1. Managing hematological conditions

   1. Hematopoietic growth agent

      1. action: stimulates production, growth, maturation, and differentiation of bone marrow stem cells

      2. example

         1. filgrastim (Neupogen)- stimulates production of white blood cells

         2. epoetin alfa (Epogen)- stimulates production of red blood cells

      3. use: chronic renal failure, HIV-infected clients, reduce bone marrow recovery after transplantation, stimulate bone marrow production after chemotherapy

      4. adverse effects

         1. filgrastim: bone pain

         2. epoetin alfa: hypertension, headache, joint pain

      5. contraindications

         1. hypersensitivity to proteins of E. Coli

      6. nursing interventions

         1. take baseline CBC and diff (complete blood count and differential count) prior to treatment

         2. monitor lab results until target reached

2. Iron supplements

   1. action: iron transported as transferrin to bone marrow and incorporated into hemoglobin

   2. examples

      1. ferrous sulfate (Feosol)

      2. ferrous fumarte (Feco-T)

      3. ferrous gluconate (Fergon)

   3. use: correct simple iron deficiency anemia

   4. adverse effects

      1. gastric disturbances

      2. with massive overdose - lethargy, drowsiness, leading to metabolic acidosis, shock and cardiovascular collapse

   5. contraindications:

      1. hypersensitivity

      2. ulcerative colitis

      3. peptic ulcer disease

      4. hemolytic anemia

      5. cirrhosis

   6. nursing interventions

      1. monitor hemoglobin level

      2. teach client

         • take on empty stomach

         • liquid preparation - take with a straw to prevent tooth discoloration

         • protect from moisture and heat

         • may cause dark or greenish stools

2. Antibiotics, Antivirals, Antifungals, Antiparasitics
1. Antibiotics

2. Action: destroys or inhibits bacteria

3. Examples

   1. penicillins, broad spectrum

      • ampicillin (Omnipen)

      • penicillin V (V-cillin)

   2. cephalosporins, broad spectrum

      • cefazolin sodium (Ancef)

      • ceftriaxone (Rocephin)

   3. macrolides

      • erythromycin (E-mycin)

      • azithromycin (Zithromax)

   4. tetracyclines, broad spectrum

      • doxycycline (Vibramycin)

      • oxytetracycline (Terramycin)

   5. aminoglycosides, broad spectrum

      • gentamicin sulfate (Garamycin)

      • streptomycin sulfate (Strycin)

   6. fluoroquinalones

      • ciprofloxacin (Cipro)

      • levofloxacin (Levaquin)

   7. polymyxin: polymyxin B sulfate (Aerosporin)

   8. chloramphenicol (Chloromycetin)

4. Use: treat bacterial infection

5. Adverse effects

   1. gastric disturbances: nausea / vomiting, poor appetite, diarrhea

   2. allergic reactions

   3. superinfection

   4. loss of water-soluble vitamins and minerals

   5. tetracyclines: hepatotoxicity, phototoxicity, hyperuricemia, tooth enamel hypoplasia, and bone defects in children under eight years of age

   6. fluoroquinolones- photosensitivity

   7. aminoglycosides: ototoxicity, leukopenia, thrombocytopenia, headache, confusion, peripheral neuropathy, optic neuritis, nephrotoxicity

   8. chloramphenicol: blood dyscrasias, fever, rash, jaundice

6. Contraindications:

   1. hypersensitivity

   2. pregnancy- tetracyclines, fluoroquinolones, aminoglycosides

   3. fluoroquinolones- children <18 years of age

7. Nursing interventions

   1. monitor client for allergies

   2. monitor client's response to treatment

   3. teach client

      1. take all of prescribed medication

      2. symptoms of allergic response

      3. if taking a liquid (suspension), shake it first

      4. take medication before meals

   4. tetracyclines

      1. not for young children or in last half of pregnancy

      2. possible oral anticoagulant effect

   5. fluoroquinolones: avoid hazardous machinery, avoid sunlight

   6. aminoglycosides and polymyxins: May potentiate neuromuscular blocking agents, general anesthesia or magnesium effects; monitor for all three potentiation effects

   7. chloramphenicol

      1. assess blood work during therapy

      2. assess for potentiation of phenytoin, oral antidiabetic agents or coumadin anticoagulant effects

3. Antivirals

   1. Action: interfere with DNA synthesis needed for viral replication

   2. Examples

      1. acyclovir sodium (Zovirax)

      2. amantadine HCL (Symmetrel)

      3. oseltamivir (Tamiflu)

   3. Use: viral infections such as herpes, viral encephalitis

   4. Adverse effects

      1. orthostatic hypotension

      2. dizziness

      3. GI disturbances

      4. nephrotoxicity

      5. blood dyscrasias

   5. Contraindications:

      1. hypersensitivity

      2. immunosuppression

   6. Nursing interventions

      1. monitor vital signs during antiviral therapy

      2. monitor effect of therapy

      3. increased fluid intake

      4. monitor for signs of superinfection: sore throat, fever, fatigue

4. Antifungals (systemic)

   1. Action: destroys fungal cells or inhibits their reproduction

   2. Examples

      1. amphotericin B (Fungizone)

      2. griseofulvin (Grisactin)

      3. nystatin (Mycostatin)

   3. Use - treat local and systematic fungal infections such as histoplasmosis, candidiasis, tinea

   4. Adverse effects

      1. gastric irritability: nausea, vomiting

      2. headache

      3. fever, chills

      4. paresthesia

      5. renal impairment

   5. Contraindications

      1. severe bone marrow depression

      2. hypersensitivity

   6. Nursing interventions

      1. monitor vital signs and I and O during therapy

      2. with amphotericin B

         1. protect IV solution from light

         2. monitor blood work

         3. use infusion device for IV administration

      3. with griseofulvin: instruct client to avoid sunlight

5. Antiparasitics

   1. Action: interferes with parasite metabolism and reproduction

   2. Examples

      1. anthelmintics: mebendazole (Vermox), piperazine (Vermizine) (illustration )

      2. amebicides: chloroquine HCL (Aralen), metronidazole (Flagyl)

      3. antimalarials: chloroquine HCL (Aralen), quinine sulfate (Quinamm)

   3. Use: kills parasites, helminths (pinworm and tapeworm), protozoa (amebiasis and malaria)

   4. Adverse effects

      1. anthelmintics: GI upset, CNS disturbances, skin rash, headache

      2. amebicides: GI upset, blood dyscrasias, skin rash, CNS disturbances

      3. antimalarials: GI upset, blood dyscrasia, visual disturbances

   5. Nursing interventions

      1. administer medication with food

      2. monitor vital signs, blood work during therapy

      3. use safety precautions if CNS disturbances manifested

      4. teach client to prevent further infection

      5. with antimalarials: frequent visual examinations, urine may turn rust colored

6. Total Parenteral Nutrition (TPN)

7. A form of specialized nutritional support in which nutrients are provided by the intravenous route

8. Purpose: to sustain clients nutritionally. Solutions consist of water, amino acids, glucose, minerals, vitamins and lipid emulsions, and trace elements which are calculated for each client individually.

9. Used for clients who are unable to digest or absorb sufficient enteral nutrition

10. Complications

    1. Hypoglycemia

    2. Hyperglycemia

    3. Fluid overload

    4. Catheter - related sepsis

    5. Air embolism

    6. Central venous thrombosis

    7. Catheter occlusion

11. Administration

    1. Via peripheral administration - up to 10% glucose solutions

    2. Via central administration - up to 35% glucose solutions

12. Nursing interventions

    1. Before administration of TPN

       1. check label of solution with medical order

       2. check rate of infusion with medical order

       3. inspect TPN bottle for precipitates or turbidity

       4. administer via an infusion pump

    2. During administration

       1. monitor vital signs every four hours

       2. observe for signs of air embolism, pneumothorax, or allergic responses (such as chills, increased temperature, urticaria etc.)

       3. monitor client's weight daily

       4. monitor laboratory values; if blood glucose levels rise, may need to use sliding-scale insulin therapy

       5. monitor client for fluid overload

       6. monitor respiratory rate: tachypnea may indicate excess carbohydrates are increasing carbon dioxide production

       7. monitor insertion site for infection

       8. monitor infusion rate

          1. if rate too high, hyperosmolar diuresis and dehydration

          2. if too slow, little benefit

          3. do not overcorrect flow rate if too slow or fast

          4. accurately record intake and output

          5. change insertion site dressing as per facility's policy

          6. encourage exercise as tolerated to promote the development of muscle instead of fat

          7. while changing tube, instruct client to use Valsalva maneuver and clamp tube to prevent an air embolism

13. Antineoplastics (Cytotoxic, Antiproliferative Agents)
1. Action

2. Highly toxic agents that attack all rapidly dividing cells, both normal and malignant

3. Represents a systemic approach that bases its action on disruption of the cell life cycle

4. Most agents modify or interfere with DNA synthesis

14. Examples

    1. Alkalyting agents: mechlorethamine HCl (Nitrogen Mustard), cyclophosphamide (Cytoxan): produce breaks in DNA molecule and cross-linking of strands thus interfering with DNA replication; most effective in hematologic malignancies

    2. Antitumor antibiotics: Biomycin; bind directly with DNA changing its configuration and inhibiting replication

    3. Antimetabolites: methotrexate, 5-fluorouracil, floxuridine, cytosine arabinoside, 6-mercaptopurine, 6-thioguanine: inhibit DNA synthesis; most effective against rapidly growing tumors enzymes necessary for cell function and replication

    4. Plant alkaloids: Vinblastine, Vincristine, Etoposide: Bind to substances needed to form mitotic spindle, thus preventing cell division

    5. Hormones and hormone inhibitors: Tamoxifen alters the endocrine environment to make it less conducive to cell growth; used in cancers of the breast, prostate, and other reproductive organs

15. Routes of administration

    1. Intravenous (peripheral or central venous access)

    2. Oral

    3. Intraarterial

    4. Intraperitoneal

    5. Intrapleural

    6. Intrathecal

    7. Via ventricular reservoir

16. Use

    1. To cure, control or palliate results of neoplasm

    2. May be used as an adjunct to surgery and radiation

17. Adverse effects: result from the damage to normal cells

    1. Nausea/ vomiting, stomatitis, alterations in taste, anorexia

    2. Diarrhea, constipation

    3. Alopecia, dermatitis, pruritus, paresthesia, rash, bruising

    4. Hemorrhagic cystitis

    5. Cardiomyopathy

    6. Fatigue, dyspnea, fever, chills

    7. Sterility, amenorrhea

    8. Depression, anxiety

    9. Myelosuppression

18. Nursing interventions

    1. Monitor lab studies as ordered

    2. Monitor IV administration site for extravasation

    3. Maintain strict asepsis

    4. Administer antiemetic agents as ordered and prophylactically before chemotherapy.

    5. Give antihistamines as ordered

    6. Withhold food and fluids for four to six hours before treatment

    7. Between treatments, give small, frequent, bland meals

    8. Give antidiarrheals as ordered

    9. Monitor for signs of dehydration and encourage fluids as tolerated

    10. Provide frequent oral hygiene, lubricate lips as indicated

    11. For stomatitis, use topical anesthetics before eating and as indicated

    12. Apply lotion to skin as indicated; avoid harsh, drying soaps

    13. Provide a restful environment, emotional support and anxiolytics as ordered

    14. Teach client

        1. medications and side effects

        2. alopecia is temporary

        3. avoid bruising, aspirin products, and persons with infections

        4. conserve energy

        5. recognize signs of bleeding; anemia, infection

        6. use a soft-bristle toothbrush

        7. avoid use of razors

19. Special nursing considerations

    1. Exposure to chemotherapeutic agents can lead to adverse reactions

       1. contact dermatitis

       2. nausea and vomiting

       3. diarrhea

    2. Exposure during pregnancy can lead to

       1. increased risk of fetal abnormalities

       2. ectopic pregnancies

       3. spontaneous abortions

    3. Guidlines for reducing risks when handling cytotoxic antineoplastic drugs

       1. wear a mask to avoid inhaling powder when handling a powder form of a drug.

       2. do not prepare drugs in eating places Wear gloves, eye protectors and protective clothing when in contact with injectable solutions.

       3. dispose of contaminated materials in puncture-proof containers labeled as hazardous material.

       4. wear gloves when handling linens contaminated with drugs for at least 48 hours after contamination.

       5. wash hands thoroughly before and after exposure to drugs.

       6. follow organizational procedure to clean-up after chemical spill.

20. Blood Transfusion

21. Use: restore blood volume or blood components

22. Nursing responsibilities and interventions

    1. Verify that blood had been typed and cross matched

    2. Verify five factors:

       1. client number

       2. blood type

       3. Rh factor

       4. blood number

       5. expiration date

    3. Pretransfusion assessment includes baseline vital signs, lung sounds, level of consciousness, IV site, and prescence of pain

    4. Verify informed consent

    5. Start infusion with blood administration set, filter, and normal saline IV

    6. Watch for signs of hemolytic reaction; usually occurs within the first 15 minutes (shivering, headache, lower back pain, oliguria, hypotension)

    7. Watch for signs of febrile reaction; usually occurs within first 30 minutes (hematemesis, confusion, back pain, elevated temperature, headache, shaking)

    8. Watch for allergic reaction (hives, wheezing, pruritus, joint pain)

    9. Monitor vital signs

    10. If reaction occurs

        1. stop blood immediately

        2. maintain IV with saline

        3. notify physician

        4. send blood and urine specimen to lab

        5. monitor client during transfusion

        6. monitor lab results - hemoglobin and hematocrit

• The dosage of medication needed for a therapeutic effect can vary with age, weight, gender, health status and environmental factors.

• Most drugs produce a mixture of therapeutic and adverse effects.

• Medications require a written order from a physician or a nurse practitioner legally permitted to prescribe them.

• Because most drugs are metabolized in the liver, it is especially susceptible to drug induced injury.

• The nurse is responsible to judge independently before giving a prescribed medication.

• The route of administration will be chosen to achieve a certain therapeutic action, at a certain speed.

• Medications interact with foods, and that interaction can block or slow therapeutic action

• People metabolize medications differently, depending on age, gender, body size, health status, drug tolerance, cumulative effect of medication, and genetics.

• Inhalers are most effective when their users know the right technique. Teach the technique and then test how well the client uses it.

• Medications are especially likely to cause hypotension in elderly people.

• There are two types of drug dependence: psychic and physical. Psychic dependence implies a craving to use the drug periodically. Physical dependence implies physical symptoms when the drug is withheld.

ASAP
Hypersusceptibility
Idiosyncrasy
Pharmacodynamics
Potentiation
Tachyphylaxis
Toxicology