Med Surge test #4 Flashcards Preview

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Flashcards in Med Surge test #4 Deck (18)
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1

Mucositis Pain mamagement

  • viscious lidocaine 2%- may be used before meals, tske chokig precautions as gag reflex may be numb, careful not to burn the pt, taste may be diinished.
  • Milk of megnesium- rinse and coat the mouth.
  • Nystatin liquid-swished and swallowed,, clotramizole lozenges dissolved in mouth.
  • sucralfate suspensions-topically-relieves pain.
  • oral/parenteral analgesics-for severe pain
  • Palifermin-kepivance-

    recombinant human keratinocyte growth factor- has been approved specifically for stimulating epithelial cell proliferation to prevent or treat the mucositis that develops in hematologic malignancies in patients undergoing chemotherapy before bone marrow transplantation. 

     

2

Mucositis oral hygiene

  • hygiene- soft bristled brus, water pik on low setting, sponged tipped applicator, severe- gravity flow irrigation or oral syringe.
  • no alcohol containing mouth was, used baking soda with water or hydrogen peroxide.
  • oral irrigations before and after meals, and bedtime. 
  • mild lesions every 2 hrs
  • severe every hr
  • with fungal right before topical meds are applied
  • no food or drinks for 15 min after
  • for dry mouth- chewing on gum or sucking ice or ice pop
  • Dry lips- coat with cocoa butter , ky, petroleum or lip balm- artificial saliva 

3

route of admin

  • viscious lidocaine and milk of magnesium - rinses
  • nystatin liquid- swish and swallow
  • sucralfate suspension- topically
  • oral and parenteral analgesics for severe pain only

4

Mouthwashes uses

  • are cosmetic or therapeutic depending on ingridients
  • cosmetic- freshen breathrinse out some debri but freshnesss only last 1-30 minutes.
  • flouride -prevent dental caries
  • medicinal- listerinereduces plaque accumulations and gingivitis
  • chlorhexidine(peridex) antibacterial to treat mucositits 
  • zinc chloride-normal saline-effective gargle-provides temp, soothing relief of pharyngeal irritation.
  • hydrogen peroxide-clean and debride minor lesions 7-10 days only
  • viscious lidocaine-use alot in cancer pt, dont allow food or dring x30 min after due to lack of gag and possibility of choking/aspiration.
  • do not sub the above for narmal hygiene unless specified by MD for a specific cond.
  • do not exfeed recommended dose, needs MD order because of systemic absorption
  • refrain from eating, smoking and drinking for 30 mintues.

5

Ger and peptic ulcer drugs

  • antacids-lower acidity of gastric secretionsby buffering hydrochloric acid to a lower hydrogen ION concentration. ( PH 1-2)
  • Premedicatin assessment- check renal function- lg quantities of magnesium not good for kidney failure. they cant be exreted and produce hypermagnesia, hyperkalemia and toxicity.
  • check patetrn of elimination for diarrhea nad constipation
  • Record a pattern of gastric pain being experienced; report coffee-ground emesis, bloody stools, or recurrent abdominal pain to the health care provider.

  • If the patient is pregnant, has edema, heart failure, hypertension, or salt restrictions, ensure that a low sodium antacid has been prescribed.

  • Schedule other prescribed medications to be taken 1 hour before or 2 hours after antacids are to be administered. 

6

histimine 2 receptor antagonists

  • Actions: The H2 antagonists act by blocking the H2 receptors come on resulting in a decrease in the volume of acid secreted. The pH of the stomach contents rises as a consequence of a reduction in acid
  • Uses: The H2 antagonists (cimetidine, ranitidine, nizatidine, famotidine) are used to treat GERD, duodenal ulcers, and pathologic hypersecretory conditions, such as Zollinger-Ellison syndrome, and for preventing and treating stress ulcers in critically ill patients. Unapproved uses include prevention of aspiration pneumonitis, stress ulcer prophylaxis, acute upper GI bleeding, hives , and hyperparathyroidism. All of the H2 antagonists have products that are available over the counter purchased for symptomatic relief of overheating and heartburn. 

  • Cimetidine- was the first approved H2 antagonist but differs from the other agents by its extensive liver metabolism and antiandrogenic effect that may result in gynecomastia. It also has many drug-drug interactions that are not seen with the others. Consequently, cimetidine is used less frequently than the other H2 antagonist. 

  • Famotidine is similar in action and use to cimetidine but has the advantages of once-daily dosing, fewer drug interactions, and no antiandrogenic effect. Upper enteral dosage form is available. 

  • Ranitidine is similar in action and used to cimetidine but as the advantages of twice-daily dosing, fewer drug interactions, and no antiandrogenic effect. upper enteral dosage form is also available. 

  • Nizatidine is similar to ranitidine and famotidine but, in contrast to other drug agents, is not available in a parenteral dosage form. 

  • Dosage and administration: see table 32.2. 

    All H2 antagonists may be administered with or without food.

    Because antacid therapy is often continued during early therapy of PUD, administer 1 hour before or 2 hours after the H2 antagonist dose. 

7

Drug Class - Gastrointestinal Prostaglandin: Cytotec (misoprostol) 

  • Actions: Misoprostol is a synthetic prostaglandin E series drug. Prostaglandins are normally present in the GI tract to inhibit gastric acid and pepsin secretion to protect the stomach and duodenal lining against ulceration. The prostaglandin E analogues may also induce uterine contractions. 
  • Common Adverse Effects: Diarrhea: Diarrhea associated w/ misoprostol therapy is dose related and usually develops after approximately 2 weeks of therapy. It often resolves after about 8 days, but a few patients require discontinuation of misoprostol therapy. Diarrhea can be minimized by taking misoprostol w/ meals and at bedtime and avoiding magnesium-containing antacids (ex: Maalox liquid, Mylanta). Encourage the patient not to discontinue therapy w/out first consulting the HCP. Encourage the patient to include sufficient roughage or fiber (fresh fruits, veggies, whole-grain products) in the diet. 

  • Contraindication Pregnancy: It is crucial that therapy be discontinued if the patient is pregnant because misoprostol may cause spontaneous abortions. The patient must receive attention from the HCP who prescribed the misoprostol, as well as an obstetrician. The question of alternative therapies to NSAIDs must also be considered. 

8

Drug Class – Proton Pump Inhibitors

  • Actions: Proton pump inhibitors inhibit gastric secretion of hydrochloric acid by inhibiting the gastric acid (hydrogen ion pump) of the stomach’s parietal cells. These inhibitors have no anticholinergic or H2 receptor antagonist actions, so some hydrochloric acid continues to be secreted unless anticholinergics or H2 antagonists are also administered. 
  • Serious adverse effects: Skeletal Risk for fractures: patients who are over the age of 50 years who receive high doses of PPI's or use them for more than one year or at greater risk for fractures of the hip, wrist, and spine. Patients who continue to receive PPI's and who are at risk for osteoporosis should receive vitamin D and calcium supplementation and have their bone status monitored. Patients should not stop taking their PPI unless told to do so by their HCP. Short term, low-dose use of over the counter product is not likely to cause an increased risk of fractures. 

  • Electrolytes Hypomagnesemia: has been reported with as little as three months of PPI therapy, but it more commonly occurs in patients receiving PPI's for more than one year. Hypomagnesemia can cause serious adverse events, including tetany, tremors, seizures, Q-T interval prolongation, and cardiac arrhythmias. HCPs should consider obtaining serum magnesium levels prior to beginning long term PPI therapy, especially in patients receiving digoxin or patients receiving diuretics or other medicines known to cause hypomagnesemia. Magnesium supplementation may resolve the hypomagnesemia, but discontinuation of the PPI may be necessary. Magnesium levels returned to normal within about a week of discontinuing PPI therapy period patients should not stop PPI therapy without first discussing it with their HCP. use of over-the-counter PPI's taken according to directions and for a limited duration has not been associated with hypomagnesemia. 

  • Vitamin B12 deficiency: treatment with PPI's or more than two years may lead to vitamin B12 malabsorption and subsequent vitamin B12 deficiency. However, patients should not be routinely screened for vitamin B12 deficiency. There is no evidence for or against testing for B12 deficiency for patients taking PPI's for longer than 2 years.

  • Integumentary Rash: persistent vesicular rash from omeprazole may be cause for discontinuing therapy. Report rashes to the HCP for further observation and possible laboratory tests. 

     

     

9

– Drug Class – Coating agents: Carafate (sucralfate)

  • Actions: when swallowed, sucralfate forms a complex that adheres to the crater of an ulcer, thereby protecting it from aggravators such as acid, pepsin, and bile salts. however, super state does not inhibit gastric secretions (as do the H2 antagonists) or alter gastric pH (as do antacids).

  • Dosage and administration: adult- PO- 1 tablet 4 times a day 1 hour before each meal and at bedtime, all an empty stomach. Because antacid therapy is often continued during early therapy for ulcer disease, administer antacid at least 30 minutes before or after sucralfate. 

10

Prokinetic Agents: Reglan (metoclopramide)

  • Actions: metoclopramide is a gastric stimulant whose mechanisms of action are not fully known. It increase is lower esophageal sphincter pressure, thereby reducing reflux; increases stomach contractions; relaxes the pyloric valve; and increases peristalsis in the GI tract, resulting in an increase rate of gastric emptying and intestinal transit. Metoclopramide is an antiemetic that blocks dopamine in the chemoreceptor trigger zone. It inhibits serotonin (5-hydroxytryptamine) when administered in higher dosages. 

11

Drug therapy for selected causes of nausea and vomiting

  • Control of vomiting is important for relieving the obvious distress associated with it and preventing aspiration of gastric contents into the lungs, dehydration, an electrolyte imbalance. 

  • primary treatment of nausea and vomiting should be directed at the underlying cause. Because this is not always possible, treatment with non-drug and drug measures is appropriate. 

  • Most medicines (anti emetics) used to treat nausea and vomiting up either by suppressing the action of VC or by inhibiting the impulses going to or coming from the center. These agents are generally more effective if administered before the onset of nausea, rather than after it has started. 

  • The seven classes of agents used as antiemetics are dopamine antagonists, serotonin antagonists, anticholinergic agents, corticosteroids, benzodiazepines, cannabinoids, and neurokinin-1 (NK1) receptor antagonists. 

12

Chemotherapy-Induced Nausea and vomiting

  • Antiemetic therapy to minimize acute CINV is based on the emetogenic potential of the antineoplastic agents used. Combinations of antiemetics are often used, based on the assumption that Antonio plastic agents produce emesis by more than one mechanism. 

  • In general, all patients being treated with chemo therapeutic agents of moderate to high emetogenic potential should receive prophylactic anti emetic therapy before chemotherapy started. 

  • Combinations of a serotonin antagonist (ondansetron, dolasetron, ganisetron, or palonosetron) with dexamethasone, aprepitant, rolapitant, and possibly lorazepam are often use. There is also an oral fixed-dose combination of an NK1 receptor antagonist (netupitant) and palonosetron available for chemotherapy -induced nausea and vomiting. 

  • Antiemetic therapy should be continued for 2 to 4 days to prevent delayed vomiting. Emesis induced by moderately emetogenic agents may be treated prophylactically with a similar regimen, and therapy should be continued for 24 hours. Dexamethasone with or without a phenothiazine (prochlorperazine) or metoclopramide is recommended if the chemotherapy has low emetic potential. 

  • Lorazepam may be added to the antiemetic regimen if necessary. Antiemetic therapy is not recommended with medications with minimum emetic risk, although dexamethasone, metoclopramide, prochlorperazine may be used to prevent the late emphasis. All anti emetic should be given an adequate amount of time before chemotherapy is initiated and should be continued for an appropriate time after the antineoplastic agent has been discontinued

13

Anticholinergic Agents

  • Actions: motion sickness is thought to be caused by an excess of acetylcholine at the CTZ and the VC by cholinergic nerves receiving impulses from the vestibular network of the inner ear. Cycle energy agents are used to counterbalance excessive amounts of acetylcholine present. 

  • Uses: anti cholinergic agents, such as scopolamine, end anti histamines (ex: diphenhydramine, dimenhydrinate, meclizine, promethazine) are used to treat motion sickness and, in the case of the antihistamines, nausea and vomiting associated with pregnancy. The choice of drug depends on both the period for which antinausea protection is required and the adverse effects. Scopolamine Is the drug of choice for short periods of motion, an antihistamine is preferred for longer periods. Of the antihistamines, promethazine is the drug of choice. Higher doses act longer, but sedation is usually a problem. Meclizine Has fewer adverse effects than promethazine but has a shorter duration of action and is less effective for severe conditions. Diphenhydramine has a long duration, but excessive sedation is often a problem, especially after the boat, plane, or car ride is over. For very severe conditions, sympathomimetic drugs such as ephedrine are used in combination with scopolamine or an antihistamine. Article energic Asians are usually not effective in CINV. 

  • Common Adverse effects 

    Neurologic  sedative effects: tolerance may develop overtime, does diminishing the effect. Caution patients to avoid operating power equipment or motor vehicles. 

    Anticholinergic effects blurred vision; Constipation; Urinary retention; dry mucosa of the mouth, throat, and nose: these symptoms are the ant cholinergic effects produced by these agents. Patients should be monitored for these adverse effects. Maintain fluid intake 8 to 10, 8 oz glasses daily. Dryness of the mucosa may be relieved by sucking hard candy or ice chips, or by chewing gum. Stool softeners, such as docusate or the occasional use of stimulant laxative, such as Bisacodyl, may be required for Constipation. Cautioned patient that blurred vision may occur and make appropriate suggestions for his or her personal safety. Patient who developed urinary hesitancy should discontinue the medication and contact their HCP for further ev

14

Benzodiazepines

  • Actions: benzodiazepines act as antiemetics through a combination of effects, including sedation, reduction in anxiety, possible depression of the VC, and amnesic effect. Of these, the amnesic effect appears to be the most important in treating cancer patients and, in this respect, lorazepam and midazolam are superior to diazepam. 

15

Cannabinoids

  • Uses: cannabinoids have been shown to be more effective than placebo an equally as effective as prochlorperazine in patients receiving moderately emetogenic chemotherapy. They are less effective than metoclopramide. because of the mind-altering effects and potential for abuse, the cannabinoids serve as antiemetics only in patients receiving chemotherapy. The cannabinoids or of more use in those younger patients who are refractory to other antiemetic regimens and in whom combination therapy may be more effective. 

  • Drug interactions: drugs that increase toxic effects drugs that increase toxic effects-> under histamines, alcohol, analgesics, benzodiazepine's, phenobarbital, antidepressants, muscle relaxants, and sedative-hypnotics increase toxic effects. Monitor the patient for excessive sedation and reduce the dosage of other sedative agents, if necessary. 

16

Laxatives

  • Osmotic laxatives: (ex: lactulose, polyethylene glycol, glycerin) are hypertonic compounds that draw water into the intestine from surrounding tissues. Last Lowe's has an unset of action within 24 to 48 hours. Polyethylene glycol usually asks within 24 to 96 hours, and glycerin suppositories usually act within 15 to 30 minutes. Polyethylene glycol-electrolyte solution is a relatively new approach to a small take laxative therapy. It is a mixture of non-absorbable iron exchange solution and electrolytes that acts as an osmotic agent. When taken orally, it pulls electrolytes and water into the solution in the lumen of the bowel an exchange is sodium ions to replace those removed from the body. The result is a diarrhea that cleanses the bowel for colonoscopy and barium enema X Ray examination with no significant dehydration or loss of electrolytes. 
  • Bulk forming laxatives: Psyllium, calcium polycarbophil, and methylcellulose are approved bulk-forming laxatives. Psyllium increases stool frequency in patients with chronic Constipation, but evidence is lacking for the efficacy of the other approved bulk-forming laxatives. Bulk forming laxatives must be administered with a with a full glass of water. The laxative causes water to be retained within the stool. This increases bulk, which stimulates peristalsis. Onset of action is usually 12 to 24 hours but maybe as long as 72 hours, depending on the patient’s GI transit time. Bulk forming agents are usually considered the safest laxatives, even when taken routinely. Fresh fruits, veggies, and cereals such as wheat bran or natural bulk forming products. 

17

Antidiarrheal Agents

  • Actions:

    Antidiarrheal agents include a wide variety of drugs that can be divided into 2 broad categories- locally acting agents and systemic agents. 

    Locally acting agents such as activated charcoal, pectin, psyllium absorb excess water to cause a formed stool and absorbed irritants or bacteria that R causing the diarrhea. Bismuth subsalicylate apps locally to stop secretion of fluids into the GI track and promote diarrhea; it may also have local antimicrobial effects, killing bacteria and viruses that may be inducing diarrhea. Lactobacillus acidophilus is used to from oh normal bacterial growth in the intestinal track with chronic (not acute) diarrhea. 

    The systemic agents act through the autonomic nervous system to reduce peristalsis and motility of the GI track, allowing the mucosal lining to absorb nutrients, water, and electrolytes, leaving a formed stool in the colon. Representatives of the systematically acting agents are loperamide (without atropine) and diphenoxylate and difenoxin with atropine to prevent abuse. That systematically acting agents or associated with more adverse effects and should not be used to treat diarrhea caused by substances toxic to the GI tract, such as bacterial contaminants or other irritants because set these agents act by reducing GI motility, to systematically acting anti diarrheal stand to allow the toxin to remain in the GI tract longer, causing further irritation. 

  • Uses: Although the ingredients of the antidiarrheal products or, in general, benign in majority are available OTC, the decision to recommend treatment or to refer the patient to a HCPD is not to be taken lightly. On Thursday real projects are usually indicated under the following conditions: 

    The diarrhea is of sudden onset, has lasted more than 2-3 days, and is causing significant fluid and water loss. Young children and elderly patients are more susceptible to rapid dehydration and electrolyte imbalance and therefore should start anti diarrheal therapy earlier. 

    Patients with inflammatory bowel disease develop diarrhea. Rapid treatment shortens the course of the incapacitating diarrhea and allows the patient to live a more normal lifestyle. Other agents come on such as adrenocorticosteroids or sulfonamides, may also be used to control the underlying bowel disease. 

    Post-GI surgery patients develop diarrhea. These patients may require chronic antidiarrheal therapy to allow adequate absorption of fluids and electrolytes. 

    The cause of the diarrhea has been diagnosed, and the HCP determines that an antidiarrheal product is appropriate for therapy period because many cases of the area or self-limiting, therapy may not be necessary. 

18

receptor antagonist chart