adverse Effects: Edema (due to sodium retention), hypokalemia if over-treated, GI disturbances (nausea, constipation, diarrhea).

Nursing Considerations: Give at least 2 hours apart from other oral medications (binds other drugs). Monitor serum potassium levels regularly. Not for emergency treatment of hyperkalemia due to delayed onset of action. Monitor for edema and fluid retention. Assess renal function. Faster onset than sodium polystyrene sulfonate.

Patient Education: Take at least 2 hours before or after other medications. Report swelling, significant weight gain, or muscle weakness. Continue potassium restriction in diet as instructed. This is a long-term medication, not for emergencies.

Antidotes/Interactions: No specific antidote. Binds many oral medications—separate dosing by at least 2 hours. Can cause hypokalemia if over-used.

Rationale: Lokelma is effective for long-term hyperkalemia management but must be taken separately from other medications due to binding interactions and is not suitable for acute emergencies.

Sodium Bicarbonate IV

Alkalinizing Agent/Electrolyte

Mechanism of Action: Increases blood pH by buffering excess hydrogen ions and raising serum bicarbonate levels. Promotes a temporary shift of potassium into cells in hyperkalemia by alkalinizing the blood.

Indications: Metabolic acidosis, hyperkalemia (temporary measure), cardiac arrest, certain drug overdoses (tricyclic antidepressants, aspirin).

Side Effects/Adverse Effects: Metabolic alkalosis, hypernatremia, fluid overload, hypokalemia (after potassium shifts back), hypocalcemia (from alkalosis), tissue necrosis if extravasation occurs.

Nursing Considerations: Monitor arterial blood gases (ABGs) and serum electrolytes frequently. Monitor pH—overcorrection causes metabolic alkalosis. For hyperkalemia, this is only a temporary measure—potassium will eventually diffuse back into the bloodstream. Administer slowly via infusion pump. Assess IV site for infiltration. Monitor for signs of fluid overload. Do not mix with calcium-containing solutions (precipitates).

Patient Education: This medication helps correct acid levels in your blood or temporarily lowers dangerous potassium levels. Report IV site pain or swelling immediately. You may need additional treatments for ongoing potassium or acid problems.

Antidotes/Interactions: No specific antidote for alkalosis; supportive care and discontinuation. Do not mix with calcium or catecholamines. Incompatible with many IV medications.

Rationale: Sodium bicarbonate temporarily shifts potassium intracellularly in hyperkalemia and corrects metabolic acidosis, but requires close monitoring of ABGs, electrolytes, and pH to prevent alkalosis.

Isoniazid (INH)

Antitubercular Agent (First-Line)

Mechanism of Action: Bactericidal drug that inhibits tubercle cell wall synthesis and interferes with pyridoxine (vitamin B6) metabolism.

Indications: First-line treatment for TB disease, often used in combination therapy to prevent drug resistance.

Side Effects/Adverse Effects: Peripheral neuropathy (due to vitamin B6 depletion), hepatotoxicity, vitamin B6 deficiency.

Nursing Considerations: Monitor liver function tests closely. Assess for signs of hepatotoxicity (jaundice, dark urine, fatigue). Assess for peripheral neuropathy (numbness, tingling in extremities). Pyridoxine (vitamin B6) may be prescribed concurrently to prevent neuropathy and vitamin deficiency. Administer orally. Single-drug therapy is ineffective; always use combination therapy.

Patient Education: Take medication as prescribed for the full 6-9 month course, even if feeling better. Report signs of liver problems (yellowing of skin/eyes, dark urine, fatigue) or numbness/tingling in hands or feet immediately. Take pyridoxine supplement if prescribed. Avoid alcohol to reduce hepatotoxicity risk.

Antidotes/Interactions: Pyridoxine (vitamin B6) supplementation prevents peripheral neuropathy. Avoid alcohol due to increased risk of hepatotoxicity.

Rationale: INH remains the cornerstone of TB treatment but requires pyridoxine supplementation to prevent neuropathy and careful monitoring for hepatotoxicity.

Rifampin

Antitubercular Agent (First-Line)

Mechanism of Action: Bactericidal drug that inhibits bacterial RNA synthesis, preventing TB bacteria from reproducing.

Indications: First-line treatment for TB disease, used in combination with other antitubercular drugs in both initial and continuation phases of therapy.

Side Effects/Adverse Effects: Orange-red discoloration of body fluids (urine, tears, saliva, sweat), hepatotoxicity, GI disturbances, drug interactions (induces liver enzymes).

Nursing Considerations: Monitor liver function tests regularly. Inform patient about harmless orange-red discoloration of body fluids. Monitor for signs of hepatotoxicity. Assess for drug interactions—rifampin is a potent enzyme inducer that decreases effectiveness of many medications including oral contraceptives, warfarin, and antiretrovirals. Administer on empty stomach if possible.

Patient Education: Expect orange-red color in urine, tears, saliva, and sweat—this is normal and harmless but may permanently stain soft contact lenses and clothing. Use alternative contraception methods as rifampin decreases effectiveness of oral contraceptives. Report signs of liver problems immediately. Take for the full prescribed course (typically 6-9 months). Do not skip doses or stop early, as this promotes drug resistance.

Antidotes/Interactions: No specific antidote. Potent enzyme inducer—decreases effectiveness of oral contraceptives, warfarin, antiretrovirals, and many other medications. Avoid alcohol.

Rationale: Rifampin is essential in TB combination therapy but causes harmless orange-red discoloration of body fluids and significantly interacts with many medications through enzyme induction.

Ethambutol

Antitubercular Agent (First-Line)

Mechanism of Action: Bacteriostatic drug that inhibits cell wall synthesis of tubercle bacteria.

Indications: First-line treatment for TB disease, used in initial 4-drug regimen to prevent resistance; may be discontinued if drug susceptibility tests show bacteria are susceptible to all other drugs.

Side Effects/Adverse Effects: Optic neuritis (vision changes, decreased visual acuity, red-green color blindness), peripheral neuropathy, hepatotoxicity.

Nursing Considerations: Baseline and periodic vision testing is essential—assess visual acuity and color discrimination before starting therapy and monthly during treatment. Instruct patient to report any vision changes immediately. Monitor liver function tests. Assess for peripheral neuropathy. Not recommended in young children who cannot report vision changes reliably. Discontinue drug if optic neuritis develops.

Patient Education: Report any vision changes immediately, including blurred vision, color blindness (especially red-green), or decreased vision—these may indicate optic neuritis. Attend all scheduled eye examinations. Take medication with food to reduce GI upset. Complete the full course of therapy as prescribed.

Antidotes/Interactions: No specific antidote. Discontinue medication if optic neuritis occurs—vision changes may be reversible if caught early but can become permanent.

Rationale: Ethambutol is included in the initial 4-drug TB regimen but requires careful vision monitoring due to the risk of optic neuritis, which can cause permanent vision loss if not detected early.

Pyrazinamide (PZA)

Antitubercular Agent (First-Line)

Mechanism of Action: Bactericidal drug that disrupts TB bacterial metabolism and membrane transport, most effective in acidic environments.

Indications: First-line treatment for TB disease, used in the initial 2-month intensive phase of therapy to rapidly reduce bacterial load.

Side Effects/Adverse Effects: Hepatotoxicity, hyperuricemia (elevated uric acid levels), gout, arthralgias (joint pain), GI disturbances.

Nursing Considerations: Monitor liver function tests closely—pyrazinamide has significant hepatotoxic potential. Monitor serum uric acid levels. Assess for signs of hepatotoxicity (jaundice, abdominal pain, fatigue). Assess for joint pain and gout symptoms. Contraindicated in liver disease and pregnancy. Typically used only during the initial 2-month phase, not the continuation phase.

Patient Education: Report signs of liver problems immediately (yellowing of skin/eyes, dark urine, severe fatigue, abdominal pain). Report severe joint pain or swelling. Take with food to reduce GI upset. Complete the full 2-month initial phase as prescribed. Stay well-hydrated.

Antidotes/Interactions: No specific antidote. Avoid alcohol due to increased hepatotoxicity risk. May increase uric acid levels—monitor patients with history of gout.

Rationale: Pyrazinamide is essential in the intensive initial phase of TB treatment but requires close monitoring for hepatotoxicity and is contraindicated in liver disease and pregnancy.

Gentamicin

Aminoglycoside Antibiotic

Mechanism of Action: Bactericidal drug that inhibits bacterial protein synthesis by binding to bacterial ribosomes.

Indications: Treatment of serious gram-negative infections.

Side Effects/Adverse Effects: Ototoxicity (hearing loss, tinnitus, balance problems), nephrotoxicity (kidney damage), superinfection.

Nursing Considerations: Monitor renal function (BUN, creatinine, urinary output). Assess hearing, balance, and tinnitus before and during therapy. Monitor therapeutic drug levels closely (TDM required) to prevent toxicity. Careful dosing especially important in younger and older patients. Administer IM or IV. Assess for prolonged use leading to superinfection.

Patient Education: Report any hearing changes, ringing in ears, dizziness, or decreased urination immediately. Stay well-hydrated. Complete full course of therapy. Attend all scheduled lab appointments for drug level monitoring.

Antidotes/Interactions: No specific antidote. Avoid concurrent use with other nephrotoxic or ototoxic drugs. Age and renal function determine toxicity risk.

Rationale: Aminoglycosides like gentamicin require careful monitoring of renal function and hearing due to serious ototoxicity and nephrotoxicity risks, with therapeutic drug monitoring essential to maintain safe and effective levels.

Streptomycin

Aminoglycoside Antibiotic

Mechanism of Action: Bactericidal drug that inhibits bacterial protein synthesis by binding to bacterial ribosomes.

Indications: Treatment of tuberculosis (second-line agent) and serious gram-negative infections.

Side Effects/Adverse Effects: Ototoxicity (hearing loss, tinnitus, vestibular damage), nephrotoxicity (kidney damage), superinfection.

Nursing Considerations: Monitor renal function (BUN, creatinine, urinary output). Assess hearing, balance, and tinnitus before and during therapy. Monitor therapeutic drug levels closely (TDM required) to prevent toxicity. Careful dosing especially important in younger and older patients. Administer IM or IV. Assess for prolonged use leading to superinfection.

Patient Education: Report any hearing changes, ringing in ears, dizziness, or decreased urination immediately. Stay well-hydrated. Complete full course of therapy (may be months for TB). Attend all scheduled lab appointments for drug level monitoring.

Antidotes/Interactions: No specific antidote. Avoid concurrent use with other nephrotoxic or ototoxic drugs. Age and renal function determine toxicity risk.

Rationale: Streptomycin is an aminoglycoside with the same serious ototoxicity and nephrotoxicity risks as gentamicin, requiring therapeutic drug monitoring and careful assessment of renal function and hearing.

Ciprofloxacin (Cipro)

Fluoroquinolone Antibiotic

Mechanism of Action: Bactericidal drug that inhibits bacterial DNA synthesis by inhibiting the enzyme DNA gyrase.

Indications: Treatment of bacterial prostatitis (acute and chronic), various bacterial infections; has high tissue distribution.

Side Effects/Adverse Effects: GI effects (dysgeusia, nausea, vomiting, abdominal pain, diarrhea), CNS reactions (headache, restlessness, dizziness, confusion), photosensitivity, tendon rupture (especially Achilles tendon), Candida infections (pharynx, vagina), Clostridium difficile infection, corneal deposits, conjunctival hyperemia, ocular ulceration.

Nursing Considerations: Assess for tendon pain or inflammation—highest risk in patients ≥60 years and transplant recipients. Monitor for C. difficile infection (severe diarrhea). Take before meals if possible (food slows absorption). Avoid antacids (decrease absorption). Monitor for CNS effects. Onset: 30 minutes to 1 hour; peak: 1-2 hours.

Patient Education: Report tendon pain, swelling, or difficulty moving joints immediately—stop drug and rest affected area. Avoid prolonged sun exposure and use sunscreen (photosensitivity risk). Take 2 hours before or 6 hours after antacids, calcium, iron, or zinc supplements. Stay well-hydrated. Complete full course of therapy. Report severe or persistent diarrhea.

Antidotes/Interactions: No specific antidote. Increases effects of theophylline and caffeine. Antacids decrease absorption. Avoid concurrent corticosteroids (increases tendon rupture risk).

Rationale: Ciprofloxacin is a fluoroquinolone used for bacterial prostatitis and other infections but carries significant risks including tendon rupture (especially in older adults and transplant recipients), photosensitivity, and C. difficile infection.

Levofloxacin

Fluoroquinolone Antibiotic

Mechanism of Action: Bactericidal drug that inhibits bacterial DNA synthesis by inhibiting the enzyme DNA gyrase.

Indications: Treatment of bacterial prostatitis (acute and chronic), various bacterial infections; has high tissue distribution.

Side Effects/Adverse Effects: GI effects (nausea, vomiting, diarrhea), CNS reactions (headache, dizziness, confusion), photosensitivity, tendon rupture (especially Achilles tendon), Candida infections, Clostridium difficile infection.

Nursing Considerations: Assess for tendon pain or inflammation—highest risk in patients ≥60 years and transplant recipients. Monitor for C. difficile infection (severe diarrhea). Avoid antacids (decrease absorption). Monitor for CNS effects. May be given orally or IV.

Patient Education: Report tendon pain, swelling, or difficulty moving joints immediately—stop drug and rest affected area. Avoid prolonged sun exposure and use sunscreen (photosensitivity risk). Take 2 hours before or 6 hours after antacids, calcium, iron, or zinc supplements. Stay well-hydrated. Complete full course of therapy (typically 6-8 weeks for bacterial prostatitis). Report severe or persistent diarrhea.

Antidotes/Interactions: No specific antidote. Antacids, calcium, iron, and zinc decrease absorption. Avoid concurrent corticosteroids (increases tendon rupture risk).

Rationale: Levofloxacin is a fluoroquinolone antibiotic used for bacterial prostatitis with 6-8 week oral therapy, carrying the same class risks of tendon rupture (especially in older adults and transplant recipients), photosensitivity, and C. difficile infection as ciprofloxacin.

Front: Ampicillin

Penicillin Antibiotic (Aminopenicillin)

Mechanism of Action: Bactericidal drug that inhibits bacterial cell wall synthesis, causing cell lysis.

Indications: Treatment of various bacterial infections including respiratory, GI, and urinary tract infections.

Side Effects/Adverse Effects: Allergic reactions (rash, anaphylaxis), GI disturbances (nausea, vomiting, diarrhea), superinfection, Clostridium difficile-associated diarrhea (CDAD).

Nursing Considerations: Assess for penicillin allergy before administration. Administer IM or IV. Monitor for allergic reactions, especially during first dose. Assess for superinfection with prolonged use. May cause false-positive results for proteinuria and glucosuria in large doses.

Patient Education: Report any signs of allergic reaction (rash, itching, difficulty breathing) immediately. Complete full course of therapy even if feeling better. Take on empty stomach for better absorption (1 hour before or 2 hours after meals). Report severe or persistent diarrhea.

Antidotes/Interactions: No specific antidote. Effects decreased when taken with erythromycin and tetracycline. Serum levels increased when taken with probenecid. Antagonistic effect when combined with bacteriostatic antibiotics like tetracycline.

Rationale: Ampicillin is a penicillin antibiotic that inhibits bacterial cell wall synthesis; its effects are reduced by erythromycin and tetracycline, and probenecid increases its serum levels by decreasing urinary excretion.

Amoxicillin

Penicillin Antibiotic (Aminopenicillin)

Mechanism of Action: Bactericidal drug that inhibits bacterial cell wall synthesis, causing cell lysis.

Indications: Treatment of various bacterial infections including respiratory, ear, urinary tract, and skin infections; broader spectrum than penicillin G with better oral absorption.

Side Effects/Adverse Effects: Allergic reactions (rash, anaphylaxis), GI disturbances (nausea, vomiting, diarrhea), superinfection, Clostridium difficile-associated diarrhea (CDAD).

Nursing Considerations: Assess for penicillin allergy before administration. Administer orally. Monitor for allergic reactions. Assess for superinfection with prolonged use. Onset, peak concentration time, and duration of action very similar to dicloxacillin.

Patient Education: Report any signs of allergic reaction (rash, itching, difficulty breathing) immediately. Complete full course of therapy even if feeling better. May be taken with or without food. Report severe or persistent diarrhea.

Antidotes/Interactions: No specific antidote. Effects decreased when taken with erythromycin and tetracycline. Serum levels increased when taken with probenecid. Antagonistic effect when combined with bacteriostatic antibiotics like tetracycline.

Rationale: Amoxicillin is a broad-spectrum penicillin with better oral absorption than penicillin G; probenecid increases its serum antibacterial levels, while erythromycin and tetracycline decrease its effectiveness.

Piperacillin

Penicillin Antibiotic (Extended-Spectrum Penicillin)

Mechanism of Action: Bactericidal drug that inhibits bacterial cell wall synthesis, causing cell lysis.

Indications: Treatment of serious gram-negative infections and mixed infections; broader spectrum activity than ampicillin or amoxicillin; penicillinase-sensitive.

Side Effects/Adverse Effects: Allergic reactions (rash, anaphylaxis), GI disturbances, superinfection, Clostridium difficile-associated diarrhea (CDAD), bleeding complications (due to platelet dysfunction).

Nursing Considerations: Assess for penicillin allergy before administration. Administer parenterally (IM or IV). Monitor for allergic reactions. Assess for superinfection with prolonged use. Monitor coagulation studies if prolonged therapy. Penicillinase-sensitive, so may be ineffective against resistant bacteria.

Patient Education: Report any signs of allergic reaction (rash, itching, difficulty breathing) immediately. Report unusual bleeding or bruising. Complete full course of therapy even if feeling better. Report severe or persistent diarrhea.

Antidotes/Interactions: No specific antidote. Antagonistic effect when combined with bacteriostatic antibiotics like tetracycline. Penicillinase-sensitive, making it susceptible to breakdown by beta-lactamase enzymes.

Rationale: Piperacillin is an extended-spectrum penicillin used for serious infections but is penicillinase-sensitive, meaning it can be broken down by bacterial beta-lactamase enzymes unless combined with a beta-lactamase inhibitor.

Ampicillin-sulbactam (Unasyn)

Penicillin Antibiotic + Beta-Lactamase Inhibitor Combination

Mechanism of Action: Bactericidal combination where ampicillin inhibits bacterial cell wall synthesis and sulbactam (a beta-lactamase inhibitor) prevents bacterial beta-lactamase enzymes from breaking down ampicillin, extending its antimicrobial effect.

Indications: Treatment of infections caused by beta-lactamase-producing bacteria, including intra-abdominal, gynecologic, and skin/soft tissue infections.

Side Effects/Adverse Effects: Allergic reactions (rash, anaphylaxis), GI disturbances (nausea, vomiting, diarrhea), superinfection, Clostridium difficile-associated diarrhea (CDAD), pain at injection site.

Nursing Considerations: Assess for penicillin allergy before administration. Administer parenterally (IM or IV). Monitor for allergic reactions. Assess for superinfection with prolonged use. Sulbactam is not given alone but combined with a penicillinase-sensitive penicillin.

Patient Education: Report any signs of allergic reaction (rash, itching, difficulty breathing) immediately. Complete full course of therapy even if feeling better. Report severe or persistent diarrhea. Expect IM injection discomfort.

Antidotes/Interactions: No specific antidote. The beta-lactamase inhibitor (sulbactam) makes the antibiotic effective against resistant bacteria by preventing enzymatic breakdown. Antagonistic effect when combined with bacteriostatic antibiotics.

Rationale: Ampicillin-sulbactam combines a broad-spectrum penicillin with a beta-lactamase inhibitor (sulbactam) that prevents bacterial enzymes from breaking down ampicillin, extending its effectiveness against resistant bacteria; it is given parenterally.

Piperacillin-tazobactam (Zosyn)

Penicillin Antibiotic + Beta-Lactamase Inhibitor Combination

Mechanism of Action: Bactericidal combination where piperacillin inhibits bacterial cell wall synthesis and tazobactam (a beta-lactamase inhibitor) prevents bacterial beta-lactamase enzymes from breaking down piperacillin, extending its antimicrobial effect.

Indications: Treatment of moderate to severe infections caused by beta-lactamase-producing bacteria, including intra-abdominal, skin/soft tissue, pneumonia, and sepsis.

Side Effects/Adverse Effects: Allergic reactions (rash, anaphylaxis), GI disturbances (nausea, vomiting, diarrhea), superinfection, Clostridium difficile-associated diarrhea (CDAD), bleeding complications, electrolyte imbalances (hypokalemia).

Nursing Considerations: Assess for penicillin allergy before administration. Administer parenterally (IV). Monitor for allergic reactions. Assess for superinfection with prolonged use. Monitor coagulation studies and electrolytes with prolonged therapy. Tazobactam is not given alone but combined with a penicillinase-sensitive penicillin.

Patient Education: Report any signs of allergic reaction (rash, itching, difficulty breathing) immediately. Report unusual bleeding or bruising. Complete full course of therapy even if feeling better. Report severe or persistent diarrhea.

Antidotes/Interactions: No specific antidote. The beta-lactamase inhibitor (tazobactam) makes the antibiotic effective against resistant bacteria by preventing enzymatic breakdown. Antagonistic effect when combined with bacteriostatic antibiotics.

Rationale: Piperacillin-tazobactam combines an extended-spectrum penicillin with a beta-lactamase inhibitor (tazobactam) that prevents bacterial beta-lactamases from breaking down piperacillin, making it highly effective against resistant bacteria; it is administered parenterally for serious infections.

Cefazolin (Ancef)

First-Generation Cephalosporin

Mechanism of Action: Bactericidal drug that inhibits bacterial cell wall synthesis.

Indications: Treatment of bone, skin, and lower respiratory tract infections; surgical prophylaxis.

Side Effects/Adverse Effects: Allergic reactions (rash, anaphylaxis), GI disturbances (nausea, vomiting, diarrhea), Clostridium difficile-associated diarrhea (CDAD), nephrotoxicity, phlebitis at IV site.

Nursing Considerations: Assess for penicillin/cephalosporin allergy before administration (cross-sensitivity 5-10%). Administer IM or IV. Onset is almost immediate with IV use; peak concentration time is 5-15 minutes. Monitor for allergic reactions. May cause false-positive laboratory results for proteinuria and glucosuria, especially in large doses.

Patient Education: Report any signs of allergic reaction (rash, itching, difficulty breathing) immediately. Complete full course of therapy even if feeling better. Report severe or persistent diarrhea.

Antidotes/Interactions: No specific antidote. Effects decreased when given with tetracyclines or erythromycin. Probenecid decreases urine excretion, increasing drug action and serum levels.

Rationale: Cefazolin is a first-generation cephalosporin with rapid IV onset used for surgical prophylaxis and infections; probenecid increases its effectiveness by decreasing urinary excretion, while tetracyclines and erythromycin decrease its bactericidal action.

Ceftriaxone

Third-Generation Cephalosporin

Mechanism of Action: Bactericidal drug that inhibits bacterial cell wall synthesis.

Indications: Treatment of serious gram-negative and some gram-positive infections, including meningitis, sepsis, pneumonia, and gonorrhea; broader spectrum than first-generation cephalosporins.

Side Effects/Adverse Effects: Allergic reactions (rash, anaphylaxis), GI disturbances (nausea, vomiting, diarrhea), Clostridium difficile-associated diarrhea (CDAD), nephrotoxicity, bleeding complications, biliary sludging.

Nursing Considerations: Assess for penicillin/cephalosporin allergy before administration (cross-sensitivity 5-10%). Administer IM or IV. Monitor for allergic reactions. May cause false-positive laboratory results for proteinuria and glucosuria, especially in large doses. Long half-life allows once or twice daily dosing.

Patient Education: Report any signs of allergic reaction (rash, itching, difficulty breathing) immediately. Complete full course of therapy even if feeling better. Report severe or persistent diarrhea. Expect IM injection discomfort.

Antidotes/Interactions: No specific antidote. Effects decreased when given with tetracyclines or erythromycin. Probenecid decreases urine excretion, increasing drug action. Do not mix with calcium-containing IV solutions (risk of precipitation).

Rationale: Ceftriaxone is a third-generation cephalosporin with broad-spectrum activity and a long half-life allowing convenient once-daily dosing; its effects are decreased by tetracyclines and erythromycin, while probenecid increases its serum levels.

Erythromycin

Macrolide Antibiotic

Mechanism of Action: Binds to the 50S ribosomal subunit and inhibits protein synthesis; bacteriostatic at low to moderate doses, bactericidal at high doses.

Indications: Treatment of respiratory, skin, and soft tissue infections; alternative for patients with penicillin allergy.

Side Effects/Adverse Effects: GI disturbances (nausea, vomiting, abdominal pain, diarrhea), hepatotoxicity, ototoxicity (with high doses), Clostridium difficile-associated diarrhea (CDAD), phlebitis with IV administration, QT prolongation.

Nursing Considerations: Administer orally or IV; never IM (too painful). Infuse IV slowly to avoid phlebitis. Monitor liver function tests with prolonged therapy. Assess for hearing changes with high-dose therapy. May be taken with food to reduce GI upset.

Patient Education: Report any signs of liver dysfunction (jaundice, dark urine, abdominal pain). Complete full course of therapy even if feeling better. Take with food if GI upset occurs. Report severe or persistent diarrhea.

Antidotes/Interactions: No specific antidote. Decreases effects of penicillins and cephalosporins (antagonistic when combined with bactericidal antibiotics). Increases serum levels of theophylline, warfarin, and digoxin. May increase risk of QT prolongation with other QT-prolonging drugs.

Rationale: Erythromycin is a macrolide antibiotic that inhibits bacterial protein synthesis by binding to the 50S ribosomal subunit; it decreases the effectiveness of bactericidal antibiotics like penicillins and cephalosporins and must be infused slowly IV to prevent phlebitis.

Azithromycin

Macrolide Antibiotic

Mechanism of Action: Binds to the 50S ribosomal subunit and inhibits protein synthesis; bacteriostatic at low to moderate doses, bactericidal at high doses.

Indications: Treatment of respiratory, skin, and soft tissue infections; sexually transmitted infections; alternative for patients with penicillin allergy; longer half-life allows once-daily dosing.

Side Effects/Adverse Effects: GI disturbances (nausea, vomiting, abdominal pain, diarrhea), hepatotoxicity, ototoxicity (rare), Clostridium difficile-associated diarrhea (CDAD), QT prolongation.

Nursing Considerations: Administer orally or IV; never IM (too painful). Infuse IV slowly to avoid phlebitis. Monitor liver function tests with prolonged therapy. Half-life up to 68 hours allows once-daily or short-course therapy. May be taken with or without food.

Patient Education: Report any signs of liver dysfunction (jaundice, dark urine, abdominal pain). Complete full course of therapy even if feeling better (often 3-5 day course). Report severe or persistent diarrhea. May be taken with or without food.

Antidotes/Interactions: No specific antidote. Decreases effects of penicillins and cephalosporins (antagonistic when combined with bactericidal antibiotics). Increases serum levels of warfarin and digoxin. May increase risk of QT prolongation with other QT-prolonging drugs.

Rationale: Azithromycin is an extended macrolide with a very long half-life (up to 68 hours) allowing convenient once-daily dosing; like erythromycin, it inhibits protein synthesis and decreases the effectiveness of bactericidal antibiotics like penicillins and cephalosporins.

Vancomycin

Glycopeptide Antibiotic

Mechanism of Action: Bactericidal drug that inhibits bacterial cell wall synthesis.

Indications: Oral: Treatment of staphylococcal enterocolitis and C. difficile-associated pseudomembranous colitis (not absorbed systemically, excreted in feces). IV: Treatment of septicemia, severe MRSA infections, and bone, skin, and lower respiratory tract infections resistant to other antibiotics.

Side Effects/Adverse Effects: Nephrotoxicity, ototoxicity (damage to auditory or vestibular branch of cranial nerve VIII causing hearing loss or balance problems), headache, dizziness, nausea, vomiting, diarrhea, infusion site reactions, peripheral edema, angioedema, eosinophilia, neutropenia, phlebitis, CDAD, hypokalemia, renal failure, Stevens-Johnson syndrome, vancomycin flushing syndrome.

Nursing Considerations: Dilute intermittent doses appropriately (100 mL for 500 mg; 200 mL for 1 g of D5W, NS, or LR). Infuse over 60-90 minutes to prevent vancomycin flushing syndrome. Monitor therapeutic drug levels (trough levels). Monitor renal function (BUN, creatinine, urinary output) and hearing/vestibular function before and during therapy. 55% protein bound; half-life 4-6 hours. Assess for red flushing of face, neck, arms, upper body during infusion.

Patient Education: Report any hearing changes, ringing in ears, dizziness, or decreased urination immediately. Report red flushing, itching, rapid heartbeat, or difficulty breathing during infusion. Complete full course of therapy. Attend all scheduled lab appointments for drug level and kidney function monitoring.

Antidotes/Interactions: No specific antidote. Avoid concurrent use with other nephrotoxic or ototoxic drugs (aminoglycosides, loop diuretics). Vancomycin flushing syndrome (red flushing, hypotension, tachycardia, chest pain, wheezing, muscle spasms) occurs with too-rapid IV infusion; slow or stop infusion to reduce severity.

Rationale: Vancomycin is given orally for C. difficile (not absorbed systemically) and IV for serious MRSA and resistant infections; it requires careful monitoring for nephrotoxicity and ototoxicity, and must be infused slowly (over 60-90 minutes) to prevent vancomycin flushing syndrome, which is characterized by red flushing of the face, neck, and upper body.