Infection Exemplar: Septic Shock

Sepsis can lead to?

septic shock

what can septic shock cause?

Multisystem failure → death

what is sepsis?

infection in the blood stream

what is shock?

hypo-perfusion (inadequate oxygen to the cell/organs)

what is septic shock?

hypo-perfusion caused by infection/sepsis

Septic shock can cause both?

vasodilation (decreases perfusion) and clotting

what to remember about the antibiotic agents?

• acquired resistance (VRE, MRSA, and MSSA)

• Selective toxicity

• Bacteriostatic (low replication) and bactericidal (kill bacteria)

• broad and narrow spectrum

what are the classification of antibiotic agents?

• sulfonamides

• Penicillins

• cephalosporins

• fluroquinolones

• tetracyclines

• macrolides

• aminoglycosides

• vancomycin

what to assess for sulfonamides?

is the med appropriate? Check for allergies

are sulfonamides nephrotoxicity, hepatotoxicity, or ototoxicity?

nephrotoxicity

what to be caution about with sulfonamides?

• avoid in pregnancy and newborns

• can cross react with loop or thiazide diuretics

• increasing risk of hyperkalemia

what are side effects of sulfonamides?

• GI N/V/D

• superinfections

• renal toxicity

• general Abx consideration

what are nursing interventions for sulfonamides?

• Nephrotoxic

• important to drink lots of water, 8-10 glasses/day

  • risk of crystaluria

• avoid in pregnancy, newborns (high bilirubin)

• photosensitivity (sunburn)

• blood dyscrasia

  • leukopenia, anemia, thrombocytopenia

• increase risk of hypokalemia

what to evaluate for sulfanamides?

• low temperature

• low WBC

what are the different types of Penicillins?

• Penicillin V/G

• amoxicillin

  • amoxicillin/clavulanate (Augmentin) (ear infection)

• Ampicillin (Unasyn)

What to assess for penicillin?

Is the med appropriate?

are penicillin nephrotoxicity, hepatotoxicity, or ototoxicity?

nephrotoxicity

what to be caution about penicillin?

• GI N/V/D

• superinfections

• renal toxicity

• monitor Na/K (cardiac dysrhythmias) - stop k supplements

what are side effects of penicillin?

• increased risk of bleeding d/t interfering with Vit K productio, careful if pt is on warfarin

• NSAIDS can increase toxicity

• most common drug allergy (skin rash, itching, hives, anaphylactic

what are nursing considerations for penicillin?

• take before or after meals (food affects absorption)

• monitor electrolytes: Na+ and K+

• May interfere with oral contraceptives

• PCN allergies: hives, rash, itching, anaphylaxis (see if wheezing occurs)

what are the types of cephalosporins?

• 1st gen: cephalexin (kelflex), cefazolin (Ancef)

• 2nd gen: cefotetan (cephotan)

• 3rd gen: ceftriaxone (rocephin)

• 4th gen: cefepime (Maxipime)

what to assess with cephalosporins?

is the med appropriate?

are cephalosporins nephrotoxicity, hepatotoxicity, or ototoxicity?

nephrotoxicity

what to be cautions for cephalosporins?

• cross-sensitivity with PCN (Percutaneous Nephrostomy)

• abstain from alcohol (disulfiram like reaction)

• bleeding risk

what are nursing considerations for cephalosporins?

• cross-sensitivity with PCN (Percutaneous Nephrostomy)

  • abstain from alcohol

  • bleeding risk

  • can enter breast milk

  • take on empty stomach

what are the types of fluoroquinolones?

• ciprofloxacin (cipro)

• Levofloxacin (Levaquin)

what to assess for fluoroquinolone?

is the med appropriate? Allergies?

are fluoroquinolos nephrotoxicity, hepatotoxicity, or ototoxicity?

hepatotoxicity

what to be caution about fluoroquinolone?

• Hepatotoxicity (sclera yellowing, no alcohol)

• increased risk of seizure, neuropathy (rare)

• avoid in pregnancy/lactating women, children <18 yrs (cartilage damage)

• photo-toxicity/photosensitivity (avoid sun)

what are the side effects of flurorquinolone?

• increased bleeding

• tendon rupture (new joint pain, swelling, hold and notify MD)

what are patient teachings for fluoroquinolone?

• take with or without foods

• avoid zinc, calcium, Alum, Mag before/after (no milk)

what are the types of tetracyclines?

• doxycycline (Doxy-100, Vibramycin)

• Minocycline (Minocin)

What to assess for tetracyclines?

is the med appropriate?

are tetracyclines nephrotoxicity, hepatotoxicity, or ototoxicity?

nephrotoxicity and hepatotoxicity

what to be caution for tetracyclines?

• GI N/V/D; superinfections; renal toxicity

• Hepatotoxic and nephrotoxic

• Photosensitivity

• avoid during pregnancy/lactation, children <8yrs

• permanent discoloration of underdeveloped teeth

what patient teachings are for tetracyclines?

• avoid calcium, iron, magnesium

• take 1-2 hrs after taking foods containing these

what are the types of macrolides?

• azithromycin (zithromax)

• Erythromycin (erymax, erythrocin, erythroped, erythroped A)

are macrolides nephrotoxicity, hepatotoxicity, or ototoxicity?

hepatotoxicity, nephrotoxicity, and ototoxicity

what to assess for macrolides?

is the med appropriate? allergies?

what to be cautions about macrolides?

• GI N/V/D; superinfections

• Hepatotoxic, ototoxic (and nephrotoxic)

• dysrhythmias (prolonged QT interval)

• many drug-drug interactions

what patient teachings are for macrolides?

• empty stomach, but give with meals if GI symptoms are severe

• food can modify absorption

• notify prescriber if symptoms are severe

what are the types of Amino-glycosides?

• gentamicin

• streptomycin

• neomycin (topical, no peak/thoughs)

• Vancomycin

are aminoglycosides nephrotoxicity, hepatotoxicity, or ototoxicity?

nephrotoxicity and ototoxicity

what to assess for amino-glycosides?

is the med appropriate? allergies?

what to be caution about amino-glycosides/

• GI N/V/D; superinfection

• renal toxicity and ototoxicity

• narrow therapeutic range -ordered with peaks/troughs

• respiratory paralysis - use caution if pt has Myasthenia Gravis, or use anesthetics, neuromuscular blocking agents

What are patient teachings for amino-glycosides?

(Neomycin: one of the ingredients in neosporin. Topical, which means less side effects)

what is vancomycin normally treating?

MRSA or C. Diff

what to assess for vancomycin?

• is the med appropriate?

• allergies?

• assess IV site frequently (risk for extravasation (outside brain or vessel))

are vancomycin nephrotoxicity, hepatotoxicity, or ototoxicity?

nephrotoxicity

what to be cautions about with vancomycin?

• nephrotoxic

• vancomycin Flush syndrome (VFS) - infuse slowly (redness)

what are patient teachings for vancomycin?

• many drug interactions

• peaks and troughs, adjust dose

what are assessments prior to administering antibiotics?

• allergies

• other meds they’re on

• kidney and liver functions

what are some nursing implementation for antibiotics?

• instruct pt to take the entire prescribed amount

• encourage adequate fluid intake (no alcohol)

• monitor for s/s allergic reactions (PCN Rx days → week)

• monitor for common adverse effects

  • nephrotoxicity

  • GI distress

  • superinfections 

what to be caution about all antibiotics?

GI distress

what to evaluate for all antibiotics?

• did the infection improve? or symptoms monitoring

• Pt teachings: complete full course of drugs and don’t stop taking once you feel better

what are antifungals?

use to kill or inactivate fungi, treating fungal infections (including yeast infections)

are antifungals nephrotoxicity, hepatotoxicity, or ototoxicity?

nephrotoxicity and ototoxicity

what are some considerations for antifungals?

• fever

• chills

• vomiting

• abdominal pain

• skin rash

what are the types of antifungals?

• polyenes

  • nystatin (mycostatin)

  • amphotericin B (Fungizone)

• Azoles (very common)

  • fluconazole (diflucan)

  • Miconazole (micatin, monistat)

  • Voriconazole

• Fungins

  • micafungin

what to assess for antifungals?

• is the med appropriate?

• premedicate for Amphotericin, Diphenhydramine (benadryl), and acetaminophen (tylenol)

• Meperidine or dantrolene (rigors)

what to be caution about and provide patient teaching for antifungals?

• adverse effects of amphotericin B:

  • chills, fever, rigors, vomiting, headache (infusion Rx)

  • nephrotoxicity

  • hypokalemia

  • ototoxicity

  • Bone marrow suppression

  • Thrombophlebitis at infusion site

what are antiprotozoals?

used for treatment of protozoan infections

what type of antiprotozoal is there?

Metronidazole (flagyl)

what are some supplemental medications?

• won’t treat the infections, just manage symptoms

  • antipyretic/analgesic

    • acetaminophen

  • NSAIDS

    • Aspirin, Ibuprofen