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N. Frillock. Florida State University.

Drugs that increase effects of cephalosporins: (1) Loop diuretics (furosemide purchase super cialis 80 mg visa erectile dysfunction caused by medications, ethacrynic acid) Increased renal toxicity (2) Gentamicin and other aminoglycoside antibiotics Additive renal toxicity especially in older clients purchase super cialis 80mg amex erectile dysfunction 2, those with renal impairment, those receiving high dosages, and those receiving probenecid (3) Probenecid Increases blood levels by decreasing renal excretion of the cephalosporins. This may be a desirable interaction to increase blood levels and therapeutic effectiveness or allow smaller doses. Drugs that decrease effects of cephalosporins: (1) Tetracyclines Tetracyclines are bacteriostatic and slow the rate of bacterial re- production. Cephalosporins are bactericidal and are most effective against rapidly multiplying bacteria. Thus, tetracyclines should not be given concurrently with cephalosporins. Give Mylanta) and histamine H2 antagonists (eg, cimetidine, the drugs at least 2 hours apart. Drugs that increase effects of carbapenems (1) Probenecid Probenecid minimally increases serum drug levels of carbapen- ems, but it is not recommended for concomitant use with any of the drugs. Drugs that alter effects of aztreonam Few documented, clinically significant interactions reported, but potential interactions are those that occur with other beta-lactam antibiotics. What are the main differences between penicillin G or V Answer: You have just administered the wrong medication to this and antistaphylococcal and antipseudomonal penicillins? What is the reason for combining clavulanate, sulbactam, sound and look alike), these are two different drugs. Cefuroxime is a second-generation cephalosporin and ceftizoxime is a third- or tazobactam with a penicillin? When giving injections of penicillin in an outpatient set- pharmacokinetics are different. When the dispensed medication is ting, it is recommended to keep clients in the area and not identical to the prescribed medication, check with the pharma- observe them for at least 30 minutes. When probenecid is given concurrently with a penicillin, what is its purpose? For clients with renal impairment, which drugs in this chapter require reduced dosages? Which drugs from this chapter may cause pseudomem- she did not state an allergy to cephalosporin antibiotics, 5% to branous (antibiotic-associated) colitis? What are the signs, symptoms, and treatment of pseudo- to cephalosporins because structurally all beta-lactams are similar. Stop the infusing cefotetan but keep the IV line open because you may need to give emergency drugs IV if her condition worsens. Take her vital signs, administer oxygen, and have someone stay SELECTED REFERENCES with her while you contact the physician. What adverse effects are associated with beta-lactam macotherapy, 33, 560–564. Antimicrobial agents: Penicillins, cephalosporins, and other beta-lactam antibiotics. Discuss the importance of serum drug levels in relation to effectiveness, safety, spectrum during aminoglycoside therapy. Describe measures to decrease nephrotoxicity administration, and observation of client and ototoxicity with aminoglycosides. Discuss factors influencing selection and effects, and nursing process implications of dosage of aminoglycosides. Critical Thinking Scenario George Masury, accompanied by his wife Jennie, visits his primary care provider complaining of upper respira- tory symptoms. George and Jennie have been married for 52 years and Jennie has always cared for George when he was sick and helped make decisions for him. George is hard of hearing, has some forgetfulness, and does not talk very much. Reflect on: How you will include George and Jennie in the teaching session. Teaching strategies to individualize for hearing deficits and memory deficits.

Digoxin trusted 80 mg super cialis erectile dysfunction drugs prostate cancer, a (extracellular fluid volume) and increase excretion of sodium and beta-adrenergic blocking agent order super cialis 80mg online statistics of erectile dysfunction in india, or spironolactone may be added to water, thereby decreasing preload. With During ACE inhibitor therapy, clients usually need to see a moderate to severe HF (pulmonary edema), an IV loop diuretic is health care provider frequently for dosage titration and monitor- indicated. IV furosemide also has a vasodilatory effect that helps ing of serum creatinine and potassium levels for increases. Although diuretic therapy re- vated creatinine levels may indicate impaired renal function, in lieves symptoms, it does not improve left ventricular function and which case dosage needs to be reduced; elevated potassium lev- decrease mortality rates. Some clients may also need drugs to in- els indicate hyperkalemia, an adverse effect of the drugs. Angiotensin Receptor Blockers (ARBs) In chronic HF, an oral diuretic is a common component of treat- Losartan and other angiotensin receptor blockers (see Chap. Depending on the severity of symptoms or degree are similar to the ACE inhibitors in their effects on cardiac func- of HF, the regimen may also include an ACE inhibitor or ARB, a tion, although they are not FDA approved for treatment of HF. Valsartan recently received FDA approval for management Potassium-sparing diuretics (eg, amiloride, triamterene) are often of clients with HF who are unable to tolerate an ACE inhibitor given concurrently with potassium-losing diuretics (eg, thiazides (eg, development of a cough, a common adverse effect of ACE or loop diuretics) to help maintain normal serum potassium lev- inhibitors). Concomitant use of ACE inhibitors and nonsteroidal anti- Beta-Adrenergic Blocking Agents inflammatory drugs and the presence of diabetes mellitus increase Although beta blockers (see Chaps. The change evolved from a Both hypokalemia and hyperkalemia are cardiotoxic or impair better understanding of chronic HF (ie, that it involves more than heart function. Venous dilators pathophysiology of HF, results in increased interstitial fibrosis that (eg, nitrates) decrease preload; arterial dilators (eg, hydralazine) may decrease systolic function and increase the risk of ventricular decrease afterload. Spironolactone is an aldosterone antagonist that re- combined to decrease both preload and afterload. The combina- duces the aldosterone-induced retention of sodium and water and tion has similar effects to those of an ACE inhibitor or an ARB, impaired vascular function. Although ACE inhibitors also decrease but may not be as well tolerated by clients. Spironolactone is given in Chapter 53; hydralazine and other vasodilators are discussed in a daily dose of 12. In clients with Oral vasodilators usually are used in clients with chronic HF adequate renal function (ie, serum creatinine 2. Overall, studies indicate that the at low doses, titrated to desired hemodynamic effects, and dis- addition of spironolactone improves cardiac function and reduces continued slowly to avoid rebound vasoconstriction. Vasodilators Vasodilators are essential components of treatment regimens for HF, and the beneficial effects of ACE inhibitors and angiotensin Drugs at a Glance: Drugs for Heart Failure Routes and Dosage Ranges Generic/Trade Name Adults Children Inotropic Agents CARDIAC GLYCOSIDE Digoxin (Lanoxin) Digitalizing dose, PO 0. Maintenance dose, PO, IV, approximately 20–35% of the digitalizing dose Newborns: Digitalizing dose, PO 0. Maintenance dose, PO, IV, approximately 20–35% of the digitalizing dose. IV infusion (maintenance dose), 10 mg/kg/d 3–5 mcg/kg/min Milrinone (Primacor) IV bolus infusion (loading dose), 50 mcg/kg over 10 min. HUMAN NATRIURETIC PEPTIDE B-TYPE Nesiritide (Natrecor) IV bolus infusion (loading dose), 2 mcg/kg followed by Safety not established continuous infusion of 0. CHAPTER 51 DRUG THERAPY OF HEART FAILURE 747 Two new classifications of drugs, human natriuretic peptides not prolong survival. In HF, it is given concomitantly with a and endothelin receptor antagonists, are also presented. In atrial dysrhythmias, digoxin slows the rate of ventricular contraction (negative chronotropic effect). Negative chro- Digoxin notropic effects are probably caused by several factors. First, digoxin has a direct depressant effect on cardiac conduction Digoxin (Lanoxin) is the only commonly used digitalis gly- tissues, especially the atrioventricular node. In the following discussion, the terms digitalization creases the number of electrical impulses allowed to reach the and digitalis toxicity refer to digoxin. Third, increased efficiency of myocardial contraction and vagal stimulation decrease com- General Characteristics pensatory tachycardia that results from the sympathetic ner- When digoxin is given orally, absorption varies among avail- vous system response to inadequate circulation. Lanoxicaps, which are liquid-filled cap- sules, and the elixir used for children are better absorbed than Indications for Use tablets. With tablets, the most frequently used formulation, differences in bioavailability are important because a person The clinical uses of digoxin are management of HF, atrial fib- who is stabilized on one formulation may be underdosed or rillation, and atrial flutter.

Here the the device or procedure is shown by the trial to cross-over rate was 2 super cialis 80 mg cheap erectile dysfunction drugs free sample. The Coronary Artery Bypass Graft not blinded super cialis 80mg impotence 101, but cross-over from single- to dual- (CABG) Patch trial42 compared transthoracic chamber pacing would have required another implantation of cardioverter defibrillators against procedure, accounting for the low cross-over rate. As with many drug trials, trials of devices At the end of an average 32 months follow- can look at either single devices (or upgrades up, there was no significant mortality difference of these devices as they become available) or between the groups. The AVID26 trial compared results of the trial and subsequent therapy was the use of advanced-generation units with tiered individualised. All patients were urged to have therapy capable of antitachycardia pacing, car- electrophysiologic testing to see if they were at dioversion and defibrillation, as well as brady- high risk of serious arrhythmia, and thus possibly cardia pacing, made by more than one company, in need of the defibrillator in the future. About against any of several drugs (though primarily 40% of the patients in the intervention group amiodarone), thus testing whether the strategy of elected to have the device turned off or removed using implantable defibrillators was preferable to [J. This kind of trial is more likely to be done by public organ- isations, such as the National Institutes of Health, TRIALS OF BEHAVIOUR CHANGE than by industry. They include trials aimed at CARDIOVASCULAR 185 smoking prevention or cessation; diet change and pressure can affect the trials in major ways. The interventions are ones vention are the Dietary Approaches to Stop that many can either implement on their own Hypertension (DASH) trial43 and a subsequent or stop because they are difficult to maintain. Implantation of devices or under 160 mm Hg and diastolic pressure 80 to surgical procedures require major efforts by the 95 mm Hg. Participants were randomly allocated investigator or surgeon, but usually only on a one- to one of three groups: a diet rich in fruits and time basis. At the consequence of the first two factors, the study end of eight weeks, both of the intervention diets duration is often much shorter than with other reduced blood pressure, with a greater reduction types of trials. Getting people to adhere to an from the diet containing low-fat dairy products. Participants were teers willing to be randomised to exercise or no assigned to either the DASH combination diet exercise will have more of an interest in exercise or the control diet and to any of three levels of than the general public. The moderate and low sodium cated to the no-exercise programme group will intake diets reduced blood pressure in both the have more of a tendency to cross-over. The DASH because of the generally shorter duration of the diet led to lower blood pressure than the control trials, surrogate outcomes are more often used diet at each sodium level. Rather than In the DASH studies, the food was spe- assessing clinical outcomes such as heart dis- cially prepared and provided to the partici- ease or stroke, the behaviour trials will often use pants. Whether or not the DASH-type diet can weight change, biochemical measures, or attitude be maintained, over time, in people obtain- or knowledge assessed by questionnaires or inter- ing their food in the usual way, was stud- views. Fifth, standardisation of the intervention ied in PREMIER, a trial of 810 participants and measurement of the degree of compliance are whose blood pressure is greater than opti- more complicated. This is particularly so if maintenance tion using behavioural approaches; and a com- of caloric intake is one of the objectives of the bined comprehensive lifestyle intervention plus trial, as weight would not be able to serve as a the DASH diet. Unlike 186 TEXTBOOK OF CLINICAL TRIALS DASH, the participants were not provided spe- enough magnitude to alter mortality. The primary outcome was happened in some of the early trials of cholesterol systolic blood pressure six months after randomi- lowering that failed to show improvement in sation. Fourth, however, hypertension were also seen in the combined even though mortality and recurrent infarction group, with the behavioural intervention group a were unchanged, the apparent improvements in close second. Thus, a combination of behavioural depression and social support are not trivial approaches and dietary changes can result in findings. Unlike surrogate outcome variables that meaningful blood pressure reduction. Even so, have little clinical meaning, these outcomes are the DASH diet, unlike in the previous feed- clinically important in their own right. The adoption of the diet in PREMIER with one group of communities compared against was not as intensive as in the feeding studies. The changes, in order to be effective, Whether the changes observed in PREMIER per- need to be community-wide. One group enrolled 2481 patients at 73 hospitals who had of cities received intervention through the media, had a myocardial infarction within the previous community organisations, and professional and 28 days.

It is reportedly effective in relieving vasomo- Assessment tor instability purchase 80mg super cialis with visa weight lifting causes erectile dysfunction. Most information is derived from small German Before drug therapy is started buy generic super cialis 80mg online erectile dysfunction statistics by age, clients need a thorough his- studies using Remifemin, the brand name of a standardized tory and physical examination, including measurements of extract that is marketed as an alternative to estrogen ther- blood pressure, serum cholesterol, and triglycerides. The product apparently does parameters must be monitored periodically as long as the not affect the endometrium or estrogen-dependent cancers; drugs are taken. Animal • Assess for conditions in which estrogens and progestins are studies indicate binding to estrogen receptors and suppres- used (eg, menstrual disorders, menopausal symptoms). A study of posthysterectomy patients indicated • Assess for conditions that increase risks of adverse effects no advantage of the herb over conventional ERT. Other or are contraindications for hormonal therapy (eg, throm- trade names include Estroven, Femtrol, and GNC Menopause boembolic disorders, pregnancy). Blood pressure should premenopausal women, especially with oral contracep- be monitored closely in hypertensive clients, because the tives, but are unlikely in women who are postmenopausal herb may increase the hypotensive effects of antihypertensive who are receiving physiologic replacement doses. Black cohosh is contraindicated in pregnancy and not • Check laboratory reports of cholesterol and triglyceride recommended for use longer than 6 months for menopausal levels when available. A high- Overall, this herb may be useful in clients who refuse es- fat diet increases the risks of gallbladder disease and per- haps other problems; cigarette smoking increases risks of trogen or have conditions in which estrogen is contraindicated. These are most likely to occur in women older than 35 years of age who take oral contraceptives, Choice of preparation depends on the reason for use, desired women who are postmenopausal who take combined route of administration, and duration of action. Conjugated estrogen/progestin hormone replacement therapy, and estrogen (eg, Premarin) is a commonly used oral estrogen women or men who take large doses for cancer. Nursing Diagnoses The choice of combination contraceptive product may be • Disturbed Body Image in women, related to effects of determined by the progestin component. Some progestins are hormone deficiency states more likely to cause weight gain, acne, and changes in blood • Disturbed Body Image in men, related to feminizing effects lipids that increase risks of myocardial infarction or stroke. 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. In addition, 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.