Nur 212/Pharmacology
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| octreotide (Sandostatin, Sandostatin LAR Depot) | Class- Somatostatin (GH inhibitor) analogue. Use- Acromegaly, metastatic carcinoid tumor (to control flushing and diarrhea symptoms), VIPoma, small bowel fistula, & esophageal varices.
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| somatoropin (Humatrope, others) | Class- Anterior pituitary hormone. Use- GH deficiency.
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| vasopressin (Pitressin) | Class- Natural or synthetic ADH. Use- Diabetes insipidus, vasodilatory shock (septic shock), GI hemorrhage, and esophageal varices.
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| cosyntropin (Cortrosyn) | Travels to the adrenal cortex, located just above the kidney, and stimulates the secretion of cortisol. Mimics ACTH. Used in the diagnosis of adrenocortical insufficiency.
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| Nursing implications for administering corticosteroids | Physical assessment for baseline weight, height, I&O, vitals (especially BP), hydration status, Immune status. Baseline labs. Assess edema and electrolyte imbalances. Assess for contraindications, drug allergies and interactions. Monitor blood glucose.
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| Implications continued... | Prepare according to manufacturer's instructions. Oral forms should be given with food. Clear nasal passages before giving a nasal corticosteroid. Teach to rinse mouth if using an orally inhaled corticosteroid. Tell pts to avoid people with infections.
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| Implications continued... | Tell pts to contact PCP if s/s of fever, increased weakness, lethargy, or sore throat. Should be taken at same time everyday. Do not suddenly stop, must be tapered. Monitor for therapeutic response or adverse effects. Pregnancy category C.
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| Adverse effects for corticosteroids | Cardio- HF, cardiac edema, hypertension (due to electrolyte imbalances- hypokalemia, hypernatremia). CNS- convulsions, HA, vertigo, mood swings, psychic impairment, nervousness, insomnia. Endocrine- growth suppression, Cushing's, menstrual irregularities,
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| Adverse effects continued... | Endocrine- carbohydrate intolerance, hyperglycemia, hypothalamic-pituitary-adrenal axis suppression. GI- peptic ulcers (possible perforation), pancreatitis, ulcerative esophagitis, abd distension. Skin- fragile skin, petechiae, ecchymosis, facial erythema
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| Adverse Effects continued... | Skin- poor wound healing, hirsutism, urticaria. Musculoskeletal- muscle weakness, loss of muscle mass, osteoporosis. Ocular- increased intraocular pressure, glaucoma, exophthalmos, cataracts. Other- weight gain.
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| Anaphylaxis symptoms | Abd pain, Abn (high-pitched) breathing sounds, anxiety, chest discomfort or tightness, cough, diarrhea, difficulty breathing and swallowing, dizziness or light-headedness, hives, itching, nasal congestion, N/V, palpitations, skin redness, slurred speech,
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| symptoms continued... | Swelling of the face, eyes, or tongue, unconsciousness, and wheezing.
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| Anaphylaxis signs | Abn heart rhythm (arrhythmia), fluid in the lungs (pulmonary edema), hives, mental confusion, rapid pulse, skin that is blue from lack of oxygen, pale skin from shock, swelling in the throat (angioedema) that may block the airway, swelling of eyes & face
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| signs continued... | Weakness and wheezing.
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| Nursing implications for IV antibiotic therapy | Assess drug allergies, renal, liver and cardiac function; obtain health Hx and immune status; assess for contraindications and possible drug interactions; obtain cultures from appropriate sites; assess s/s for superinfection; stay with pt first 15 min;
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| Implications continued... | Infuse over recommended time; Check site frequently for s/s of swelling, tenderness, heat, redness and pain. If anaphylactic reaction were to occur, stop infusion immediately, call rapid response & prepare to administer epinephrine & antihistamines.
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| Why is it recommended that all antibiotics should be taken with a full glass of water? | They are absorbed better & prevent crystalluria and GI upset.
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| What is Pseudomembranous colitis? | Necrotizing inflammatory bowel condition due to antibiotics disrupt the normal gut flora and can cause an overgrowth of Clostridium difficile.
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| What symptoms does the patient with this condition experience? | Most common symptoms are watery diarrhea, abd pain, and fever.
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| What nursing actions are indicated if this is suspected? | Send a culture immediately!
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| What are the therapeutic responses we would expect to see in our patient if the antibiotic therapy is effective? | Improvement of s/s of infection; decreasing WBC; return to normal vitals; neg. culture and sensitivity tests; disappearance of fever, lethargy, drainage, and redness.
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| Empiric Therapy | Tx of an infection before specific culture info has been reported or obtained.
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| Definitive Therapy | Antibiotic therapy tailored to treat organism identified with cultures.
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| Prophylactic Therapy | Tx with antibiotics to prevent an infection, as in intraabdominal surgery or after trauma.
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| What is superinfection? | An infection occurring during antimicrobial Tx for another infection, resulting from overgrowth of an organism not susceptible to the antibiotic used. It is secondary to primary infection, often due to weakening of the pt's immune system.
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| What causes superinfection? | Occurs when antibiotics reduce or eliminate normal flora needed to maintain function of organs. Other bacteria and/or fungi cause another infection.
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| What preventative measures can the nurse initiate for superinfection? | Patients should be told to take antibiotics exactly as directed and for the entire course of Tx. Advise to consume products with probiotics (yogurts, buttermilk & kefir).
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| Name the two priority adverse effects of aminoglycosides | Nephrotoxicity- monitor urine for presence of casts, proteinuria, elevated BUN & CR levels. Ototoxicity (8th cranial nerve)- Monitor for dizziness, tinnitus, fullness in ears, and hearing loss.
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| What is therapeutic drug monitoring and how and why is it carried out? | Ongoing monitoring of plasma drug concentrations & dosage adjustment based on these values as well as other lab indicators such as kidney & liver function test results; it is often carried out by a pharmacist with medical, nursing, & lab staff.
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| Therapeutic drug monitoring continued... | Trough is measured to ensure adequate renal clearance. Drawn 8-12 hrs after completion dose. Goal is <1 mcg/mL. Levels >2 associated with increased risk of ototoxicity & nephrotoxicity. Measured initially and q 5-7 until drugs DC'd.
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| For what common resistant infection is vancomycin the drug of choice? | Tx of choice for MRSA and other gram-pos. infections. Oral vancomycin is indicated for the Tx of antibiotic-induced colitis & for the Tx of staphylococcal enterocolitis.
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| Intravenous administration of vancomycin | Should be infused over a min of 60 min. Rapid infusions may cause hypotension. Monitor for adverse effects. Red Man Syndrome may occur.
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| How is Red Man Syndrome prevented? | Antihistamine may be ordered to prevent Red Man Syndrome.
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| What other class of antibiotics is often administered with aminoglycosides and why? | Most often used in combo with other antibiotics for synergistic effect (Beta lactams & vancomycin). When given with beta lactams, b-lactam is administered first.
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| Synergistic effect | Drug interaction in which the bacterial killing effect of 2 antibiotics given together is greater than the sum of the individual effects of the same drugs given alone.
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| Normal values for vancomycin trough | Trough should be 10-20 mcg/mL
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| Nursing implications associated with low therapeutic values | Bacteria may become drug resistant.
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| Nursing implications associated therapeutic high values | Toxicity can occur (ototoxicity & nephrotoxicity).
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| amikacin (generic only) (pregnancy-D) | Indications- Primarily infection with gentamicin and tobramycin-resistant gram-neg organisms along with severe staphylococcal infections.
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| gentamicin (generic only) (pregnancy-C) | Indications- Primarily gram-neg infections along with severe staphylococcal infections.
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| neomycin (pregnancy-C) | Indication- Preoperative bowel cleansing (also used with different dosage regimens for hepatic encephalopathy).
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| tobramycin (generic, TOBI) (pregnancy-D) | Indications- Primarily gram-neg infections along with severe staphylococcal infections.
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| Adverse effects for Quinolones-CNS | Headache, dizziness, insomnia, depression, restlessness, and convulsions.
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| Adverse effects for Quinolones-GI | N/V/D, constipation, increased AST & ALT levels, flatulence, heartburn, oral candidiasis and dysphagia.
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| Adverse effects for Quinolones-Skin | Rash, pruritus, urticaria (hives), and flushing
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| Adverse effects for Quinolones- | Ruptured tendons and tendonitis (black box warning added in 2008), fever, chills, blurred vision, and tinnitus.
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| norfloxacin (Noroxin, 1986) | Antibacterial spectrum- extensive gram-neg and selected gram-pos. coverage. Indications- UTI's, prostatitis, STI's.
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| ciprofloxacin (Cipro, 1987) | Antibacterial spectrum- same as norfloxacin. Indications- Anthrax (inhalation, post-exposure), respiratory, skin, urinary tract, prostate, intraabdominal, GI, bone & joint infections. Typhoid fever and selected nosocomial pneumonias.
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| levofloxacin (Levaquin, 1996) | Antibacterial spectrum- same as Cipro, but better gram-pos coverage. Indications- Respiratory and urinary tract infections, prophylaxis in various transrectal and transurethral prostate surgical procedures.
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| moxifloxacin (Avelox, 1999) | Antibacterial spectrum- same as levofloxacin plus anaerobic coverage. Indications- Respiratory and skin infections, CAP caused by PRSP, anaerobic infections.
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| gemifloxacin (Factive, 2004) | Antibacterial spectrum- same as Cipro. Indications- CAP, exacerbation of COPD.
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| acyclovir adverse effects | N/D, headache, burning when topically applied.
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| didanosine adverse effects | Pancreatitis, peripheral neuropathies, seizures.
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| ganciclovir adverse effects | Bone marrow toxicity, N/V, headache, seizures
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| amantadine, rimantadine adverse effects | Insomnia, nervousness, lightheadedness, anorexia, anticholinergic effects, orthostatic hypotension, and blurred vision
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| foscarnet adverse effects | Headache, seizures, electrolyte disturbances, acute renal failure, bone marrow suppression, and N/V/D.
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| indinavir adverse effects | N/V/D, abd, back, or flank pain, headache, weakness, taste changes, acid regurgitation, and nephrolithiasis.
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| nevirapine adverse effects | Rash, fever, nausea, headache, elevation in liver enzyme levels.
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| ribavirin adverse effects | Rash, conjunctivitis, anemia, mild bronchospasm
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| trifluridine adverse effects | Ophthalamic effects: burning, swelling, stinging, photophobia, pain
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| vidarabine adverse effects | Ophthalamic effects: burning, lacrimation, keratitis, foreign body sensation, pain, photophobia, uveitis.
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| zalcitabine adverse effects | Peripheral neuropathy, rash, ulcers
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| zidovudine adverse effects | Bone marrow suppression, nausea, headache.
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| acyclovir (Zovirax) (pregnancy, B) | Pharmacologic Class- antiherpesvirus. Indications- HSV-1 &2 infection, including genital herpes, mucocutaneous herpes, herpes encephalitis, herpes zoster (shingles), higher-dose therapy for acute therapies, lower-dose for viral suppression, chickenpox.
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| amantadine (Symmetrel) (Pregnancy, C) | Class- antiinfluenza. Indication- Influenza A
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| ganciclovir (Cytovene) (Pregnancy, C) | Class- antiviral. Indications- CMV retinitis Tx or maintenance.
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| oseltamivir (Tamiflu) (pregnancy, C) | Class- antiinfluenza. Indication- Influenza A or B.
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| ribavirin (Virazole) (pregnancy, X) | Class- anti-RSV. Indication- Severe RSV infection in hospitalized infants and toddlers.
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| zanamivir (Relenza) (pregnancy, C) | Class- antiinfluenza. Indication- Influenza A or B.
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| zivudine (Retrovir) or AZT | Nucleoside analogue of thymidine. Inhibits viral DNA replication bu inhibiting enzyme DNA polymerase. First drug developed for AIDS. Given to pregnant women & newborns to prevent transmission from mother to baby. SE is bone marrow suppression-monitor CBC
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| acyclovir (Zovirax) | Synthetic nucleoside analog. Used to suppress replication of HSV-1 &2, VZV. Drug of choice for Tx of initial & recurrent episodes of these infections. Oral, topical & parenteral forms Topical SE- burning (pt must report if severe).
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| acyclovir continued... | IV is stable at room temp. for 12 hrs, may precipitate if refrigerated. Infuse over > than 1 hr to avoid renal tubule damage, encourage fluid intake for several hrs post infusion (prevent crystalluria).
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| ganciclovir (Cytovene) | CMV carried by 50% of population, causes no harm. Most often seen in immunocompromised & can result in life threatening opportunistic infections. Synthetic nucleoside analog. Used to treat infection with cytomegalovirus (CMV). Oral, parenteral forms.
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| ganciclovir (Cytovene) continued... | CMV retinitis, ophthalmic form surgically implanted (Vitrasert). Bone marrow toxicity.
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| oseltamivir (Tamiflu) | Active against influenza A or B. Inhibits the enzyme that enables budding virions to escape the cell & spread. Reduce duration of illness by several days. SE- N/V. Tx should begin within 2 days of influenza symptom onset.
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| Benign tumors | Does not metastasize; encapsulated; similar to tissue of origin; rate of growth is slow; recurrence after surgery is rare.
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| Malignant tumors | Potential to metastasize; not encapsulated; not similar to tissue of origin; rate of growth is unpredictable & unrestrained; recurrence after surgery is common.
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| Epithelial | Carcinomas
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| Glands or ducts | Adenocarcinomas
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| Respiratory tract | Small & large cell carcinomas
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| Kidney | Renal cell carcinoma
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| Skin | Squamous cell, epidermoid, and basal cell carcinoma; melanoma
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| Connective | Sarcomas
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| Fibrous Tissue | Fibrosarcoma
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| Cartilage | Chondrosarcoma
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| Bone | Osteogenic sarcoma (Ewing's tumor)
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| Blood vessels | Kaposi's sarcoma
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| Synovia | Synoviosarcoma
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| Mesothelium | Mesothelioma
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| Lymphatic | Lymphomas
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| Lymph tissue | Lymphomas (Hodgkin's, non-Hodgkin's)
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| Glia | Glioma
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| Adrenal medulla nerves | Pheochromocytoma
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| WBC | Leukemia
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| Bone Marrow | Multiple myeloma
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| Dose-limiting adverse effects | Patient can no longer tolerate an increase in dosage that may be necessary to adequately treat the cancer & achieve good disease response.
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| Bone-marrow suppression implications | Monitor CBC. Watch for s/s of infection. Prophylactic antibiotics may be ordered or when the pt shows any s/s of infection. Hematopoetic drugs will be given to hasten bone marrow recovery.
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| Antineoplastic adverse effects | Kill rapidly dividing normal cells: Oral & GI mucous membranes, hair follicles, reproductive germinal epithelium and components of bone marrow.
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| GI | Stomatitis with inflammation and/or ulceration of the oral mucosa throughout the GI tract, altered bowel function, poor appetite, N/V/D
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| Hair follicles | Alopecia (loss of hair)
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| Bone marrow | Dangerously low (life threatening) blood cell counts. Check CBC & ANC. ANC of 500 cells/mm3 or lower indicates high risk of infection.
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| Germinal epithelial cells | Sterility (irreversible) in males, damage to the ovaries with subsequent amenorrhea in females, and teratogenic effects with possible fetal death in pregnant women.
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| RBC count | Male: 4.6-6.2 million cells/mm3
Female: 4.2-5.4 million cells/mm3
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| Hct | Male: 40%-54%
Female: 37%-47%
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| Hgb level | Male: 14-18 g/dL
Female: 12-16 g/dL
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| Platelet count | 150,000-140,000 platelets/mm3
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| Methotrexate, folic acid antagonism | Interferes with the use of folic acid. DNA is not produced and the cell dies. High dose methotrexate associate with severe bone marrow suppression. Always given in conjunction with the rescue drug "leukovorin" (helps protect healthy cells).
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| Methotrexate continued... | Also Tx for psoriasis and RA. Nurse must wear gloves with this drug!
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| Nadir | The lowest level of WBC's (neutrophils) in the blood following chemo. Time to reach nadir may become shorter and bone marrow recovery time longer with each successive Tx. Administer colony-stimulating factors (Neupogen).
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| Nadir continued... | Chemo will be held until neutrophil counts recover if absolute neutrophil count is <500. Prophylactic antibiotics may be given and blood stimulants, hematopoietic growth factors.
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| Monoclonal antibodies | Antibodies that a single plasma cell produces: they are all identical. Produced in a lab using recombinant DNA technology. Tx of cancer, RA, MS, and organ transplantation. Specifically target cancer cells and have min effect on normal cells. Fewer SE.
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| Interferons indications | Chronic hep C, hairy cell leukemia, AIDS-related Kaposi's sarcoma, chronic myelogenous leukemia, malignant melanoma, follicular lymphoma, condylomata acuminata (venereal-genital warts), chronic hep B, MS, chronic granulomatous disease, osteoporosis.
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| Interferons adverse effects | Flulike symptoms-fever, chills, headache, malaise, myalgia and fatigue. Cardio-tachycardia, cyanosis, ECG changes, orthostatic hypotension. CNS-confusion, somnolence, irritability, seizures, hallucinations. GI-N/V/D, anorexia, taste alterations, dry mouth
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| Interferons adverse effects continued... | Hematologic- neutropenia, thrombocytopenia. Renal & hepatic- increased BUN & creatinine levels, proteinuria, abd liver function test.
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| Interferons dose-limiting adverse effects | Fatigue
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| Epogen indications | Chemo-induced anemia, anemia due to chronic renal failure, zidovudine therapy, reduction of need for blood transfusions in surgical pts.
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| Neupogen indications | Chemo-induced leukopenia.
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| Neumega indications | Chemo-induced thrombocytopenia.
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| Leukine indications | Chemo-induced leukopenia.
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| aldesleukin (IL-2) Proleukin indications | Metastatic renal cell carcinoma or melanoma
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| anakinra (Kineret) indication | RA
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| denileukin diftitox (Ontak) indication | Cutaneous T-cell lymphoma
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| tocilizumab (Actemra) indication | RA
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| Capillary Leak Syndrome | Severe toxicity of aldesleukin therapy. Capillaries lose ability to retain vital colloids in the blood; these substances are leaked into the surrounding tissues. Result- massive fluid retention (respiratory distress, HF, MI, & dysrhythmias).
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| Immunosuppressant drugs indications | Autoimmune diseases, organ transplantation rejection prevention
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| Azathioprine adverse effects | Hematologic- Leukopenia, thrombocytopenia. Hepatic- hepatoxicity.
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| Cyclosporine adverse effects | Cardio- moderate hypertension (50% of pts). CNS- neurotoxicity, including tremors. Hepatic- hepatotoxicity with cholestasis and hyperbilirubinemia. Renal- nephrotoxicity (dose-limiting). Other- Posttransplant, DM, gingival hyperplasia and hirsutism.
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| Muromonab-CD3 adverse effects | Cardio- chest pain. CNS-pyrexia, chills, tremors. GI- N/V/D. Respiratory- dyspnea, wheezing, pulmonary edema. Other- flulike symptoms, fluid retention.
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| Tacrolimus adverse effects | CNS- agitation, anxiety, confusion, hallucinations, neuropathy. Renal- albuminuria, dysuria, acute renal failure, renal tubular necrosis. Other- posttransplant DM
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| Antibody immunosuppressants | Multiple body systems- cytokine release syndrome, which includes such immune-mediated symptoms as fever, dyspnea, tachycardia, sweating, chills, headache, N/V/D, muscle and joint pain and general malaise.
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| Immunosuppressant implications | Infection- watch for s/s of infection, check labs, should be taken with food for GI upset, Keep mouth clean, do not use styrofoam cups, tell pt they will be on drug for life if had an organ transplant.
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