PHARM FINAL PT. 2

What is Vancomycin used for?

C Diff, other GI infections, or systemic infections

What is Vancomycin's mechanism of action

Inhibits cell wall synthesis (like other beta-lactam antibiotics). This causes the bacterial cells to be unable to survive which results in death

When should a patient be given IV Vancomycin?

It doesn't absorb well in the GI so IV is preferred. This would be given to someone with a systemic infection

When should a patient be given PO Vancomycin?

Oral cant leave the GI system to treat systemic infections so this should be given to someone with a GI infection such as C. Diff because it stays in the GI system

How is Vancomycin distributed?

To most bodily fluids and tissuses

How is Vancomycin Eliminated?

Unchanged in the kidneys

What has to be checked before giving a patient Vancomycin?

Because it is eliminated unchanged in the kidneys, renal function has to be checked. If there is renal impairment, dosages should be reduced.

What are the possible adverse effects of Vancomycin?

- Renal failure/nephrotoxicity
- Ototoxicity
- Redman Syndrome
- Thrombophlebitis

How to know if a patient has renal toxicity when taking Vancomycin? What should the nurse do?

- To avoid this check trough levels (10-20 mcg/mL)--> draw blood 1 hr before the dose and the trough levels will determine dosages for the NEXT dose
- If trough levels higher than 20---> next dose will be decreased
- Check creatinine
- Teach patient to hydrate!!!

How to know if a patient has Ototoxicity when taking Vancomycin? What should the nurse do?

They experience ringing in the ears and difficulty hearing (would get this when on this medication for an extended period of time or if trough levels are too high)

How to know if a patient has Redman Syndrome when taking Vancomycin? What should the nurse do?

* They experience flushing, rash, tachycardia, and HTN


* This can occur if this medication is given too fast causing a histamine response.


* If this occurs the nurse should slow down the infusion and let the provider know

How to know if a patient has Thrombophlebitis when taking Vancomycin? What should the nurse do?

- Inflammation of the vessel when given this IV
- Advocate for a central line (PIC) if the patient is getting it every day to avoid this
- If this occurs move to a different site

What does a trough level of less than 10 mcg/mL mean?

There is not enough of the antibiotic in the blood to eradicate the bacteria

What does a trough level 10-20 mcg/mL mean?

There is enough of the antibiotic in the blood to eradicate the bacteria. This is a good range

What does a trough level of more than 20 mcg/mL mean?

There is toxic levels of the antibiotic in the blood which can cause renal toxicity

What is Cancer?

A disorder characterized by abnormal growth of cells

T/F: Everyone has cancerous cells

True! Everyone has cancerous cells in their body every day but our immune systems fight them off. Its when our immune system cant fight them off that it becomes a problem

What is oncology? What do oncology nurses do?

-The study of cancers
- Oncology nurses care for patients with cancer

What is included the continuum of cancer?

- Prevention and detection
- Abnormal finding and Diagnostic evaluation
- 1st line treatment, adjuvant treatment, symptom management
- 2nd and 3rd line treatment, increasing acuity, increasing symptom experience, changes in functional status and quality of life
- End of life care

When are nursing services the highest in the continuum of cancer?

2nd and 3rd line treatment

Why do people get cancer?

-Viruses/bacteria (over and over, HPV, Hep B)
-Physical agents (smoking, tobacco, tanning)
-Chemical agents
-Genetics/familial factors
-Lifestyle (smoking, obesity, alcohol, activity)
-Hormonal agents (hormone replacement therapy- estrogen)

T/F: Nothing can be done to protect yourself when you know you have high rates of cancer in your family tree

False!
If you know you have high rates of cancer you need to do everything in your power to live a healthy lifestyle. 50% is genetic, the rest is other factors

What is the number one cause of cancer? What is the second?

1) Smoking
2) Obesity

What are the different types of cancer prevention?

Primary, Secondary, Tertiary

What is Primary Prevention?

* Includes health promotion and risk reduction of cancer


* The goal is to prevent cancer before it starts
* The US does a lousy job at this

What is Secondary Prevention?

- Includes screening and early detection of cancer
- Includes things such as colonoscopy's, breast scanning, pap smear etc...
- The US does a good job at this

What is Tertiary Prevention?

- Diagnosis and treatment of cancer
- Since cancer can spread, where is it? Is it everywhere, or just in one area?
- PET scan

What is a nurses role in secondary prevention?

Make sure to give them pamphlets and educate them when they are of age to be screened for different things

What is a nurses role in primary prevention?

Includes things like: how to eat healthy, exercise, sex ed...

What does a PET scan tell us? How is it done?

- It tell us if the cancer has spread to any other parts of the body
-inject body with glucose, since tumors use glucose for energy they follow glucose throughout the body
- NOT diagnostic

What are the different surgery's done for cancer

- Diagnostic surgery
- Surgery as primary treatment (removing the whole tumor= debulking)
- Prophylactic surgery
- Palliative surgery
- Reconstructive surgery

What is diagnostic surgery?

* This is a biopsy to see if someone has cancer


* 3 types:
* Can be Excisional (on the skin, scrape superficially) or Incisional (make an incision into the body to take tissue) or Needle (for deep/buried places)

T/F: If a patient has cancer and they don't know yet and ask you, can you tell them and their family members about the diagnosis?

FALSE!
Don't ever be the first one to tell them. That is the doctors job. The nurses role in this is to be in the room when they are told

What is staging of cancer?

-1,2,3,4
-The higher the stage, the worse the cancer is. Can also tell the tumor size

When looking at cells we want them to be _____ to the area

Native

When can surgery not be done for cancer? What else would be done?

In an rea where you cant get to or its to risky (such as a tumor on the aorta). They can do chemo and/or radiation then.

What is surgery as primary treatment for cancer (debulking)?

-Remove the entire tumor and everything around it to make sure they really got it
-They remove until they don’t see cancerous cells

What is prophylatic surgery for cancer?

Surgery done when the patient doesn't have cancer yet but there is a strong reason such as the presence of a gene and family history. This is done so they WONT get it.

What is Palliative surgery for cancer?

- Surgery done to make someone with cancer more comfortable even if they have a terminal cancer.
-For example if someone has a tumor that causes them extreme nausea in one spot, they can remove that one even if they have it everywhere and they have a terminal diagnosis
- NOT curative

What is reconstructive surgery for cancer?

-Reconstructs the area
- This can be done for breast surgery (lumpectomy, unilateral mastectomy…)
- Makes the patient feel more confident

What needs to be done by the nurse before surgery?

- Witness informed consent/signature
- Preoperative assessment (get good baselines for where they were BEFORE the surgery, can compare after)
-Nutritional and fluid status (some may not be able to chew= feeding tube- NOT TPN cause their GI system still works, NPO 8 hours before the surgery, if its a GI surgery need to cleanse the GI)
- Psychosocial (this is scary and nerve wracking, help them with anxiety management)

What needs to be done by the nurse after surgery?

- Deep breathing, coughing, incentive spirometry (even if they have lung surgery. they are at a high risk for pneumonia)
- Mobility (at high risk for DVT so the have to get up and moving)
- Pain management
- Monitor for potential complications (if they were on chemo/radiation before surgery they are at a high risk for infection and delayed wound healing, monitor for suspicious drainage)

T/F: if a patient was on chemo and/or radiation before getting surgery they need to stop it before the surgery

TRUE!
They need to stop it for a bit to build up their WBC count again to try to lower their risk for infection.

What should be done for suspicious drainage after a surgery?

Culture wound and drainage first and then get the order after

What kinds of radiation is there?

External and Internal radiation

What is external radiation? What precautions must be taken for the patient? What precautions must be taken for the nurse?

-Radiation that kills the tumor from the outside in
- No precautions for the patient
- Nurse must be at least 6 feet away, wear a dosimeter to make sure their radiation levels aren't too high, wear lead

What are possible side effects from external radiation?

* Alopecia=no hair growth (head radiation)
* Desquamation= radiation going through the skin causing irritation, scar tissue, and skin gets leaky
* Stomatitis= mouth inflammation which may cause a pt to be unable to eat (radiation of head/mouth)
* Organ dysfunction
* Fatigue, malaise, anorexia
* Skin breakdown

What is internal radiation? What precautions must be taken for the patient? What precautions must be taken for the nurse?

- Also called brachytherapy
- Inserting seeds into the area
- Can do it with breast cancer, prostate, and GU
- For nurses: use precaution when handling urine, and bodily fluid, sheets, wear gown and gloves, limit time in the room to no more tha 30 minutes, distance 6 feet, not pregnant

What is chemotherapy?

-Antineoplastic drugs that kill cancer cells AND healthy cells

What would someone who gets chemo often need?

A port placed. This is done so they wont need to get an IV placed every time which is hard on the vessels.

Where to avoid putting an IV when administering chemo

Hand- you want as high up as possible with bigger vessels. This is done to avoid extravasation

What are potential adverse effects of Chemotherapy?

- Extravasation (leakage of the chemo into the tissue/skin)
- Hypersensitivity reactions (not usually on the 1st round, itchy/throat closing off- can turn into an anaphylactic reaction)
- Tumor Lysis Syndrome (this occurs when they have lots of tumors that release potassium when killed- this causes high potassium and they could die)

What should be done when a patient has a hypersensitivity reaction when getting chemotherapy?

- Stop giving the chemo
- If its affecting the airway, give epinephrine IV
- If its not affecting the airway just let the provider know
- If at a high risk for a hypersensitivity reaction premedicate with Benadryl and acetaminophen, or a steroid if they think its going to be really bad

What ca be given to a patient who has tumor lysis syndrome?

Sodium polystyrene or zirconium, calcium, insulin, dextrose, HCO3, Albuterol treatment, can do dialysis

GI Nursing Considerations for a patient who is receiving chemotherapy

-They may get diarrhea, or constipation, swelling in the mouth, mouth sores, nausea/vomiting, may not eat (NG/feeding tube)
-no hot foods or spicy food
- N/v: give drugs

Hematopoietic Nursing Considerations for a patient who is receiving chemotherapy

-Their counts decrease (WBC, RBC, neutrophils), anemic
-Worry about infection and bleeding
- If anemic they may need blood transfusions and iron

Renal Nursing Considerations for a patient who is receiving chemotherapy

- Some chemo is hard on the kidneys (creatinine has to be less than 2 for some chemo- hydrating patient and holding off until kidney function gets better)
- Monitor creatinine and BUN

Cardiopulmonary Nursing Considerations for a patient who is receiving chemotherapy

- Some chemos have negative properties on the heart (heart becomes weak and they go into heart failure)
- Do beginning EKG, monitor BP, can do an ultrasound

Reproductive Nursing Considerations for a patient who is receiving chemotherapy

- chemo can cause birth defects
- If the are of reproductive years they suggest birth control
- Can affect ability to reproduce in the future

Neurologic Nursing Considerations for a patient who is receiving chemotherapy

-Most patients on chemo for a while end up with peripheral neuropathy (numbness and tingling)
- Every patient is on gabapentin to help

Cognitive Nursing Considerations for a patient who is receiving chemotherapy

May have memory issues or become forgetful

Fatigue Nursing Considerations for a patient who is receiving chemotherapy

They may get tired bc they are knocking out their RBC

Nursing management for patients getting chemotherapy

- Want to flush out chemo after it has done its job, drink lots of fluids or get IV fluids
- If they are vomiting need to give fluids IV
- Monitor potassium levels
-Make sure safety is done= dont drive if bad or stay home alone
- If they are running a temp, let provider know RIGHT AWAY- infection is serious in chemo patients
- Prophylactically give then ondansetron even if they arent nausous
- Rest but still need activity

What needs to be taught to nurses or any other caregiver of patients getting chemotherapy

Cant touch ANY type of secretion

What should be considered by the nurse when caring for a cancer patient

- Tissue integrity/skin integrity (stomatitis= inflammation of the mouth)
- Alopecia
- Nutritional impairment (mouth hurts they wont eat, enteral/TPN)
- Pain (PCA in hospital, transdermal patch at home)
-Fatigue (may need blood transfusions)
- Body image
-Sexuality (cant have sex on chemo, affects ability to have kids)
- Grieving
- Psychosocial (fear of the unknown)

What medication can be taken it a patient receiving chemotherapy has mouth sores and inflammation?

-Palifermin (it builds up the keratin in the mouth to help heal the sores).
- Continue with oral hygiene even if it hurts!

What medication can be given to a patient receiving chemotherapy who has no appetite?

Dronabinol or Megestrol

What does beta-lactam mean?

It is a chemical structure that some antibiotics have that are similar

What is penicillin and how does it work?

It binds and stops the formation of the bacterial cell wall causing the bacteria to fill with water and explode.

Why is penicillinase a problem?

It is produces by some bacteria and it disrupts the beta lactam ring causing penicillin to be ineffective

What is the purpose of beta lactamase inhibitors?

-To prevent penicillinase from making penicillin affective.
- cillin/bactam
- cillin/clavulanate
- Patients receiving long term antibiotics will use this combo, most kids wont unless taking it a lot.
- In the hospital they do it right away

Why is hand hygiene so important when dealing with antibiotics?

You could spread resistance to antibiotics from one patient to another

Penicillin G has what 4 salts? What is the purpose of the salts?

-Procaine, Benzathine, Potassium, Sodium
- They bind to the penicillin and releases it at different rates

What is special about Potassium Penicillin G & Sodium Penicillin G

- Works fast with high levels of penicillin G in the blood
-These KILL and are used for major infections

What is special about Procaine or Benzathine Penicillin G

- They work slower and are longer acting
- They are used for STI's
- Just stops replication

How does it feel for the patient to get penicillin? What should the nurse warn them about for administration?

It BURNS

How should oral penicillin's be given (ampicillin and amoxicillin)

Take on an empty stomach and drink it with lots of water

What kind of infections does Penicillin work on?

Any type of tissue infection since it distributes really well through tissue (it DOESNT cross the BBB though)

What does penicillin require before being administered?

Good functioning kidneys since it is excreted unchanged within the renal system. If they don't have good functioning kidneys the doctor will lower the dose.

What may happen if the dose of penicillin is too high?

Seizures

Why may someone need penicillin prophylactically ?

People with heart conditions who need dental work will go on penicillin for that to prevent any infection going to the heart

How would someone know if an antibiotic is a penicillin?

it ends in "-cillin"

What are the possible side effects of penicillin?

-Hyperkalemia leading to dysrhythmias (potassium penicillin G)
- Hypernatremia (sodium penicillin G)
- Renal function
- Pain at IM injection site

What should be monitored when giving a patient penicillin?

- Potassium levels or sodium levels
- Creatinine levels
- Monitor for seizures, confusion, and hallucinations (neurotoxicity)
- Monitor for gangrene, necrosis, and sloughing of tissue (intra-arterial injection: don't want it to go into the arteries)
- Any allergy/anaphylaxis

What does a lactic acid greater than 2 mean for a patient?

They are in sepsis- risk to go into shock

What would the patient experience if they had a penicillin allergy or anaphylaxis?

- Allergy: rash, hives
- Anaphylaxis: Closed airway

What should the nurse do if a patient experiences a penicillin allergy or anaphylaxis?

Stop the infusion, flush the line, stay with the patient, if there is a problem with the airway use an EpiPen, if not contact the provider- may use Benadryl or a steroid

What can a patient never recieve again if they have a reaction to penicillin?

Penicillin and cephalosporins (cross sensitivity reaction)

What can be done to determine if someone has a penicillin allergy?

-Skin test (like TB test but with penicillin)
- Have an EpiPen and monitor incase
- No skin reaction= negative= no allergy
- Skin reaction= positive= allergy

When would a sensitivity panel be done for penicillin?

Can do this to see if penicillin will work if they have been on an antibiotic for so long- do a benefit risk for administration UNLESS they are anaphylactic)

T/F: People can have a reaction even if they have never had penicillin

TRUE!
The foods we eat contains penicillin (meat products)- unless they were raised vegetarian/vegan

How should complications be prevented when administering penicillin?

10 rights of medication administration

How should penicillin be administered?

- Oral: take with lots of water (8oz)
- IM: use a big muscle, the gluteal
- Ampicillin/amoxicillin can be upsetting on stomach so take with food

How should therapeutic effects be assessed for someone taking penicillin? How do we know its working?

-Decreased WBC count
- Decreased fever
-Wound may look less red/swollen/drainage goes down- things get better
-Respiratory infection: o2 stats stay high so the need for it goes down, clear lung sounds

What patient education should a nurse provider to a patient receiving Penicillin?

-Take the full course!!!
- With all oral antibiotics- be careful if taking oral birth control (could increase risk of getting pregnant)
-Take with plenty of water
-Stay hydrated and urinate frequently
-Anyone on it for a while is at risk for a yeast infection (mouth or GU)

What could happen if someone is taking penicillin and they aren't urinating frequently?

If the kidneys aren't functioning and they cant get rid of it they will have toxicity

T/F: It is possible to grow out of resistance to an antibiotic

FALSE!
Once resistant- always resistant. Can grow out of an allergy though

What is Methicillin-Resistant Staphylococcus Aureus? How is it tested?

-A type of staph bacteria that's become resistant to many of the antibiotics used to treat ordinary staph infections
- Not a huge deal, lots of people have it especially working in a nursing home
- Tested by a swab in their nose

What can nurses do to prevent the spread of MSRA?

Wash their hands

What are Cephalosporins a cousin to?

Penicillin!