Study Guide: Micro Exam 4 Outline

Concept: Hormonal Regulation

Exemplars: Hyperthyroidism and Hypothyroidism (6 questions)

Definition: Hormonal Regulation

• Hormonal regulation refers to the mechanisms by which the endocrine system controls the release, action, and balance of hormones in the body to maintain homeostasis.

Hyperthyroid vs. Hypothyroid

Nursing Process for Hormonal Regulation

1. Recognize Cues

   • Hyperthyroidism: Increased metabolic rate, nervousness, palpitations.

   • Hypothyroidism: Fatigue, weight gain, slow metabolic rate.

2. Analyze Cues, Generate Solutions, Take Action

   • Hyperthyroid: Administer antithyroid medications, beta blockers for heart rate, manage anxiety, educate on avoiding iodine.

   • Hypothyroid: Administer thyroid hormone replacement (Levothyroxine), manage constipation, educate on diet high in fiber.

3. Nursing & Collaborative Interventions

   • Monitor thyroid levels (T3, T4, TSH), cardiac monitoring, temperature regulation, medication management.

   • Collaborate with endocrinologists, dietitians.

4. Client Education for Management

   • Hyperthyroid: Medication adherence, regular blood tests, signs of thyroid storm.

   • Hypothyroid: Lifelong medication, regular follow-ups, signs of myxedema coma.

Concept: Infection

Exemplar: Cellulitis (6 questions)

Definition: Infection

• Infection occurs when pathogens such as bacteria, viruses, or fungi invade the body, leading to localized or systemic illness.

Infection Control

• Standard Precautions: Hand hygiene, use of gloves when in contact with bodily fluids.

• Isolation Precautions:

  • Contact: Gloves, gown (e.g., MRSA, VRE).

  • Airborne: N95 mask, negative pressure room (e.g., TB, measles).

  • Droplet: Surgical mask (e.g., flu, meningitis).

Localized Infection

• Definition: An infection confined to a specific area or part of the body.

• Common Sites: Skin (e.g., cellulitis), wound infections, urinary tract (UTI), respiratory tract (bronchitis), etc.

• Clinical Manifestations:

  • Redness, warmth, swelling, and pain at the affected site.

  • Pus or discharge (if an abscess or wound is present).

  • Local tenderness or discomfort.

  • No or mild systemic symptoms (e.g., slight fever, mild malaise).

• Examples:

  • Skin infections like cellulitis.

  • Abscesses or boils.

  • Urinary tract infection (without systemic spread).

Systemic Infection

• Definition: An infection that has spread throughout the body, often via the bloodstream, affecting multiple systems or organs.

• Common Signs:

  • Fever, chills, fatigue, or malaise.

  • Increased heart rate (tachycardia), rapid breathing (tachypnea).

  • Low blood pressure (hypotension).

  • Altered mental status (confusion, lethargy, especially in severe cases).

  • Organ dysfunction (e.g., kidney failure, liver involvement, sepsis).

• Clinical Manifestations:

  • Widespread inflammation and immune response affecting multiple organs.

  • Presence of abnormal laboratory values (e.g., elevated WBC count, positive blood cultures).

• Examples:

  • Sepsis (severe, life-threatening response to infection).

  • Bacteremia (bacteria in the bloodstream).

  • Severe pneumonia that spreads to the bloodstream.

Key Differences:

Cellulitis

• Definition: A bacterial infection of the skin and underlying tissues, often caused by streptococci or staphylococci.

Recognize Cues

• Risk Factors: Skin trauma, diabetes, immunocompromised state, poor circulation, lymphedema.

• Clinical Manifestations:

  • Local: Redness, warmth, swelling, tenderness, pain, skin lesions.

  • Systemic: Fever, chills, malaise if infection spreads.

Priority Nursing Assessments

• Inspect and palpate affected area, monitor for signs of systemic infection (fever, increased WBCs), assess for pain and edema.

Nursing Process for Cellulitis

1. Recognize Cues: Local redness, swelling, warmth, systemic signs like fever.

2. Analyze Cues, Generate Solutions, Take Action:

   • Administer antibiotics, manage pain, elevate affected limb, apply warm compresses.

   • Monitor for complications like abscess formation or sepsis.

3. Nursing & Collaborative Interventions:

   • Administer IV/oral antibiotics, wound care if necessary, monitor for systemic infection.

   • Collaborate with infectious disease specialists, wound care team.

4. Client Education for Management:

   • Complete full course of antibiotics, wound care at home, recognize signs of worsening infection, maintain good hygiene.

Concept: Elimination

Exemplars: Constipation and Diarrhea (6 questions)

Definition: Elimination

• The process by which the body excretes waste products, primarily through bowel movements.

Constipation and Diarrhea

Nursing Process for Elimination

1. Recognize Cues

   • Constipation: Straining, infrequent bowel movements, discomfort.

   • Diarrhea: Frequent, loose stools, abdominal cramping, dehydration.

2. Analyze Cues, Generate Solutions, Take Action

   • Constipation: Increase dietary fiber, fluid intake, encourage mobility, administer stool softeners/laxatives.

   • Diarrhea: Encourage fluids, monitor electrolyte levels, administer anti-diarrheal medications as needed, monitor for infection.

3. Nursing & Collaborative Interventions

   • Constipation: Dietary changes, stool softeners, encourage activity, hydration.

   • Diarrhea: Fluid replacement, monitor skin integrity, maintain electrolyte balance.

4. Client Education for Management

   • Constipation: Increase dietary fiber, drink plenty of water, engage in physical activity.

   • Diarrhea: Stay hydrated, follow prescribed medications, avoid triggers like certain foods, recognize signs of dehydration.

Drugs Therapy for Thyroid Disorders 

Thyroid Replacements-levothyroxine

Therapeutic Use

• Hypothyroidism

  • Levothyroxine is primarily used to treat hypothyroidism.

Adverse Drug Reactions

• Thyrotoxicosis and Hyperthyroidism

  • Can occur from excessive doses.

• Neurological Symptoms

  • Headache, irritability, insomnia.

• Gastrointestinal Symptoms

  • Abdominal cramping, diarrhea.

• Cardiovascular Symptoms

  • Tachycardia, arrhythmia.

• Heat Intolerance

  • Diaphoresis (excessive sweating).

• Menstrual Irregularities

Interventions

• Monitoring

  • Regularly monitor thyroid function.

  • Watch for signs of hyperthyroidism: anxiety, tachycardia, palpitations, tremors, altered appetite, heat intolerance, fever, diaphoresis, weight loss.

Administration

• Route of Administration

  • Administer orally for hypothyroidism; IV for myxedema coma.

• Timing

  • Give daily on an empty stomach (30 to 60 minutes before breakfast with a full glass of water).

• Baseline Measurements

  • Measure and monitor vital signs, weight, and height periodically.

• Cardiac Monitoring

  • Monitor for cardiac excitability (angina, chest pain, palpitations, dysrhythmias).

• Thyroid Levels

  • Monitor T4 and TSH levels.

• Formulation Awareness

  • Different formulations of thyroxine are not interchangeable; clients should notify providers if a different product is dispensed.

• Lifelong Therapy

  • Expect lifelong replacement therapy.

Client Instructions

• Symptom Awareness

  • Instruct clients to watch for and report nervousness, rapid heart rate, palpitations, tremors, altered appetite, heat intolerance, fever, sweating, weight loss, and chest pain.

Contraindications

• Thyrotoxicosis

• Recent Myocardial Infarction

Precautions

• Cardiovascular Disorders

  • Includes hypertension, angina pectoris, ischemic heart disease.

• Renal Impairment

• Diabetes Mellitus

• Older Adults

Interactions

• Absorption Inhibitors

  • Cholestyramine, antacids, iron and calcium supplements, and sucralfate reduce absorption; avoid taking levothyroxine within 4 hours of these medications.

• Food Interaction

  • Food can also reduce absorption.

• Medication Interactions

  • Many antiseizure and antidepressant medications (e.g., carbamazepine, phenytoin, phenobarbital, sertraline) decrease levothyroxine levels.

• Warfarin Interaction

  • Anticoagulant effects of warfarin may increase.

• Catecholamine Response

  • Cardiac response to catecholamines (e.g., epinephrine) may increase

Antithyroid Drugs-propylthiouracil

Therapeutic Use

• Hyperthyroidism (Graves’ disease)

• Thyrotoxic crisis

• Suppression of thyroid hormone production in preparation for thyroidectomy

Adverse Drug Reactions

• Hypothyroidism

• Agranulocytosis

• Hepatotoxicity

• Aplastic Anemia

• Rash

• Arthralgia, headache

• Vertigo, drowsiness, headache

Interventions

• Monitor thyroid function.

• Monitor for manifestations of hypothyroidism:

  • Fatigue and weakness

  • Weight gain

  • Cold intolerance

  • Dry skin

  • Listlessness

• Recommend a reduced dosage for clients who develop these effects.

• Monitor CBC at baseline and periodically thereafter:

  • Leukocytes

  • Neutrophils

• Monitor for manifestations of agranulocytosis; stop therapy if present.

• Monitor integumentary status.

• Monitor for joint and muscle pain and headache.

Administration

• Give orally at regular intervals (e.g., every 8 hours).

• Measure baseline vital signs and weight; monitor periodically thereafter.

• Monitor T3 and T4 levels.

Client Instructions

• Watch for and report manifestations of hyperthyroidism and hypothyroidism.

• Report fever or sore throat.

• Report rash.

• Report joint or muscle pain or headache.

• Report any OTC medications, herbal remedies, and supplements to the provider.

Contraindications

• Hypersensitivity

Precautions

• Immunosuppression

• Bone marrow depression

• Infection

• Liver dysfunction

• Pregnancy

Interactions

• Concurrent use with antineoplastics or radiation therapy can lead to additional bone marrow depression.

• Increased antithyroid effects noted when taken with lithium or potassium iodide.

• Risk of agranulocytosis increases with concurrent use of phenothiazines.

Antithyroid Drugs--radioactive Iodine

Radioactive Iodine – Iodine-131

Therapeutic Use

• Hyperthyroidism (Graves’ disease)

• Thyroid cancer

Adverse Drug Reactions

• Hypothyroidism

  • Expected for most clients, but still requires medication therapy.

• Bone marrow depression

  • Rare occurrence.

• Radiation sickness

  • Rare occurrence.

Interventions

• Monitor thyroid function.

• Monitor for indications of thyroid dysfunction:

  • Drowsiness

  • Depression

  • Weight gain

  • Edema

  • Anorexia

  • Cold intolerance

  • Dry skin

  • Menorrhagia

• Monitor CBC and platelet count:

  • At baseline and periodically thereafter.

• Monitor for indications of:

  • Anemia

  • Leukopenia

  • Thrombocytopenia

• Monitor for manifestations of radiation sickness:

  • Hematemesis

  • Epistaxis

  • Intense nausea

  • Vomiting

Administration

• Route: Give orally.

• Pregnancy Test: Obtain a negative pregnancy test before administration.

• Vital Signs and Weight: Measure baseline vital signs and weight; monitor periodically thereafter.

• Dosage:

  • Miniscule for thyroid disorders.

  • Larger for thyroid cancers.

• Radiation Precautions:

  • Initiate for large doses (limited contact, increased fluids, body waste disposal per facility protocol).

Client Instructions

• Report symptoms:

  • Anxiety

  • Drowsiness

  • Depression

  • Weight gain

  • Swelling

  • Appetite loss

  • Cold intolerance

  • Dry skin

• Report serious symptoms:

  • Fever

  • Sore throat

  • Weakness

  • Fatigue

  • Bloody vomit

  • Nosebleeds

  • Severe nausea and vomiting

Contraindications

• Pregnancy: Teratogenic effects.

• Lactation.

Precautions

• Children prior to puberty.

Interactions

• Other antithyroid medications: Reduce uptake.

Antibacterials: Drug Therapy for Infection

Penicillin-amoxicillan or Penicillin 

Therapeutic Use

• Broad-Spectrum Infections:

  • Treats infections caused by gram-positive cocci and bacilli (e.g., ear and throat infections, urinary tract infections).

• Gonorrhea Treatment:

  • Effective against gonorrhea caused by non-penicillinase-producing bacteria.

• Clavulanic Acid Addition:

  • Enhances the spectrum of disorders treated and increases bacterial killing ability.

Adverse Drug Reactions

• Gastrointestinal Manifestations:

  • Symptoms include diarrhea, nausea, and vomiting.

• Superinfections:

  • Rarely causes Clostridium difficile (C. diff) superinfection; more common with other antibiotics.

  • Possible superinfection with Candida albicans.

• Allergic Reactions:

  • Symptoms may include rash, hives, wheezing, and difficulty breathing.

Interventions

• Monitoring:

  • Observe for GI manifestations and report bloody stools or long-term watery diarrhea.

  • Monitor for Candida infections in the mouth or vagina and prepare for antifungal treatment.

• Allergy Assessment:

  • Inquire about allergies before administering the first dose.

  • Monitor for allergy manifestations and notify the provider.

• Post-Administration Care:

  • For injectable forms (IM or IV), keep the client in the facility for 30 minutes post-administration to monitor for allergies.

  • Be prepared to treat rash/hives with antihistamines and anaphylaxis with epinephrine and respiratory support.

Administration

• Dosage Forms:

  • Do not crush or chew extended-release forms; chew chewable forms before swallowing.

  • For infants/young children, administer drops directly on the tongue or mix with juice/formula to ensure full dose intake.

• Timing:

  • Administer at the beginning of meals to reduce GI manifestations and enhance absorption.

• Combination Therapy:

  • Administer with probenecid, if prescribed, to increase therapeutic activity.

Client Instructions

• Reporting Symptoms:

  • Report watery or bloody diarrhea to the provider.

  • Take medication at the start of meals.

  • Report mouth pain or inability to eat.

  • Report vaginal burning, itching, and discharge.

• Allergic Reactions:

  • Stop medication and notify the provider for possible allergic reactions.

  • Call 911 for severe symptoms, such as difficulty breathing.

Contraindications

• Allergies:

  • Contraindicated in individuals with allergies to penicillins or hypersensitivity to procaine and benzathine.

Precautions

• Renal Impairment:

  • Patients with renal impairment may require a reduced dose.

Interactions

• Probenecid:

  • Increases penicillin blood levels.

• Bacteriostatic Agents:

  • May decrease the therapeutic effects of amoxicillin.

• Oral Contraceptives:

  • Reduced effectiveness when taken concurrently with amoxic

Cephalosporins-first generation cephalexin

Therapeutic Use

• First-generation cephalosporin that effectively treats infections caused by gram-positive cocci.

• Subsequent Generations Characteristics:

  • Increased activity against gram-negative bacteria

  • Enhanced resistance to beta-lactamase producing gram-positive bacteria

  • Improved ability to penetrate cerebrospinal fluid (CSF) for treating infections like meningitis

Adverse Drug Reactions

• Gastrointestinal:

  • Diarrhea

  • Nausea

• Clostridium Difficile-Associated Diarrhea (CDAD): Rare but may occur as a superinfection.

• Allergic Reactions: Potential cross-allergy in patients with history of severe penicillin allergy.

• Cefotetan Specific Reactions:

  • Risk of hemorrhage

  • Disulfiram-like reaction if combined with alcohol

• Infusion Site Reactions: Thrombophlebitis (if infused via IV)

Interventions

• Monitoring:

  • Report any bloody stools or watery diarrhea to the healthcare provider.

  • Assess for allergies to cephalosporins/penicillins and inform the provider.

  • Monitor prothrombin and bleeding time; administer vitamin K as needed.

• Treatment Preparation:

  • Be prepared to treat rash/hives with antihistamines and anaphylaxis with epinephrine.

• IV Infusion:

  • Monitor for thrombophlebitis during infusion; change IV site if necessary.

  • Follow proper dilution recommendations and infuse slowly.

• Client Education: Inform the client about potential disulfiram-like reactions with alcohol.

Administration

• Available forms: Capsules, tablets, or oral suspension.

• Other cephalosporins may be administered via oral, IM, or IV routes.

• Important to differentiate between cephalosporin prescriptions due to similar generic names.

Client Instructions

• To minimize GI effects, take cephalexin with food.

• Report: watery or bloody diarrhea, unusual bruising or bleeding, and any burning, pain, or swelling at the IV site.

• Immediate action: Call 911 for severe allergic reactions (e.g., difficulty breathing).

• Inform clients about the potential for nausea, vomiting, severe headache, and hypotension with alcohol use.

Contraindications

• Known allergies to: Cephalosporin antibiotics or penicillin (cross-sensitivity).

• Specificity for cefditoren: Carnitine deficiency or milk protein allergy.

• Cefotetan Warning: Avoid alcohol due to disulfiram-like reactions.

Precautions

• Use cautiously in clients with renal failure or gastrointestinal diseases.

Interactions

• Probenecid: May prolong the effect of most cephalosporins.

• Cefotetan Specifics: Alcohol or medications that promote bleeding.

• IV calcium and ceftriaxone: Should be monitored.

Vancomycin-vancomycin

Therapeutic Use

• Severe Infections: Effective for treating serious bacterial infections.

• MRSA Infections: Treats methicillin-resistant Staphylococcus aureus (MRSA).

• Penicillin Allergy: Used for infections in patients allergic to penicillin.

• CDAD: Treats Clostridium difficile-associated diarrhea.

Adverse Drug Reactions

• Renal Failure: Possible nephrotoxicity leading to renal failure.

• Cardiovascular Effects: Can cause hypotension, tachycardia, and facial flushing if infused rapidly.

• Ototoxicity: Rare but potentially reversible hearing loss.

• Local Reactions: Thrombophlebitis at IV site; tissue damage with infiltration.

Nursing Interventions

• IV Administration: Administer vancomycin over 1 hour; adhere to dilution recommendations.

• Vital Signs Monitoring: Monitor vital signs throughout infusion.

• Trough Levels: Check vancomycin trough levels to avoid toxicity.

• BUN and Creatinine: Regular monitoring of blood urea nitrogen (BUN) and creatinine.

• IV Site Assessment: Inspect infusion site for redness or swelling.

• IV Patency: Ensure IV line remains patent during administration.

Administration Guidelines

• Oral for C. Diff: Administer orally for Clostridium difficile infections.

• IV for Other Use: Administer via IV for all other indications.

• Slow IV Infusion: Infuse IV slowly as per guidelines and dilute as required.

• Separate Infusion: If possible, infuse separately from other IV medications due to incompatibility.

Client Instructions

• Monitor Symptoms: Advise clients to report flushing or faintness during infusion.

• Hearing Changes: Instruct clients to report tinnitus or hearing loss.

• Urine Output: Advise reporting any changes in urine output.

• IV Site Issues: Report any pain, swelling, or redness at the IV site promptly.

• Vertigo: Inform clients to report feelings of vertigo.

Contraindications

• Allergy: Known allergy to vancomycin.

• Hypersensitivity: History of hypersensitivity reaction.

Precautions

• Renal Insufficiency: Reduce dosage in cases of renal insufficiency.

• Hearing Impairment: Caution in patients with hearing issues.

• Colitis: Monitor closely for colitis complications.

Drug Interactions

• Nephrotoxic/Ototoxic Drugs: Increased risk of ototoxicity and nephrotoxicity when combined with other drugs affecting kidneys or hearing.

• IV Incompatibility: Vancomycin is not compatible in solution with many IV medications.

Tetracyclines-tetracycline

Therapeutic Use

• First-choice antibiotic for:

  • Chlamydia infections

  • Mycoplasmal infections

  • Rickettsial infections (e.g., typhus)

  • Syphilis and gram-negative infections in clients with penicillin allergy

  • Gram-positive infections (e.g., tetanus)

  • Cholera

  • Anthrax

• Treats acne vulgaris (available in both topical and oral forms)

Adverse Drug Reactions

• GI Manifestations:

  • Nausea

  • Vomiting

  • Diarrhea

  • Abdominal pain

• Dental Effects:

  • Permanently discolors deciduous teeth of fetus (after 4th month gestation) and permanent teeth in children under 8 years

• Hepatotoxicity:

  • Particularly in large doses or to pregnant/postpartum clients

• Superinfections:

  • Risk of C. diff and Candida infections

• Photosensitivity:

  • Severe sunburn-type reactions

• Growth Suppression:

  • Suppresses long-bone growth in preterm infants

Interventions

• Administer with non-dairy foods if GI manifestations occur.

• Monitor and report gastrointestinal manifestations; a decreased dose may be necessary.

• Check if the client could be pregnant before administration to clients of childbearing age.

• Monitor liver function tests and watch for signs of liver damage.

• Observe for signs of superinfection and monitor skin reactions.

• Check for lymphadenopathy and facial swelling.

Administration Guidelines

• Administer orally on an empty stomach:

  • 1 hour before or 2 hours after meals; can give with non-dairy food if intolerance occurs.

• Do not administer right before bedtime.

• Use topical forms for acne vulgaris treatment.

• IM and IV forms only if the oral form is not tolerated.

• Shake solution well before measuring.

• Ensure outdated medication is not used, as it can cause kidney dysfunction.

• Doxycycline, another tetracycline, can be given effectively with food and is safer for clients with renal failure.

Client Instructions

• Consume with non-dairy foods if GI issues arise.

• Report any GI manifestations or symptoms to the provider.

• Inform the provider if pregnant.

• Avoid giving the medication to children under 8 years.

• Report jaundice, abdominal pain, or fatigue to the provider.

• Report mouth pain, difficulty chewing, or swallowing issues.

• Notify about vaginal irritation/discharge.

• Report signs of watery or bloody stools.

• Advise wearing protective clothing and sunscreen for sun exposure.

Contraindications

• Pregnancy risk (teratogenic effects)

• Children younger than 8 years

• Allergy to tetracycline

• UV light exposure

• Serious renal or liver failure

Precautions

• History of liver or kidney disorders

Interactions

• Absorption is decreased by:

  • Antidiarrheals containing kaolin

  • Supplements and antacids with calcium, magnesium, or aluminum

  • Dairy products and iron/zinc supplements

• Tetracyclines decrease the effectiveness of oral contraceptives.

Macrolides-erythromycin

Therapeutic Use

• First-line treatments for:

  • Legionnaires’ disease

  • Whooping cough

  • Acute diphtheria

  • Clients who are carriers of diphtheria

  • Some Chlamydia infections

  • Certain pneumonias

• Treats common infections in clients with a penicillin allergy.

• Ophthalmic ointment prevents eye infections in neonates.

Adverse Drug Reactions

• Gastrointestinal Manifestations:

  • Nausea, vomiting, abdominal pain, and diarrhea

• Cardiac Issues:

  • Serious ventricular dysrhythmias, potential for death

• Ototoxicity:

  • Hearing loss, vertigo, tinnitus (reversible upon treatment cessation)

• Superinfection:

  • C. difficile-associated diarrhea, candidiasis

Interventions

• Monitor for and report any GI reactions; adjust dosage if necessary.

• Check for concurrent medications that may increase erythromycin blood levels.

• Assess client history for prolonged QT syndrome.

• Monitor for signs of ototoxicity and report findings.

• Watch for indications of superinfection and report accordingly.

• Monitor liver function for patients on long-term erythromycin therapy.

Administration

• Available forms:

  • Erythromycin base: tablets, capsules, topical, and ophthalmic ointment

  • Erythromycin stearate: tablets

  • Erythromycin ethylsuccinate (EES): tablets

  • Erythromycin lactobionate: IV form

• Dosing Guidelines:

  • Erythromycin base and stearate should be taken on an empty stomach (1 hour before or 2 hours after meals) with 8 oz. of water.

  • If GI symptoms occur, can be taken with food.

  • EES enteric-coated forms can be taken with or without meals.

  • For IV administration, adhere to dilution and rate recommendations to minimize thrombophlebitis risk.

Client Instructions

• Take with food if GI symptoms occur.

• Report ongoing GI symptoms to provider.

• Inform provider of palpitations and fainting spells immediately.

• Report any hearing loss, vertigo, or tinnitus.

• Report bloody or watery diarrhea.

• Notify provider of mouth pain with white patches or vaginal discomfort/discharge.

Contraindications

• Allergy to erythromycin or other macrolide antibiotics.

• History of prolonged QT syndrome.

• Hypokalemia and Hypomagnesemia.

Precautions

• GI disorders.

• Liver disorders.

Interactions

• Decreases blood levels of: Chloramphenicol and clindamycin antibiotics.

• Increases blood levels of:

  • Digoxin

  • Warfarin

  • Theophylline

• Medications that inhibit CYP3A4 (verapamil, azole antifungals, protease inhibitors for HIV, diltiazem) can increase erythromycin levels.

Aminoglycosides-gentamicin

Therapeutic Use

• Indications:

  • Treats severe infections caused by gram-negative aerobic bacilli.

  • In combination with another antibiotic, used for severe infections caused by some gram-positive cocci.

  • Available in topical form for skin and eye infections.

Adverse Drug Reactions

• Ototoxicity:

  • Elevated trough levels can lead to tinnitus, headache, and vertigo.

• Nephrotoxicity:

  • Symptoms include polyuria, dilute urine, protein, and casts detected in urine, increased BUN, and creatinine levels.

• Cerebellar Ataxia:

  • Potential adverse effect impacting balance and coordination.

Interventions

• Monitoring:

  • Check for early signs of ototoxicity such as tinnitus.

  • Monitor peak and trough blood levels regularly.

  • Assess laboratory values for BUN, creatinine, and check urine for protein and casts; report any elevations.

  • Conduct audiometry to evaluate the status of the eighth cranial nerve.

  • Monitor intake and output (I&O).

Administration

• Forms Available:

  • Topical, ophthalmic, IM/IV, and intrathecal.

• Ophthalmic Drops:

  • Press the inner canthus for 1-2 minutes post-instillation to prevent systemic absorption.

  • Instruct clients to keep eyes shut for 1-2 minutes for optimal local absorption.

• Topical Cream:

  • Avoid application over large skin areas to reduce risk of systemic toxicity.

• IM Injection:

  • Administer deeply into a large muscle to ensure proper absorption.

• IV Infusion:

  • Administer as an intermittent infusion; adhere to recommended rates and dilutions.

• Intrathecal:

  • Use preservative-free formulations and discard any unused portions.

Client Instructions

• Reporting Requirements:

  • Instruct clients to report symptoms like tinnitus, headache, vertigo, or hearing loss immediately.

  • Notify provider if there is an increase in output of dilute urine.

Contraindications

• Allergies:

  • Known allergies to any aminoglycoside.

• Pregnancy Risk:

  • Classified as teratogenic; use with caution in pregnant individuals.

Precautions

• Increased Risks:

  • History of acoustic nerve damage raises the risk of hearing loss.

  • Existing tinnitus or vertigo, renal disorders, chronic neuromuscular disorders, and dehydration may warrant cautious use.

Interactions

• Ototoxicity Risks:

  • Concurrent use of other ototoxic medications can increase risk.

• Nephrotoxicity Risks:

  • Combination with Amphotericin B, NSAIDs or other nephrotoxic drugs raises risk level.

• Enhanced Effects:

  • Cephalosporins, vancomycin, and penicillin can enhance the bactericidal effects of gentamicin.

• IV Medication Mixing:

  • Avoid mixing other medications (like penicillin, cephalosporins, or heparin) in the same IV solution.

• Respiratory Risks:

  • May prolong respiratory paralysis when combined with neuromuscular blockers (pancuronium, succinylcholine)

Sulfonamides-trimethoprim/sulfamethoxazole

Therapeutic Use

• Indications for Use:

  • Urinary tract infections

  • Pneumocystis pneumonia

  • Shigella enteritis (shigellosis, also known as traveler’s diarrhea)

  • Chronic bronchitis (acute phase)

  • Acute otitis media in children

Adverse Drug Reactions

• Gastrointestinal Manifestations:

  • Nausea

  • Vomiting

  • Anorexia

• Allergic Reactions:

  • Skin reactions

• Blood Cell Deficiencies:

  • Thrombocytopenia

  • Leukopenia

  • Anemia

  • Agranulocytosis

  • Aplastic anemia

• Superinfections:

  • Clostridium difficile-associated diarrhea (CDAD)

  • Candida infections

• Severe Rash:

  • Including Stevens-Johnson syndrome

• Kernicterus

Interventions

• Monitoring:

  • Report severe manifestations

  • Monitor for rash and hives

  • Report severe diarrhea

  • Monitor and report rash/blisters on skin

• Encouragement:

  • Encourage fluid intake

• Monitoring Parameters:

  • Input and output (I & O)

  • Complete blood counts (CBCs) and urinalysis throughout treatment

Administration

• Forms Available:

  • Fixed-dose combination in tablets, liquid solution, and IV form

• Dosage Instructions:

  • Oral dose with 8 oz. of water

  • Administer intermittent IV infusion slowly (over 60 to 90 min) with recommended dilution

• Fluid Intake:

  • Drink at least 1,200 to 1,500 mL of water/day during treatment

Client Instructions

• Reporting Symptoms:

  • Report manifestations to provider

  • Report rash and hives

  • Report fatigue, pallor, easy bruising, or new infections

  • Report watery or bloody diarrhea

  • Report pain in mouth, difficulty eating, or vaginal burning/discharge

  • Report onset of rash and/or blisters on skin

• Medication Guidance:

  • Take with food to minimize GI manifestations

  • Warn clients that sulfonamides decrease the effectiveness of oral contraceptives; use an alternative form of contraception

Contraindications

• Not Recommended For:

  • Pregnant or nursing clients

  • Allergy to sulfonamides, trimethoprim, cyclooxygenase-2 inhibitors (e.g., celecoxib)

  • Clients with megaloblastic anemia due to folic acid deficiency

  • Children under 2 months

  • Pharyngitis caused by group A beta-hemolytic Streptococci

  • Hyperkalemia

  • Severely impaired urine creatinine clearance

Precautions

• Caution in Patients With:

  • Decreased kidney or liver function

  • Hypersensitivity to sulfites (used as preservatives)

  • Suppressed bone marrow

  • Risk for megaloblastic anemia (e.g., clients with alcohol use disorder, pregnant clients, debilitated clients)

Interactions

• Drug Interactions:

  • Alcohol may cause a disulfiram-type reaction

  • May increase effects of warfarin, phenytoin, tolbutamide, and other sulfonylurea oral antidiabetic medications

  • Increased immunosuppression when taken with methotrexate

  • Reduced effectiveness of oral contraceptives