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NR566 Midterm Study Guide well detailed, Study Guides, Projects, Research of Nursing

Cheyney University of PennsylvaniaNursing

NR566 Midterm Study Guide well detailed

Typology: Study Guides, Projects, Research

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NR566 Midterm Study Guide well
detailed
Week 1: Chapters 79, 80, 81, and 83
Chapter 79: Antifungal Drugs
Pharmacokinetics of Amphotericin B (polyene antifungal class;
available in IV form)
•
Drug of choice to be used as a broad spectrum for most
systemic mycoses
•
Minimizing Nephrotoxicity
o
Dose exceeding 4G likely to cause renal impairment
▪
Should be administered for the shortest time
possible (typically 6-8 weeks, up to 3-4 months) and
only for a life- threatening condition.
▪
Contraindicated in patients with severe renal
impairment.
Itraconazole (Sporanox); azole antifungal class; available in PO form
•
Alternative to amphotericin B as a broad spectrum for
systemic and superficial mycoses with less toxicity.
•
Drug Interactions:
o
Decreased Itraconazole absorption when used with
PPIs, H2 antagonists, and antacids
▪
Administer 1 hour before Itraconazole or 2 hours
after.
o
As a CYP3A4 inhibitor, Itraconazole can increase serum
levels of
drugs such as cisapride, pimozide, dofetilide,
and quinidine -
>
increased risk of fatal ventricular
dysrythmias.
▪
Also increases cyclosporine, digoxin, warfarin and
sulfonylurea serum levels.
•
Do not treat superficial mycoses in patients with HF/other
cardiac dysfunction.
Caspofungin (Cancidas); echinocandin antifungal agent
•
Indications: narrow spectrum IV antifungal for use against
aspergillus and candida species
o
With invasive aspergillosis that is unresponsive to
Amphotericin B or Itraconazole
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NR566 Midterm Study Guide well

detailed

Week 1: Chapters 79, 80, 81, and 83

Chapter 79: Antifungal Drugs

Pharmacokinetics of Amphotericin B (polyene antifungal class; available in IV form)

  • Drug of choice to be used as a broad spectrum for most systemic mycoses
  • Minimizing Nephrotoxicity o Dose exceeding 4G likely to cause renal impairment ▪ Should be administered for the shortest time possible (typically 6-8 weeks, up to 3-4 months) and only for a life- threatening condition. ▪ Contraindicated in patients with severe renal impairment. Itraconazole (Sporanox); azole antifungal class; available in PO form
  • Alternative to amphotericin B as a broad spectrum for systemic and superficial mycoses with less toxicity.
  • Drug Interactions: o Decreased Itraconazole absorption when used with PPIs, H2 antagonists, and antacids ▪ Administer 1 hour before Itraconazole or 2 hours after. o As a CYP3A4 inhibitor, Itraconazole can increase serum levels of drugs such as cisapride, pimozide, dofetilide, and quinidine - > increased risk of fatal ventricular dysrythmias. ▪ Also increases cyclosporine, digoxin, warfarin and sulfonylurea serum levels.
  • Do not treat superficial mycoses in patients with HF/other cardiac dysfunction. Caspofungin (Cancidas); echinocandin antifungal agent
  • Indications: narrow spectrum IV antifungal for use against aspergillus and candida species o With invasive aspergillosis that is unresponsive to Amphotericin B or Itraconazole

o Systemic candida infections (candidemia and candida- related peritonitis, pleural space infections, and intraabdominal abscesses).

  • Adverse Effects o Histamine Response - rash, facial flush, pruritis, anaphylaxis, or a sense of warmth o Phlebitis at injection-site o Common - Fever, headache, rash, nausea, or vomiting. Griseofulvin (Gris-PEG); other antifungal class
  • Indications: treatment of superficial mycoses; PO administration o Dermatophytic infections of the skin, hair, and nails. o Is NOT active against Candida species or systemic mycoses. Terbinafine (Lamisil); allylamine antifungal agent
  • Oral Terbinafien Indications – use against dermatophytes (highly effective) and against Candida species (less effective) o Specifically systemic fungal infections like tinea and onychomycosis. Azole Use in Older Adults
  • Reduced gastric hydrochloric production (achlorhydria) is greater in older adults which can make absorption of some antifungal agents unpredictable.
  • Practice of medication reconciliation is important due to many drug interactions such as changed plasma levels of medications (warfarin, phenytoin, and oral hypoglycemic agents) that are increased by azoles.
  • Consider cognitive ability to safely self-administer medications without skipping or doubling doses.
  • Consider altered pharmacokinetics based on age-related changes. Tinea Pedis Treatment
  • One of the four types of “ring worm” or dermatophytic fungal infections. o Ring worm of the foot, also known as “athletes' foot”.
  • Responds well to topical antifungal therapy
  • Patient education: o Wear absorbent cotton socks o Change their shoes often

Palivizumab (Synagis); monoclonal antibody

  • Indications: for preventing RSV infection in premature infants and in young children with chronic lung disease Influenza Vaccine
  • Purpose of annual vaccination: o Influenza viruses are constantly evolving, so the influenza vaccines must continuously change too. Manufacturers produce a new vaccine directed against the three (trivalent) or four (quadrivalent) strains of influenza virus deemed most likely to cause disease during the upcoming flu season each year.
  • Contraindications: o People at high risk for flu complications: ▪ Pregnant women should not receive the live influenza vaccine but can have the inactivated vaccine. ▪ Current recommendations have one main contraindication
  • a severe allergic reaction to influenza vaccine or a vaccine component.

Chapter 81: Antiretroviral Drugs

NRTIs

  • MOA: prodrugs that inhibit HIV replication by suppressing synthesis of viral DNA
  • Adverse Effects - are associated with mitochondrial toxicity since NRTIs can disrupt synthesis of mitochondrial DNA and impair mitochondrial function: o Lactic Acidosis as lactic acid accumulates due to dysfunctional mitochondria that cannot break down lactic acid. ▪ Nausea, malaise, fatigue, anorexia, and hyperventilation (blowing off carbon dioxide can reduce acidosis) ▪ Most likely to occur with NRTIs, didanosine and stavudine, and come with Black Box Warning. o Hepatic Steatosis since there is a decreased breakdown of fatty acids by mitochondria leading to fatty deposits in the liver. o May also lead to pancreatitis and myopathies. Protease Inhibitors (PIs)
  • MOA: prevent HIV maturation by blocking the HIV enzyme protease. This maturation is necessary for HIV to infect CD cells -> immature forms are noninfectious.
  • Adverse Effects: o Hyperglycemia and the development of diabetes o Lipodystrophy (fat redistribution) o Elevation of serum transaminases o Decreased cardiac conduction velocity o Can also increase bleeding in patients with hemophilia.
  • Prescribing Considerations o Increased risk of bone loss – take Calcium and Vitamin D o St John’s Wort reduces serum levels of PIs o PIs, Indinavir and fosamprenavir, may cause kidney stones Integrase Strand Transfer Inhibitors (INSTIs)
  • MOA: target HIV by terminating the integration of HIV into DNA. Integrase is one of three viral enzymes needed for HIV replication and inserts HIV genetic material into the DNA of CD4 cells. Inhibition of integrase prevents insertion of HIV DNA - > stops HIV replication. o Integrase inhibitors are combined with other antiretroviral agents to treat adults infected with HIV-1.
  • Adverse Effects: o Few adverse effects, but commonly patients may have dizziness and insomnia. o Depression and SI have been noted in patients with previous psychiatric issues. Chemokine Receptor 5 Antagonists (CCR5 Antagonists)
  • MOA: block entry of HIV into CD4 T-cells

Chapter 83: Anthelmintics

Albendazole (Albenza); first choice anthelmintic drug

  • MOA: inhibits polymerization of tubulin and hence prevents the formation of cytoplasmic microtubules. As a result, microtubule- dependent uptake of glucose is prevented.
  • Drug of choice for infestation with hookworms, pinworms, whipworms, Chinese liver flukes, giant roundworms, and pork roundworms, the cause of trichinosis.

diffusion.

  • Lifespan Considerations of Infants o Highly vulnerable to drug toxicity due to underdeveloped kidney and liver functioning -> eliminate drugs slowly.

o Use of sulfonamides in newborns can produce kernicterus, a severe neurologic disorder caused by displacement of bilirubin from plasma proteins

  • Antibiotic Stewardship o Prophylactic Use ▪ Common in severe infections pending test results - Choose treatment based on clinical evaluation and knowledge of which microbes are most likely to cause infection at a particular site - Do not begin until after the specimen has been sampled for testing. ▪ Surgery ▪ Bacterial Endocarditis ▪ Neutropenia ▪ Other uses for prophylactic treatment: - Bactrim for recurrent urinary tract infection, Oseltamivir for influenza, and used for after exposure to organisms responsible for sexually transmitted diseases (e.g., syphilis and gonorrhea). o Misuse of Antimicrobial Drugs ▪ Attempted treatment for viral infection ▪ Treatment for fever of unknown origin ▪ Improper dose ▪ Treatment in the absence of adequate bacteriologic information ▪ Omission of surgical drainage o Four focus areas to decrease resistance: ▪ Focus Area I: Surveillance, Prevention, and Control of Antimicrobial Resistant Infections. Goals include improving the detection, monitoring, and characterization of drug- resistant infections in humans and animals, as well as improving the definition, characterization, and measurement of the impact of antimicrobial drug use. ▪ Focus Area II: Research. Goals include facilitation of basic research on antimicrobial resistance, as well as translation of basic research into practice. Support for epidemiologic studies to identify key drivers of the emergence and spread of antimicrobial resistance is of great importance.

etc.)

  • Other side effects depend on which of the four types of Penicillin G is given (potassium penicillin G, procaine penicillin G, benzathine penicillin G, and sodium penicillin G). o Penicillin V; main different is acid stability ▪ Penicillin V is stable in stomach acid and Penicillin G is not - > more use of penicillin V in oral therapy.
  • MOA - penicillin beta-lactams: Inhibit cell wall synthesis by preventing bacteria from creating or maintaining their cell wall, essential for protecting the cell and maintaining its shape, resulting in cell lysis and death.
  • Gram-Negative Penicillin Activity

Chapter 72 (Drugs that weaken the bacterial cell

wall: part II)

Cephalosporins (bactericidal)

  • MOA - cephalosporin beta-lactams: Inhibit cell wall synthesis by preventing bacteria from creating or maintaining their cell wall, essential for protecting the cell and maintaining its shape, resulting in cell lysis and death.
  • Drug Interactions o Alcohol: cefazolin and cefotetan can cause alcohol intolerance o Cefotetan, cefazolin, and ceftriaxone can promote bleeding due to containing a side chain that interferes with Vitamin K metabolism -> inhibits formation of clotting factors; use with caution in combination with anticoagulants, NSAIDs, thrombolytics, etc.
  • Structure – similar in structure and actions to penicillin: bactericidal, often resistant to β-lactamases, and active against a broad spectrum of pathogens. Their toxicity is low; they contain B- lactam ring fused to second ring around nucleus. o Beta-lactam ring is required for antibacterial activity. Carbapenems (bactericidal)
  • MOA - Inhibit cell wall synthesis by preventing bacteria from creating or maintaining their cell wall, essential for protecting the cell and maintaining its shape, resulting in cell lysis and death.
  • Dose Adjustments

Chapter 73 (Bactreriostatic Inhibitors of Protein

Synthesis)

Tetracyclines (bacteriostatic); broad-spectrum

  • MOA - Inhibits protein synthesis - block the bacterial ribosome's ability to make proteins, which are crucial for bacterial growth and function
  • Patient Education o Should not be administered with calcium supplements, milk products (which contain calcium), iron supplements, magnesium- containing laxatives, and most antacids (contain mg, al, or both); decreased absorption of tetracycline agent and should be given at different times of day. o Increase sensitivity to UV light – wear protective clothing, apply sunscreen, avoid prolonged exposure to sunlight.
  • Effects in Pregnancy o Avoid in pregnant women; shown to cause fetal harm in animals. Macrolides (bateriostatic); Inhibits protein synthesis - block the bacterial ribosome's ability to make proteins, which are crucial for bacterial growth and function; broad-spectrum
  • Erythromycin, Azithromycin and Clarithromycin
  • Adverse Effects o Generally free of serious toxicity and one of the safest ABX. o Does carry small risk for sudden cardiac death from QT prolongation. o Minor adverse effects include GI disturbances (epigastric pain, N/V/D) and should be taken with food. Clindamycin
  • MOA – inhibits protein synthesis within bacterial ribosomes.
  • Therapeutic Indication o Can cause severe C. Diff, so indications are limited as an alternative to penicillin due to its efficiency against gram positive cocci. o Severe Group A Streptococal infection o Gas Gangrene
  • Patient Education o Due to higher risk of C.Diff, patients should report significant diarrhea (5+ stool/day)
  • Drug Interactions o Binding overlaps the binding sites for erythromycin and chloramphenicol -> antagonize each other's effects and should not be use concurrently.

Chapter 74

Aminoglycosides (bactericidal); narrow-spectrum primarily for gram- negative bacilli (Gentamicin, tobramycin, and amikacin); parenteral administration only

  • Beneficial Drug Interactions o Penicillins ▪ Used in combination to enhance bactericidal effects o Cephalosporins and Vancomycin ▪ These medications also weaken the bacterial cell wall, so in combination with aminoglycoside can enhance bacterial kill.
  • Bad Drug Interactions o Concurrent use with ototoxic drugs worsens the risk (ex. Loop diuretics) o Nephrotoxic drug concurrent use increases risk of nephrotoxicity (ex. Amphotericin B, cephalosporin, polymyxins, vancomycin, cyclosporine, ASA, and other NSAIDs).
  • MOA - Inhibits protein synthesis - block the bacterial ribosome's ability to make proteins, which are crucial for bacterial growth and function; the greater the concentration the greater the infection will clear
  • Cause of Resistance o The main cause is the production of enzymes that can inactivate aminoglycosides ▪ Amikacin is the least susceptible to inactivation by bacterial enzymes ▪ There are 20 known aminoglycoside-inactivating enzymes that have been identified.
  • Adverse Effects o Serious injury to inner ears and kidneys ▪ Ototoxicity is typically irreversible. ▪ Withdrawal medication at the first sign of injury. o Possible neurotoxicity (numbness, tingling, muscle twitching and seizures)

o certain bacteria (ex: proteus species) can elevate urinary pH (by splitting urea to form ammonia). Because formaldehyde is not released under alkaline conditions, infections with urea-splitting organisms are often unresponsive. Nitrofurantoin (bacteriostatic); Block pathways and inhibit metabolism by interrupting key metabolic reactions within the bacterial cell, critical for energy production and DNA synthesis.

  • Adverse Effects: o GI disturbances - anorexia, N/V/D - administer with milk or meals, or reduce dose o Pulmonary reactions – acute vs subacute reactions ▪ Acute is more common with dyspnea, chest pain chills, fever, cough, and alveolars infiltrates that go away 2-4 days after discontinuing drug. ▪ Subacute is rare and happens with prolonged treatment consisting of dyspnea, cough and malaise that take weeks/months to go away after discontinuation. ▪ Permanent lung damage can occur. o Hematologic –agranulocytosis, leukopenia, thrombocytopenia, and megaloblastic anemia o Peripheral neuropathy – demyelinization can occur and be irreversible (begins with muscle weakness, tingling, and numbness); inform patients to report these symptoms. ▪ Most likely to occur in patients with renal impairment and taking medication long term. o Hepatotoxicity – rarely can cause liver injury; liver function tests should be completed periodically o Birth defects

Week 3: Chapters 50, 51, 52, 53, and

National STD Curriculum

Chapter 50

Estrogen

  • Metabolic Actions

o Affects the follow systems: bone, cardiovascular, blood, and neural tissue. ▪ Estrogens also have an important roles glucose homeostasis. o Bone (positive effect): The principal effect of estrogens on the process is to block bone resorption, although estrogens may also promote mineral deposition. o Cardiovascular: estrogen receptors (ERs) in the vascular smooth muscle respond to activation by decreasing vasoconstriction. This is caused by the production of nitric oxide -> vasodilation and increased perfusion. ▪ Estrogen also decreases atherosclerosis through favorable effects on cholesterol levels: low-density lipoprotein (LDL) cholesterol is reduced, and high-density lipoprotein (HDL) cholesterol is elevated. o Blood Coagulation: Estrogens both promote and suppress blood coagulation. ▪ Promotes coagulation by (1) increasing levels of coagulation factors (e.g., factors II, VII, IX, X, and XII) and (2) decreasing levels of factors that suppress coagulation (e.g., antithrombin). ▪ Suppresses coagulation by increasing the activity of factors that promote breakdown of fibrin, a protein that reinforces blood clots. o Central Nervous System Effects: has a neuroprotective effect by defending neurons from the effects of oxidative stress and injury and repairing neurons through stimulation of nerve growth factors. Cerebral perfusion is also enhanced by the release of nitric acid and the resulting vasodilation. o Glucose homeostasis: estrogen has been shown to increase insulin sensitivity to promote glucose uptake, have a role in insulin secretion, and are believed to protect pancreatic islet beta cells from certain types of injury.

  • MOA o It diffuses into cells, migrates to the nucleus, and then binds with an estrogen receptor (ER). The estrogen-ER complex then binds with an estrogen response element on

▪ ER α is highly expressed in the vagina, uterus, ovaries, mammary glands, vascular epithelium, and hypothalamus. ▪ ER β is expressed in the ovary and prostate and to a lesser extent in the lungs, brain, bones, and blood vessels. ▪ Some cells have both types of ER receptor. o Support the development and maintenance of the female reproductive tract and secondary sex characteristics (growth and maturation of the uterus, vagina, fallopian tubes, breast and pigmentation of the nipples and genitalia).

  • Female Hypogonadism (estrogen deficiency) o Causes: primary ovarian failure, hypopituitarism, bilateral oophorectomy (removal of both ovaries), and Turner syndrome (a genetic disorder that impairs gonadal function). o Puberty can be induced by giving exogenous estrogens which also help promote breast development, mature the reproductive organs, and develop pubic and axillary hair. o To stimulate normal estrogen secretion, therapy should consist of continuous low-dose therapy (for approximately a year) followed by cyclic administration of estrogen in higher doses.
  • Interactions o Estrogens are major substrates of CYP1A2 and CYP3A4. ▪ Inducers of these isoenzymes may lower estrogen levels, whereas drugs that are inhibitors may raise estrogen levels. ▪ May decrease the effectiveness of some antidiabetic drugs and thyroid preparations. ▪ Can interact with anticoagulants and other drugs that affect clotting.
  • Cancer Palliation: Estrogens are sometimes used in the management of advanced prostate cancer in men and in a select type of metastatic breast cancer in both men and women. Progestins
  • Contraindications o Undiagnosed abnormal vaginal bleeding o Relative contraindications include active thrombophlebitis or a history of thromboembolic disorders, active liver disease, and carcinoma of the

breast.

  • Menopausal Hormone Therapy (HT)