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Lidocaine may be used to treat ventricular dysrhythmias Hepatic impairment increases plasma half-life of several precipitated by cardiac surgery or digitalis toxicity 100mg kamagra gold with visa. Class I antidysrhythmic drugs trusted 100mg kamagra gold, and dosage usually should be re- or III drugs are usually started in a hospital setting order kamagra gold 100mg with amex, at lower duced 100mg kamagra gold otc. These include disopyramide discount kamagra gold 100 mg with visa, flecainide, lidocaine, dosage ranges, because of prodysrhythmic effects. Prodys- mexiletine, moricizine, procainamide, propafenone, quini- rhythmia is more common in children with structural heart dine, and tocainide. In general, serum levels Dosages of adenosine and ibutilide are unlikely to need should be monitored with class IA and IC drugs and IV lido- reductions in clients with hepatic impairment. Class III drugs are used in pediatrics mainly to treat life-threatening refractory tachydysrhythmias. Use in Critical Illness As in adults, most antidysrhythmic drugs and their metabolites are excreted through the kidneys and may accu- Critically ill clients often have multiple cardiovascular and mulate in children with impaired renal function. They may also have refractory dysrhythmias that re- quire strong, potentially toxic antidysrhythmic drugs. Thus, Cardiac dysrhythmias are common in older adults, but in gen- antidysrhythmic drugs are often given IV in critical care eral only those causing symptoms of circulatory impairment settings for rapid reversal of a fast rhythm. Compared IV or oral drugs may be given to prevent recurrence of the with younger adults, older adults are more likely to experi- dysrhythmia. Cautious use is required, and in preventing, recognizing, and treating conditions that predis- dosage usually needs to be reduced to compensate for heart pose to the development of serious dysrhythmias (eg, elec- disease or impaired drug elimination processes. If dysrhythmias cannot be prevented, early recognition and treatment are needed. Overall, any antidysrhythmic drug therapy in critically ill Use in Renal Impairment clients is preferably performed or at least initiated in critical care units or other facilities with appropriate equipment and Antidysrhythmic drug therapy in clients with renal impair- personnel. For example, nurses who work in emergency de- ment should be very cautious, with close monitoring of drug partments or critical care units must be certified in cardio- effects (eg, plasma drug levels, ECG changes, symptoms that pulmonary resuscitation and advanced cardiac life support may indicate drug toxicity). With ACLS, the American Heart Association and dysrhythmic drugs and their metabolites. As a result, decreased others have developed algorithms to guide drug therapy of renal perfusion or other renal impairment can reduce drug dysrhythmias. As a general rule, dosage of bretylium, digoxin, disopyramide, flecainide, lidocaine, moricizine, pro- Home Care cainamide, propafenone, quinidine, sotalol, and tocainide should be reduced in clients with significant impairment of Clients receiving chronic antidysrhythmic drug therapy are renal function. Dosage of adenosine, amiodarone, ibutilide, likely to have significant cardiovascular disease. In addition, clients and caregivers should be taught to report symptoms (eg, dizziness or fainting, chest As with renal impairment, antidysrhythmic drug therapy in pain) and avoid over-the-counter drugs unless discussed with clients with hepatic impairment should be very cautious, with a health care provider. CHAPTER 52 ANTIDYSRHYTHMIC DRUGS 771 NURSING Antidysrhythmic Drugs ACTIONS NURSING ACTIONS RATIONALE/EXPLANATION 1. Withhold Bradycardia may indicate impending heart block or cardio- the dose and report to the physician if marked changes are noted vascular collapse. Check blood pressure at least once daily in hospitalized To detect hypotension, which is most likely to occur when anti- clients. During intravenous (IV) administration of antidysrhythmic For early detection of hypotension and impending cardiac col- drugs, maintain continuous cardiac monitoring and check blood lapse. With oral amiodarone, give once daily or in two divided doses if stomach upset occurs. The drug should be given in a critical care setting, by experienced personnel, preferably through a central venous catheter. Give lidocaine parenterally only, as a bolus injection or a Lidocaine solutions that contain epinephrine are used for local continuous drip. They should never be given intravenously in car- rhythmias, and do not use solutions containing epinephrine. Rapid injection (within approximately 30 sec) pro- duces transient blood levels several times greater than therapeutic range limits. Therefore, there is increased risk of toxicity without a concomitant increase in therapeutic effectiveness. Conversion to normal sinus rhythm After a single oral dose, peak plasma levels are reached in ap- b. Improvement in rate, rhythm, and quality of apical and proximately 1–4 h with quinidine, procainamide, and propranolol radial pulses and the electrocardiogram (ECG) and in 6–12 h with phenytoin.

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Critical Thinking Scenario George Masury generic kamagra gold 100 mg with mastercard, accompanied by his wife Jennie order 100 mg kamagra gold with amex, visits his primary care provider complaining of upper respira- tory symptoms kamagra gold 100 mg fast delivery. 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 100mg kamagra gold. George is hard of hearing purchase kamagra gold 100mg overnight delivery, 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. OVERVIEW ual drugs, with routes of administration and dosage ranges, are listed in the Drugs at a Glance tables. The aminoglycosides have been widely used to treat serious gram-negative infections for many years. The quinolones are AMINOGLYCOSIDES also older drugs originally used only for treatment of urinary tract infections (see Chap. The fluoroquinolones are Aminoglycosides are bactericidal agents with similar pharma- synthesized by adding a fluorine molecule to the quinolone cologic, antimicrobial, and toxicologic characteristics. This addition increases drug activity against gram- used to treat infections caused by gram-negative microorgan- negative microorganisms, broadens the antimicrobial spec- isms such as Pseudomonas and Proteus species, Escherichia trum to include several other microorganisms, and allows use coli, and Klebsiella, Enterobacter, and Serratia species. General character- These drugs are poorly absorbed from the gastrointestinal istics, mechanisms of action, indications for and contraindica- (GI) tract. Thus, when given orally, they exert local effects in tions to use, nursing process implications, and principles of the GI tract. They are well absorbed from intramuscular injec- therapy for these drugs are described in this chapter. Individ- tion sites and reach peak effects in 30 to 90 minutes if circula- 527 528 SECTION 6 DRUGS USED TO TREAT INFECTIONS Drugs at a Glance: Aminoglycosides Routes and Dosage Ranges Generic/Trade Name Characteristics Adults Children Amikacin (Amikin) Retains a broader spectrum of antibac- IM, IV 15 mg/kg q24h, 7. Hepatic coma PO 4–12 g daily in Used topically, often in combination divided doses with other drugs, to treat infections of the eye, ear, and skin (burns, wounds, ulcers, dermatoses) When used for wound or bladder irriga- tions, systemic absorption may occur if the area is large or if drug concen- tration exceeds 0. Netilmicin (Netromycin) Similar to gentamicin in antimicrobial IM, IV 4–6. However, systemic absorption may occur in the presence of inflamma- tory or ulcerative bowel disease. CHAPTER 35 AMINOGLYCOSIDES AND FLUOROQUINOLONES 529 Drugs at a Glance: Aminoglycosides (continued) Routes and Dosage Ranges Generic/Trade Name Characteristics Adults Children Streptomycin May be used in a four- to six-drug IM 15 mg/kg/d (maximum 1 g) or IM 20–40 mg/kg/d in two divided regimen for treatment of multidrug- 25–30 mg/kg two or three doses, q12h (maximum dose, resistant tuberculosis times weekly (maximum 1. They accumulate in high concentrations in the kidney effects occur within 30 to 60 minutes. They are poorly distributed to the central nervous 4 hours with normal renal function. After parenteral administration, aminoglycosides are widely Injected drugs are not metabolized; they are excreted un- distributed in extracellular fluid and reach therapeutic levels changed in the urine, primarily by glomerular filtration. Oral in blood, urine, bone, inflamed joints, and pleural and ascitic drugs are excreted in feces. Drugs at a Glance: Fluoroquinolones Generic/Trade Name Characteristics Routes and Dosage Ranges Cinoxacin (Cinobac) 1. Used only for UTI PO 1 g daily in two to four divided doses for 7–14 d 2. Effective against most gram-negative bacteria that commonly cause UTI (Escherichia coli, Klebsiella, Enterobacter, Proteus) Ciprofloxacin (Cipro) 1. Effective in respiratory, urinary tract, gastro- PO 250–750 mg q12h intestinal tract, and skin and soft tissue infec- IV 200–400 mg q8–12h tions as well as sexually transmitted diseases caused by chlamydiae and gonor- rhea organisms 2. Used as one of four to six drugs in treatment of multidrug-resistant tuberculosis Enoxacin (Penetrex) Used only for UTI and uncomplicated gonorrhea UTI, PO 200–400 mg q12h for 7–14 d Gonorrhea, PO 400 mg as a single dose Gatifloxacin (Tequin) Indicated for pneumonia, bronchitis, sinusitis, skin PO, IV infusion 400 mg once daily and soft tissue infections, urinary infections, Give IV dose over 60 minutes; avoid rapid pyelonephritis, and gonorrhea administration Levofloxacin (Levaquin) A broad-spectrum agent effective for treatment of PO, IV 250–750 mg once daily. Infuse IV dose slowly bronchitis, cystitis, pneumonia, sinusitis, skin and over 60 min skin structure infections, and pyelonephritis Lomefloxacin (Maxaquin) Approved for bronchitis, urinary infections, and PO 400 mg once daily transurethral surgical procedures Preoperatively, PO 400 mg as a single dose, 1–6 h before surgery Moxifloxacin (Avelox) Indicated for pneumonia, sinusitis, bronchitis, skin PO, IV 400 mg once daily. Infuse IV dose slowly over and soft tissue infections 60 min Norfloxacin (Noroxin) Used only for UTI and uncomplicated gonorrhea PO 400 mg twice daily Ofloxacin (Floxin) See ciprofloxacin, above PO, IV 200–400 mg q12h for 3–10 d Gonorrhea, PO 400 mg as a single dose Sparfloxacin (Zagam) Indicated for community-acquired pneumonia caused PO 400 mg as loading dose, then 200 mg once daily by Chlamydia pneumoniae, Streptococcus pneu- for 10 d moniae, or Hemophilus influenzae and acute bac- Renal impairment (creatinine clearance terial exacerbations of chronic bronchitis caused <50 mL/min), PO 400 mg as loading dose, by above organisms, Klebsiella pneumoniae, or then 200 mg q48h for a total of 9 d of therapy Staphylococcus aureus UTI, urinary tract infection. These are discussed in Chapters 65 and 66, Aminoglycosides penetrate the cell walls of susceptible bac- respectively. As a result, the bacteria cannot synthesize the proteins necessary for their function Contraindications to Use and replication.

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Children are very sensitive absorption 100mg kamagra gold overnight delivery, are available OTC best 100 mg kamagra gold, and are widely used generic kamagra gold 100mg amex. However quality kamagra gold 100 mg, to drug effects buy cheap kamagra gold 100 mg line, including cardiac and CNS stimulation, and overuse leads to decreased effectiveness (tolerance), irritation recommended doses usually should not be exceeded. These effects can be minimized by using small doses of bronchospasm due to asthma or allergic reactions. They also may cause more adverse ef- but if given, the first dose should be approximately half that fects. There is little reason to use the in- atic adverse effects are cardiac and CNS stimulation. Com- halation route because in children, as in adults, selective monly used oral agents are pseudoephedrine and ephedrine. Ephedrine Phenylephrine is most often used to relieve congestion of may cause hypertension even in normotensive people, with the upper respiratory tract and may be given topically, as nose higher risks in hypertensive people. Toxicity of Adrenergics: Use in Older Adults Recognition and Management Adrenergic agents are used to treat asthma, hypotension, Unlike catecholamines, which are quickly cleared from the shock, cardiac arrest, and anaphylaxis in older adults. These drugs are an ingredient in OTC have chronic cardiovascular conditions (eg, angina, dys- products such as nasal decongestants, cold preparations, and rhythmias, congestive heart failure, coronary artery dis- appetite suppressants. Ephedrine and ephedra-containing ease, hypertension, peripheral vascular disease) that are herbal preparations (eg, ma huang and herbal ecstasy) are aggravated by adrenergic drugs, careful monitoring by the often abused as an alternative to amphetamines or to aid in nurse is required. Adrenergic drugs are often prescribed as bronchodilators Phenylephrine and ephedrine have a narrow therapeutic and decongestants in older adults. Therapeutic doses increase index with toxic doses only two to three times greater than the the workload of the heart and may cause symptoms of impaired therapeutic dose. Pseudoephedrine toxicity occurs with doses cardiovascular function; overdoses may cause severe cardio- four to five times greater than the normal therapeutic dose. The primary clinical manifestation of noncatecholamine The drugs also cause CNS stimulation. With therapeutic doses, adrenergic drug toxicity is severe hypertension, which may anxiety, restlessness, nervousness, and insomnia often occur in lead to headache, confusion, seizures, and intracranial hem- older adults. Reflex bradycardia and atrioventricular block also CNS depression, and death. Adrenergics are ingredients in OTC asthma remedies, Treatment involves maintaining an airway and assisting cold remedies, nasal decongestants, and appetite suppres- with ventilation if needed. Cautious use of these preparations is required for older istered early in treatment. They should not be taken concurrently with prescrip- with vasodilators such as phentolamine or nitroprusside. Beta tion adrenergic drugs because of the high risk of overdose and blockers are not used alone to treat hypertension without first toxicity. For example, phenylephrine is used as a vaso- Dialysis and hemoperfusion are not effective in clearing constrictor and mydriatic. Urinary acidification may enhance doses to the normal eye or usual doses to the traumatized, in- elimination of ephedrine and pseudoephedrine; however, this flamed, or diseased eye may result in enough systemic absorp- technique is not routinely used because of the risk of renal tion of the drug to cause increased blood pressure and other damage from myoglobin deposition in the kidney. Potential for the vasopressor action of adrenergic drugs to result in diminished renal perfusion and decreased Adrenergic drugs exert effects on the renal system that may urine output cause problems for clients with renal impairment. Potential for adrenergic drugs with beta1 activity to in- ple, adrenergic drugs with alpha1 activity cause constriction of duce irritable cardiac dysrhythmias renal arteries, thereby diminishing renal blood flow and urine 3. These drugs also constrict urinary sphincters, crease myocardial oxygen requirement causing urinary retention and painful urination, especially in 4. Potential for adrenergic drugs with vasopressor action men with prostatic hyperplasia. Hyperglycemia, hypokalemia, and hypophosphatemia these compounds may accumulate and cause increased ad- due to beta1-adrenergic effects verse effects. Tissue necrosis after extravasation Occurrence of any of these adverse effects may compli- Use in Hepatic Impairment cate the already complex care of the critically ill client. Care- ful assessment and prompt nursing intervention are essential The liver is rich in the enzymes MAO and COMT, which are in caring for the critically ill client experiencing these health responsible for metabolism of circulating epinephrine and problems. However, other tissues in the body also pos- sess these enzymes and are capable of metabolizing natural Home Care and synthetic catecholamines.

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