Feldene

By G. Temmy. Newberry College. 2018.

Progestins with minimal an- • Risk for Injury related to increased risks of hypertension drogenic activity are desogestrel and norgestimate; those and gallbladder disease with intermediate activity include norethindrone and ethy- Planning/Goals nodiol; norgestrel has high androgenic effects trusted feldene 20 mg. In addition purchase feldene 20mg, there are long-acting progestin contraceptive preparations The client will: such as IM depot medroxyprogesterone (Depo-Provera) that • Be assisted to cope with self-concept and body image lasts 3 months per injection, intrauterine progesterone that lasts changes 1 year, and levonorgestrel subcutaneous implants (Norplant) • Take the drugs accurately, for the length of time prescribed that last 5 years. In one regimen, the drug is progestin combination, help the client take it accurately. These regimens more and vitamin D in the diet and adequate weight-bearing ex- closely resemble normal secretion of estrogen and avoid pro- ercise to maintain bone strength and prevent osteoporosis. Evaluation • Interview and observe for compliance with instructions Effects of Estrogens and Oral for taking the drugs. Contraceptives on Other Drugs • Interview and observe for therapeutic and adverse drug effects. These drugs may interact with several drugs or drug groups to increase or decrease their effects. Estrogens may decrease the effectiveness of sulfonylurea PRINCIPLES OF THERAPY antidiabetic drugs (probably by increasing their metabolism); warfarin, an oral anticoagulant (by increasing hepatic produc- Need for Continuous Supervision tion of several clotting factors); and phenytoin, an anticon- vulsant (possibly by increasing fluid retention). Estrogens Because estrogens, progestins, and hormonal contraceptives may increase the adverse effects and risks of toxicity with cor- are often taken for years and may cause adverse reactions, ticosteroids, ropinirole, and tacrine by inhibiting their metab- clients taking these drugs need continued supervision by a olism. Ropinirole and tacrine should not be used concurrently health care provider. These examinations should be repeated at least an- drugs is taken concurrently with an oral contraceptive, in- nually as long as the client is taking the drugs. Contra- CHAPTER 28 ESTROGENS, PROGESTINS, AND HORMONAL CONTRACEPTIVES 419 CLIENT TEACHING GUIDELINES Hormone Replacement Therapy General Considerations ✔ Combined estrogen–progestin therapy may increase blood ✔ Estrogen replacement therapy relieves symptoms of meno- sugar levels in women with diabetes. This effect is attrib- pause and helps to prevent or treat osteoporosis. However, a well-done study ✔ Apply skin patch estrogen (eg, Estraderm) to clean, dry reported in 2002 concluded that risks of adverse effects skin, preferably the abdomen. Press the patch tightly for with estrogen–progestin combinations are greater than 10 seconds to get a good seal and rotate sites so that at previously believed. Women with an intact uterus who are least a week passes between applications to a site. Fluid re- symptoms of menopause) should discuss their individual tention and edema may occur and produce weight gain. CLIENT TEACHING GUIDELINES Oral Contraceptives General Considerations ✔ Avoid pregnancy for approximately 3 to 6 months after ✔ Seek information about the use of oral contraceptives. These inserts provide ✔ See a health care provider every 6 to 12 months for blood information about safe and effective use of the drugs. Cigarette smoking increases ✔ Take about the same time every day to maintain effective risks of blood clots in the legs, lungs, heart, or brain. If you forget to take one pill, take it as soon as ✔ Several medications may reduce the effectiveness of you remember. If you do not remember until the next oral contraceptives (ie, increase the likelihood of preg- scheduled pill, you can take two pills at once. These include several antibiotics (eg, ampicillin, miss two pills in a row, you may take two pills for the clarithromycin and similar drugs, rifampin, penicillin V, next 2 days. If you miss more than two pills, notify your sulfonamides [eg, Bactrim], tetracyclines, and antiseizure health care provider. Inform all health care providers who The drugs may cause photosensitivity, with increased like- prescribe medications for you that you are taking a birth lihood of sunburn after short periods of exposure. The drugs ✔ Be prepared to use an additional or alternative method of may cause fluid retention; decreasing salt intake may be birth control if a dose is missed, if you are unable to take helpful. For exam- redness, or swelling; chest pain; weakness or numb- ple, use a different method of birth control while taking an ness in an arm or leg; or sudden difficulty with seeing or antibiotic and for the remainder of that cycle. Compliance involves the willingness to on the therapeutic effects of the birth control pills? How should take the drugs as prescribed and to have examinations you advise her? What teaching can you provide that will help her of breasts and pelvis and blood pressure measurements remember to take her birth control pills regularly? Assessment also includes identi- fying clients in whom hormonal contraceptives are con- traindicated or who are at increased risk for adverse drug effects. These include alcohol, some benzodiazepines estrogen–progestin combinations (see Table 28–1).

The drug-resistant pneumococcus: tis is often associated with the use of clindamycin buy feldene 20mg with visa. Hospital Infection Control Practices Advisory Committee (HICPAC) Treatment includes metronidazole (Flagyl) or oral vancomycin discount 20mg feldene fast delivery. What are adverse effects with erythromycin, and how may they be prevented or minimized? Discuss ways to increase adherence to anti- drug-resistant tuberculosis infections. Describe factors affecting the use of primary, implications of using primary antitubercular secondary, and other drugs in the treatment of drugs. Critical Thinking Scenario John Phillips, a homeless person with a history of drug and alcohol abuse, comes to the emergency depart- ment with a productive cough, complaints of night sweats, and fatigue. The physician suspects tuberculosis (TB) and orders a purified protein derivative (PPD) skin test, chest x-ray, and sputum for acid-fast bacilli. Reflect on: The necessary infection control measures to use before TB is confirmed or ruled out. Factors that affect compliance with drug treatment for John Phillips and a plan to improve and monitor compliance. Phillips will require drug treatment, and how you can evaluate when the TB is cured. OVERVIEW Tuberculosis commonly occurs in many parts of the world and causes many deaths annually. In the United Tuberculosis (TB) is an infectious disease that usually affects States, active disease has waned to a historical low level. It is caused by Mycobac- include increased exposure during a resurgence of active terium tuberculosis, the tubercle bacillus. In general, these disease between 1985 and 1992, immigration from coun- bacilli multiply slowly; they may lie dormant in the body for tries where the disease is common, and increasing numbers many years; they resist phagocytosis and survive in phagocytic of people with conditions or medications that depress the cells; and they develop resistance to antitubercular drugs. The bacteria be- come inactive, but they remain alive in the body and There are four distinct phases in the initiation and progres- can become active later. Transmission occurs when an uninfected person in- not spread TB to others, usually have a positive skin hales infected airborne particles that are exhaled by an test reaction, and can develop active TB disease years infected person. Major factors affecting transmission later if the latent infection is not effectively treated. In are the number of bacteria expelled by the infected per- many people with LTBI, the infection remains inactive son and the closeness and duration of the contact be- throughout their lives. In others, the TB bacteria be- tween the infected and the uninfected person. About 6 to 8 weeks after exposure, those latent infection, although new infection can also occur. Both reactivated and new infections are more likely to Within approximately 6 months of exposure, sponta- occur in people whose immune systems are depressed neous healing occurs as the bacilli are encapsulated in by disease (eg, human immunodeficiency virus [HIV] in- calcified tubercles. Among people with who become infected with TB bacteria, the immune LTBI, signs and symptoms of active disease (eg, cough Transmission Primary tuberculosis Latent tuberculosis "Reactivation" tuberculosis Progression after 2 years, 5% Skin-test Spontaneous conversion in healing in Progression 6 to 8 weeks 6 months within 2 years, 5% Progression with concurrent HIV infection, 10% each year Figure 38–1 Transmission of Tuberculosis and Progression from Latent Infection to Reactivated Disease. Among persons who are seronegative for the human immunodeficiency virus (HIV), approximately 30 percent of heavily exposed persons will become infected. In 5% of persons with latent infection, active disease will develop within two years, and in an additional 5%, progression to active disease will occur later. The rate of progression to active disease is dramatically increased among persons who are coinfected with HIV. In addition, patients are more likely to complete a weakness, lack of appetite, a positive skin test, abnormal shorter course of therapy, which reduces the occurrence of chest radiograph, and/or positive sputum smear or cul- drug-resistant TB. Among people with both for TB control programs, some authorities urge increased test- LTBI and HIV infection, LTBI progresses to active dis- ing and treatment in primary care settings and settings where ease more rapidly (approximately 10% each year), is high-risk groups are found (eg, homeless shelters). DRUG-RESISTANT TUBERCULOSIS Nurses have important roles to play in TB control.

Heparin In addition feldene 20 mg without prescription, warfarin is eliminated only by hepatic me- should be discontinued if the platelet count falls below tabolism and may accumulate with liver impairment discount 20mg feldene otc. Clients and family members should be educated disease because of high risks of excessive bleeding. When anagrelide is given, blood tests when indicated, and taking safety precautions. In clients should be closely monitored for signs of hepa- addition, assess the environment for risk factors for injury. It should be used the drugs, assisting clients to obtain laboratory tests, and teach- cautiously. CHAPTER 57 DRUGS THAT AFFECT BLOOD COAGULATION 847 NURSING Drugs That Affect Blood Coagulation ACTIONS NURSING ACTIONS RATIONALE/EXPLANATION 1. With standard heparin: (1) When handwriting a heparin dose, write out units This is a safety precaution to avoid erroneous dosage. Underdosage may cause thromboembolism, and overdosage may cause bleeding. In addition, heparin is available in several con- centrations (1000, 2500, 5000, 10,000, 15,000, 20,000, and 40,000 units/mL). To minimize trauma and risk of bleeding (b) Leave a small air bubble in the syringe to follow Locks drug into subcutaneous space and minimizes trauma dose (c) Grasp a skinfold and inject the heparin into it, at a To give the drug in a deep subcutaneous or fat layer, with minimal 90-degree angle, without aspirating. Whatever effective method is to fill the volume-control set method is used, it is desirable to standardize concentration of (eg, Volutrol) with 100 mL of 5% dextrose in water heparin solutions within an institution. Standardization is safer, and add 5000 units of heparin to yield a concentration because it reduces risks of errors in dosage. For example, administration of 1000 units/h requires a flow rate of 20 mL/h. Another method is to add 25,000 units of heparin to 500 mL of IV solution. With low–molecular-weight heparins: (1) Give by deep SC injection, into an abdominal skin fold, To decrease bruising with the patient lying down, using the same technique as standard heparin. After the initial dose of warfarin, check the international The INR is measured daily until a maintenance dose is established, normalized ratio (INR) before giving a subsequent dose. Give ticlopidine with food or after meals; give cilostazol 30 min before or 2 h after morning and evening meals; give clopidogrel with or without food. With prophylactic heparins and warfarin, observe for the absence of signs and symptoms of thrombotic disorders. With therapeutic heparins and warfarin, observe for de- crease or improvement in signs and symptoms (eg, less edema and pain with deep vein thrombosis, less chest pain and respi- ratory difficulty with pulmonary embolism). With prophylactic or therapeutic warfarin, observe for an Frequency of INR determinations varies, but the test should be INR between 2. With therapeutic heparin, observe for an activated partial thromboplastin time of 1. Platelet counts should be done every 2 days during the first week of management and weekly until a maintenance dose is reached. With aspirin, clopidogrel, and other antiplatelet drugs, ob- serve for the absence of thrombotic disorders (eg, myocardial infarction, stroke) g. With cilostazol, observe for ability to walk farther without Improvement may occur within 2 to 4 wk or take as long as 12 wk. It may occur anywhere in the body, spontaneously or in response to minor trauma. With eptifibatide and tirofiban, most major bleeding occurs at the arterial access site for cardiac catheterization. Gastrointestinal (GI) bleeding is fairly common; risks are increased with intubation. Blood in stools may be bright red, tarry (blood that has been digested by GI secretions), or occult (hidden to the naked eye but present with a guaiac test). Genitourinary bleeding also is fairly common; risks are increased with catheterization or instrumentation. Urine may be red (indi- cating fresh bleeding) or brownish or smoky gray (indicating old blood).

Third-generation drugs should not be used for surgi- sistance before prescribing penicillins for streptococcal in- cal prophylaxis because they are less active against staphy- fections cheap feldene 20 mg without a prescription. When used discount feldene 20 mg fast delivery, penicillins should be given for the full lococci than cefazolin, the gram-negative organisms they are prescribed course to prevent complications such as rheumatic most useful against are rarely encountered in elective surgery, fever, endocarditis, and glomerulonephritis. With Probenecid When used perioperatively, a cephalosporin should be Probenecid (Benemid) can be given concurrently with peni- given within 2 hours before the first skin incision is made so cillins to increase serum drug levels. Probenecid acts by the drug has time to reach therapeutic serum and tissue con- blocking renal excretion of the penicillins. A single dose is usually sufficient, although be useful when high serum levels are needed with oral peni- clients undergoing a surgical procedure exceeding 3 hours cillins or when a single large dose is given IM for prevention should receive additional doses at 3-hour intervals. With an Aminoglycoside A penicillin is often given concomitantly with an amino- Use in Children glycoside for serious infections, such as those caused by P. The drugs should not be admixed in a sy- Penicillins and cephalosporins are widely used to treat infec- ringe or an IV solution because the penicillin inactivates the tions in children and are generally safe. Hyperkalemia may occur with large IV doses of penicillin G potassium (1. Use in Older Adults Cephalosporins Beta-lactam antibacterials are relatively safe, although de- creased renal function, other disease processes, and concurrent • Reduce dosage because usual doses may produce high drug therapies increase the risks of adverse effects in older and prolonged serum drug levels. With penicillins, hyperkalemia may occur with large < 20 to 30 mL/minute), dosage of all cephalosporins ex- IV doses of penicillin G potassium and hypernatremia may cept cefoperazone should be reduced. Hypernatremia is less likely with excreted primarily through the bile and therefore does other antipseudomonal penicillins such as mezlocillin and not accumulate with renal failure. Cephalosporins may aggravate renal impairment, • Cefotaxime is converted to active metabolites that are especially when other nephrotoxic drugs are used concurrently. These metabolites Dosage of most cephalosporins must be reduced in the pres- accumulate and may cause toxicity in clients with renal ence of renal impairment, depending on creatinine clearance. With aztreonam, imipenem/cilastatin, and meropenem, dose and frequency of administration are determined by renal Aztreonam status as indicated by creatinine clearance. Dosage of many beta-lactams must be decreased according to creatinine clearance (CrCl) levels. References should be consulted to de- termine dosages recommended for various levels of creati- • Dosage of imipenem should be reduced in most clients nine clearance. Additional considerations are included in the with renal impairment and the drug is contraindicated in following sections. For clients already on hemodialysis, the drug Penicillins may cause seizures and should be used very cautiously, • Dosage of penicillin G, carbenicillin, mezlocillin, if at all. For clients tial amounts and produces subtherapeutic serum drug on hemodialysis, administer the daily dose after dialysis. Amoxicillin/clavulanate (Augmentin) should be often associated with high doses of parenteral peni- used with caution in clients with hepatic impairment. Hepatotoxicity is attributed to the clavulanate • Electrolyte imbalances, mainly hypernatremia and hyper- component and has also occurred with ticarcillin/clavulanate kalemia, may occur. CHAPTER 34 BETA-LACTAM ANTIBACTERIALS: PENICILLINS, CEPHALOSPORINS, AND OTHERS 523 Cefoperazone is excreted mainly in bile and its serum (eg, Unasyn) are most likely to be used. With cephalosporins, half-life increases in clients with hepatic impairment or bil- third-generation drugs are commonly used and usually given iary obstruction. Adverse effects include cholestasis, jaun- by intermittent IV infusions every 8 or 12 hours. Serum drug levels should be monitored if possible advantages of continuous infusion are being studied. Blood levels of cephalosporins and penicillins need to be Aztreonam, imipenem, meropenem, and ertapenem may maintained above the minimum inhibitory concentration for cause abnormalities in liver function test results (ie, elevated microorganisms causing the infection being treated. Thus, con- aspartate and alanine aminotransferase and alkaline phos- tinuous infusions may be of benefit with serious infections, es- phatase), but hepatitis and jaundice rarely occur. Use in Critical Illness Home Care Beta-lactam antimicrobials are commonly used in critical care units to treat pneumonia, bloodstream, wound, and other Many beta-lactam antibiotics are given in the home setting. With oral agents, the role of the home care nurse is mainly to Because clients often have multiorganism or nosocomial in- teach accurate administration and observation for therapeutic fections, the beta-lactam drugs are often given concomitantly and adverse effects. With liquid suspensions for children, shak- with other antimicrobial drugs. Because clients are seriously ing to resuspend medication and measuring with a measuring ill, renal, hepatic, and other organ functions should be moni- spoon or calibrated device are required for safe dosing. General guidelines for IV therapy are discussed in acillin) and penicillin–beta-lactamase inhibitor combinations Chapter 33; specific guidelines depend on the drug being given.