Cholinergic-Blocking Drugs Mosby items and derived items © 2011, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.

Definition  Drugs that block or inhibit the actions of acetylcholine (ACh) in the parasympathetic nervous system (PSNS)  Also known as anticholinergics

Chemical Class NaturalSynthetic/Semisynthetic atropinebenztropineclidinium belladonnadicyclomineglycopyrrolate hyoscyaminehomatropineipratropium scopolamineisopropamide methscopolamine oxybutynin propantheline tolterodine trihexyphenidyl solifenacin

GU: Drug Effects/Indication  Expected Effect  Relaxed detrusor muscle  Increased constriction of internal sphincter  Result: urinary retention  Indication  Reflex neurogenic bladder  Incontinence

Side effects

Interactions  Antihistamines, phenothiazines, tricyclic antidepressants, MAOIs  When given with cholinergic blocking drugs, cause additive cholinergic effects, resulting in increased effects

Nursing Implications  Assess:  Allergies, presence of BPH, glaucoma, tachycardia, MI, HF, hiatal hernia, and GI or GU obstruction  Baseline vital signs and systems overview  Improved urinary patterns with treatment  less hypermotility, increased time between voiding  Adverse effects

Nursing Implications  Treat:  Medications should be taken exactly as prescribed to have the maximum therapeutic effect  Overdosing can cause life-threatening problems  Antidote for atropine overdose is physostigmine

Nursing Implications  Teach :  Patients may experience sensitivity to light and may want to wear dark glasses or sunglasses  Blurred vision may cause problems with driving or operating machinery  Dry mouth may occur; can be handled by chewing gum, frequent mouth care, and hard candy

Nursing Implications  Teach:  Check with physician before taking any other medication, including over-the-counter medications  Teach patients to limit physical exertion and avoid high temperatures and strenuous exercise  Emphasize the importance of adequate fluid and salt intake  Patients to report the following symptoms to their physician:  urinary hesitancy and/or retention, constipation, palpitations, tremors, confusion, sedation or amnesia, excessive dry mouth (especially if they have chronic lung infections or disease), or fever

Antibiotics For the GU system Mosby items and derived items © 2011, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.

Antibiotics: Classes  Sulfonamides  Penicillins  Cephalosporins  Macrolides   Quinolones  Aminoglycosides  Tetracyclines  glycopepetides

Antibiotic Therapy: Mechanism of Action  Interference with cell wall synthesis  Interference with protein synthesis  Interference with DNA replication  Acting as a metabolite to disrupt critical metabolic reactions inside the bacterial cell

Actions of Antibiotics  Bactericidal: kill bacteria  Bacteriostatic : inhibit growth of susceptible bacteria, rather than killing them immediately; will eventually lead to bacterial death

Antibiotics: Sulfonamides  One of the first groups of antibiotics  Sulfadiazine  Sulfamethoxazole  Sulfisoxazole  Often combined with another antibiotic  Sulfamethoxazole combined with trimethoprim (a nonsulfonamide antibiotic), known as Bactrim, Septra, or co-trimoxazole (SMX-TMP)  This combination is used commonly

Sulfonamides: Mechanism of Action  Bacteriostatic action  Prevent synthesis of folic acid required for synthesis of purines and nucleic acid  Do not affect human cells or certain bacteria— they can use preformed folic acid  Only affect organisms that synthesize their own folic acid

Sulfonamides: Indications  Effective against both gram-positive and gram-negative bacteria  Pneumocystis jirovecii pneumonia (PJP)  Co-trimoxazole  Upper respiratory tract infections  Treatment of UTIs caused by susceptible strains of:  Enterobacter spp., Escherichia coli, Klebsiella spp., Proteus mirabilis, Proteus vulgaris, Staphylococcus aureus

Sulfonamides: Adverse Effects Body System Adverse Effects Blood Hemolytic and aplastic anemia, agranulocytosis, thrombocytopenia Integumentary exfoliative dermatitis, Stevens- Johnson syndrome, epidermal necrolysis GI Nausea, vomiting, diarrhea, pancreatitis Other Convulsions, crystalluria, toxic nephrosis, headache, peripheral, neuritis, urticaria

Nursing Implications  Assess:  Before beginning therapy, assess drug allergies; renal, liver, and cardiac function; and other lab studies  Be sure to obtain thorough patient health history, including immune status  Assess for conditions that may be contraindications to antibiotic use or that may indicate cautious use  Assess for potential drug interactions

Nursing Implications  Treat:  It is ESSENTIAL to obtain cultures from appropriate sites BEFORE beginning antibiotic therapy  All oral antibiotics are absorbed better if taken with at least 6 to 8 ounces of water  For safety reasons, check the name of the medication carefully because there are many drugs that sound alike or have similar spellings

Nursing Implications  Teach:  Patients to take antibiotics exactly as prescribed and for the length of time prescribed;  they should not stop taking the medication early when they feel better  Assess for signs and symptoms of superinfection: fever, perineal itching, cough, lethargy, or any unusual discharge

Aminoglycosides  gentamicin (Garamycin)  neomycin (Neo-fradin)  tobramycin (Nebcin)  amikacin (Amikin)  kanamycin  streptomycin

Aminoglycosides  Natural and semisynthetic  Produced from Streptomyces  Poor oral absorption; no PO forms  Very potent antibiotics with serious toxicities  Bactericidal; prevent protein synthesis  Kill mostly gram-negative bacteria; some gram-positive also

Antibiotic Therapy: Toxicities  Ototoxicity  Temporary or permanent hearing loss, balance problems  Nephrotoxicity  Varying degrees of reduced renal function  Rising serum creatinine may indicate reduced creatinine clearance  Monitor trough levels every 5 to 7 days while on therapy or as ordered  Monitor serum creatinine levels at least every 3 days as an index of renal function

Aminoglycosides: Adverse Effects  Cause serious toxicities  Nephrotoxicity (renal damage)  Ototoxicity (auditory impairment and vestibular impairment [eighth cranial nerve])  Must monitor drug levels to prevent toxicities

Aminoglycosides : Adverse Effects  Ototoxicity and nephrotoxicity arethe most significant  Headache  Paresthesia  Fever  Superinfections  Vertigo  Skin rash  dizziness

Quinolones  ciprofloxacin (Cipro)  norfloxacin (Noroxin)  levofloxacin (Levaquin)  moxifloxacin (Avelox)

Quinolones: Mechanism of Action  Bactericidal  Alter DNA of bacteria, causing death  Do not affect human DNA

Quinolones: Indications  Gram-negative bacteria such as pseudomonas  Respiratory infections  Bone and joint infections  GI, GU infections  Skin infections  Sexually transmitted diseases  Anthrax

Fluoroquinolones: Adverse Effects Body System Adverse Effects CNS Headache, dizziness, fatigue, depression, restlessness, insomnia GI Nausea, vomiting, diarrhea, constipation, thrush, increased liver function studies, Cardiac Prolonged QT interval Integumentary Rash, pruritus, urticaria, flushing, photosensitivity (with lomefloxacin) Other Fever, chills, blurred vision, tinnitus Black box warning: increased risk of tendonitis and tendon rupture

Other Antibiotics  nitrofurantoin (Macrodantin)  Primarily used for UTIs (E. coli, S. aureus, Klebsiella spp., Enterobacter spp.)  Use carefully if renal function is impaired  Drug concentrates in the urine  May cause fatal hepatotoxicity  Usually well-tolerated if patient is kept well- hydrated

Bladder analgesics  Phenazopyridine  Reduces bladder pain and dysuria  3 x a day

Other Antibiotics  vancomycin (Vancocin)  Natural, bactericidal antibiotic  Destroys cell wall  Treatment of choice for MRSA and other gram-positive infections  Must monitor blood levels to ensure therapeutic levels and prevent toxicity  May cause ototoxicity and nephrotoxicity  Should be infused over 60 minutes  Rapid infusions may cause hypotension

Other Antibiotics  vancomycin (Vancocin) (cont’d)  Monitor IV site closely  Red man syndrome may occur  Flushing/itching of head, neck, face, upper trunk  Antihistamine may be ordered to reduce these effects  Ensure adequate hydration (2 L fluids/24 hr) if not contraindicated to prevent nephrotoxicity  Monitor trough levels carefully

Nursing Implications  Aminoglycosides  Monitor peak and trough blood levels of these drugs to prevent nephrotoxicity and ototoxicity  Symptoms of ototoxicity include dizziness, tinnitus, and hearing loss  Symptoms of nephrotoxicity include urinary casts, proteinuria, and increased BUN and serum creatinine levels

Nursing Implications  Monitor for therapeutic effects  Improvement of signs and symptoms of infection  Return to normal vital signs  Negative culture and sensitivity tests  Disappearance of fever, lethargy, drainage, and redness  Monitor for adverse reactions

 Finasteride (Proscar) and dutasteride (Avodart)  Block the effects of endogenous androgens  Used to treat benign prostatic hyperplasia (BPH)  Results in alleviation of symptoms of BPH  Easier passage of urine  May also be used for treatment of male- pattern baldness (minoxidil) 5-Alpha-Reductase Inhibitors Copyright © 2014 by Mosby, an imprint of Elsevier Inc. 38

 Used for symptomatic relief of obstruction caused by BPH  doxazosin (Cardura)  tamsulosin (Flomax)  terazosin (Hytrin)  alfuzosin (Uroxatral)  silodosin (Rapaflo) Alpha 1 -Adrenergic Blockers Copyright © 2014 by Mosby, an imprint of Elsevier Inc. 39

 Assessment should include complete history, including medication history, urinary elimination problems, potential contraindications  Obtain baseline vital signs, weight, height, serum electrolyte levels Nursing Implications Copyright © 2014 by Mosby, an imprint of Elsevier Inc. 40

 Assess renal and liver function  Assess PSA level and perform digital rectal examination (DRE) before beginning any drugs for treatment of prostate disease  Assess current medications for potential interactions Nursing Implications (cont’d) Copyright © 2014 by Mosby, an imprint of Elsevier Inc. 41