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Generic/Trade name Classification Mechanism of Action Dosage and Route Is this a Safe Dose?

Drug/food Interactions

linezolid/Zyvox Therapeutic: Broad spectrum antiinfective Pharmacologic: Oxazolidinone chemical class) Inhibits bacterial protein synthesis at the level of the 23S ribosome of the 50S subunit. Therapeutic effects: Negative blood cultures, absence of signs/symptoms of infection 600mg Q12 g-tube The amount is safe and is correct for Pneumonia, however this pt has a g-tube, thus a paraenteral route is preferred. Absorption begins in the stomach although the majority of absorption takes place in the small intestine, so full absorption may not occur if linezolid is delivered directly into the jejunum. Hold medication and request Dr and/or pharmacy switch to intravenous infusion of 600mg linezolid in 300mL (2mg/mL) dosage single-use, ready-touse flexible plastic infusion bag in foil laminate overwrap. *See contraindications. Individual drugs: Amoxapine, cyclobenzaprine, maprotiline, methyldopa, mirtazapine, trazodone, promethazine, hydrocodone, oxycodone, salmeterol, albuterol, novolog Drug Classifications: Adrenergic blockers, Antidepressants (tricyclics), MAOIs, SSRSs, Serotoninergic agents Herbs: green tea, valerian, ginseng, yohimbe, kava Food: Tyramine foods Specific to this pt:  Trazodone interaction includes increased hypertensive crisis, seizures, coma;  promethazine (Phenergan) interaction can increase side effects of both medications and pt is more likely to develop low BP and related problems such as dizziness, fainting, weakness.  Hyrocodone and linezolid together can cause extremely low BP, shallow breathing and coma  Oxycodone and linezolid together can cause extremely low BP, shallow breathing and coma  Salmeterol can increase cardiovascular side effects such as heart palpitations and chest pain  Albuterol with linezolid may increase cardiovascular side effects such as heart palpitations and chest pain  Novolog can increase risk of hypoglycemia (Zyvox Drug Interactions, 2020)

Side Effects / Adverse Reactions

Lab / VS needed prior to administration of each dose

Nursing Considerations

CNS: headache, dizziness, insomnia GI: Nausea, diarrhea, increased ALT, AST, vomiting, taste change, tongue color change, pseudomembranous colitis HEMA: Myelosuppression MISC: fungal infection, oral moniliasis, lactic acidosis, anaphylaxis, angio-edema, StevensJohnson syndrome, serotonin syndrome CBC weekly for assessment of anemia, leukopenia, pancytopenia and thrombocytopenia (Myelosuppression) to detect if it occurs after administration; watch for bone marrow suppression Monitor liver function test (AST, ALT) CBC prior to initial administration and on a monitoring basis (monitor symptoms also) for elevated WBC, low serum albumin (possible Pseudomembranous colitis) V/S should be monitored for Serotonin syndrome occurrence (increased HR, high BP) Obtain specimens for culture and sensitivity prior to initiating therapy Assessment: Assess for infection (v/s, appearance of sputum, urine, stool, WBC) Monitor for recurrent nausea and vomiting (can cause lactic acidosis) Monitor visual functions Monitor bowel function for diarrhea, abdominal cramping, fever, and bloody stools. Monitor for serotonin syndrome (hyperthermia, rigidity, myoclonus, autonomic instability, mental status changes especially because this pt is taking serotonergic drugs – oxycodone, hydrocodone, trazodone Monitor for increased hypoglycemia since pt is taking insulin and is DM type II Implementation: If prescriber changes to intermittent IV route, administer the premixed solution. Store at room temp in original packaging and do not use if particulate is present. Yellow color is normal. Infuse over 30-120minutes, flush line before and after infusion. Teaching: Advise pt to ambulate with assistance if dizziness occurs; advise that full course of medication must be completed (good teaching even though given IV route), advise pt to contact prescriber if adverse reaction occurs, avoid large amount of tyramine-containing foods such as aged chicken liver, aged cheese, beer on tap, fermented meat, red wine, sauerkraut (give full list to pt) Pharmacodynamics: Absorption: rapid and extensive (100%), readily distributes to well-

perfused tissues. 65% metabolized, mostly by liver, 30% excreted unchanged by kidneys. Half-life 6.4 hours. Peak (for IV): end of infusion, Duration: 12 hours Why is this patient taking this? Is it effective? Provide the evidence.

Generic/Trade name Classification Mechanism of Action Dosage and Route Is this a Safe Dose?

Drug/food Interactions

Pt has pneumonia; more information may be needed because there may be medications that are more appropriate for aspiration pneumonia It is unknown at this time if this medication has been effective because the pt just started it and a full course of treatment is required to determine if there are decreased symptoms of infection and negative blood cultures. Trazodone XRT/Oleptro Therapeutic: antidepressant Selectively inhibits serotonin, norephinephrine uptake by brain, potentiates behavior changes 150mg daily g-tube (use tablet form and crush for g-tube); geriatric may not tolerate once/day dosing. This is a safe dosage, however, given that the pt is geriatric, he should be monitored for how well he tolerates the extended release version. That said, the extended release product shouldn’t be crushed and consumed. I would contact provider to review if the regular version would be more appropriate if giving through g-tube. Additionally, because this pt is geriatric, it may be beneficial to start at a lower dose such as 75mg/day. Individual drugs: alcohol, carbamazepine, digoxin, phytoin, fluoxetine, nefazodone, guanethidine, clonidine, warfarin Drug classes: barbiturates, benzodiazapenes, CNS depressants, CYP3A4, 2D6 inhibitors, MAOIs, SNRIs, Sympathomimetics, Sympathomimetics Drug/herb: hops, kava, lavender, valerian, SAM-e, St. John’s wort Specific to this pt:  linezolid interaction includes increased hypertensive crisis, seizures, coma; Do NOT start this pt on trazodone if pt is receiving linezolid due to serotonin syndrome  Oxycodone can increase risk of serotonin syndrome (confusion, seizures, extreme changes in BP)  Albuterol can increase risk of irregular heart rhythm

Side Effects / Adverse Reactions

Lab / VS needed prior to administration of each dose

Nursing Considerations

 Promethazine increase risk of irregular heart rhythm  Hydrocodone can increase risk of serotonin syndrome  Salmeterol can increase risk of irregular heart rhythm (Zyvox Drug Interactions, 2020) CNS: dissiness, drowsiness, confusion, headache, anxiety, tremors, stimulation, weakness, insomnia, nightmares, EPS, CV: orthostatic hypotension, ECG changes, tachycardia, hypertension, palpitations EENT: blurred vision, tinnitus, mydriasis GI: diarrhea, dry mouth, nausea, vomiting, paralytic ileus, increased appetite, cramps, epigastric distress, jaundice, hepatitis, stomatitis, constipation GU: retention, acute renal failure, priapism HEMA: agranulocytosis, thrombocytopenia, eosinophilia, leukopenia INTEG: rash, urticaria, sweating, pruritius Assess CBC and renal and hepatic function before and periodically during therapy. Monitor leukocyte and neutrophil counts, although it is expected that those levels may have a clinical insignificant drop. Check BP/Pulse before starting therapy Assessment: Monitor BP and pulse q4hr during therapy – if systolic bp drops 20mm Hg hold drug and notify prescriber. Assess for serotonin syndrome. Assess for mental status change, specifically depression. Assess location, duration, intensity and characteristics of pain before and periodically during therapy. Assess weight q4 week due to increase in appetite. Assess for EPS since pt is geriatric. Monitor I/O – constipation more likely since geriatric. Implementation: Give with food or milk for GI symptoms (check g-tube restrictions and compatibility); give dose at bedtime (consider that geriatric pt may not tolerate once/day dose) Teaching: Teach pt that – therapeutic effect may take 2-3wks; do not double dose if dose is skipped; medication can cause drowsiness (use caution if driving); avoid alcohol; do not discontinue abruptly w/out consulting provider; wear sunscreen due to photosensitivity; increase fluids; chew gum or hard candy to help w/dry mouth; rise slowly to prevent dizziness. Advise family to look for suicidal or other mental changes. Pharmacodynamics: Onset: unknown; Peak: 1 hr without food, 2 hr with food; Duration:

unknown Why is this patient taking this?

Is it effective? Provide the evidence.

Generic/Trade name Classification Mechanism of Action Dosage and Route Is this a Safe Dose?

Drug/food Interactions

It is likely that this pt is taking this medication to treat major depression. It is also possible that he is using it for an unlabeled use such as insomnia, or a chronic pain syndrome such as diabetic neuropathy. This medication has not yet been effective because the provider was called due to clarification of dosage, regular vs extended release, and ample interactions with other prescribed drugs. Salmetrol/fluticasone (Advair) Respiratory corticosteroids in combination w/respiratory long-acting beta-2 agonists Fluticasone is an anti-inflammatory corticosteroid and salmeterol is a long-acting selective beta agonist and when used together the combo is more effective than either drug alone. 50mcg/500mcg 1 puff inhaled twice a day No. This pt has been prescribed this medication for COPD and this dosage is too high. The correct dosage for this pt is 250mg/50mg 1 puff, twice daily. (HIGHLIGHTS OF PRESCRIBING INFORMATION, 2017)  Contraindicated w/severe hypersensitivity to milk proteins  Interacts with MAOIs and tricyclic antidepressants  Interacts with beta blockers  May interact with diuretics Specific to this pt:  Linezolid may increase cardiovascular side effects such as heart palpitations  Salmeterol may interfere w/blood glucose control and reduce effectiveness of insulin aspart  Using albuterol w/salmeterol may increase cardiovascular effects such as elevations in heart rate and blood pressure or irregular heart rhythm  Trazodone can increase the risk of an irregular heart rhythm *salmeterol/fluticasone is an inhaled smooth muscle relaxant, as is albuterol. There may be some duplication of this type of medication so although I wouldn’t hold this medication to verify, I would follow up with provider to confirm that taking two medicines in this category

Side Effects / Adverse Reactions

Lab / VS needed prior to administration of each dose Nursing Considerations

Why is this patient taking this? Is it effective? Provide the

is acceptable. One is a short acting and one is a long acting.  Increased risk of pneumonia in patients w/COPD.  Use w/caution in patients w/CNS disorder b/c of beta-adrenergic stimulation  Use w/caution b/c pt has diabetes mellitus  Oral candidiasis  Throat irritation  Dysphonia  Viral respiratory infections  Headaches  Musculoskeletal pain CBC prior to starting therapy to gather baseline for hepatic and renal function. Would also gather ABG’s as a baseline prior to starting therapy. Prior to each dose: listen to breath sounds and heart rate/rhythm. Assessment: Assess pt vital signs, FEV, ABGs, lung sounds, heart rate, rhythm. Assess ability to use device correctly. Implementation: ADVAIR DISKUS 250/50 is supplied as a disposable purple plastic inhaler containing a foil blister strip with 60 blisters. The inhaler is packaged in a plastic-coated, moisture-protective foil pouch Teaching: Teach pt to contact prescriber if he notices decreasing effectiveness of medication, needs more inhalations than usual, or has a significant decrease in lung function as outlined by provider. Teach pt to not stop therapy without provider guidance. Teach pt to rinse mouth after each use to prevent fungal infections in the mouth and dry mouth. Pharmacodynamics: Some of the pharmacodynamics are dependent upon pt’s ability to inhale proper amount of medication. The estimated onset is 30-60 minutes. The maximum improvement is estimated to be reached at 3 hours and maintained for 12 hours. (Advair Diskus (fluticasone propionate): For Asthma, COPD, Warning, Dosage, Side Effects & Interactions, 2020) Maintenance treatment of airflow obstruction and reducing exacerbations in patients with COPD. Yes, this medication is effective. However, at this point, the provider should review if this

evidence.

medication is appropriate since it can exacerbate pneumonia, which the pt is currently diagnosed with.

Generic/Trade name Classification

Albuterol (Proair HFA, Proventil HFA) Functional class: bronchodilator, Chemical class: adrenergic beta2-agonist, sympathomimetic, bronchodilator Causes bronchodilation by action on pulmonary receptors by increasing levels of cyclic AMP, which relaxes smooth muscle; produces bronchodilation; CNS, cardiac stimulation, increased diuresis, and increased gastric acid secretion; longer acting than isoproterenol 2.5mg/3ml 1 vial as needed for cough or wheeze (inhalation via nebulizer) Yes, this is a safe dose. 2.5mg is a safe dose 3-4 times a day by nebulization, over approximately 5-15 minutes. Specific medications: arsenic trioxide, atomoxetine, digoxin Drug classifications: adrenergics, Beta adrenergic blockers, bronchodilators, Class III/IV antidysrhythmics, CNS stimulants, diuretics, MAOIs, Oxytocics, Theophylline Herb/Food: black tea, green tea, kola nut, guarana, yerba mate, caffeine Specific to this pt: *salmeterol/fluticasone is an inhaled smooth muscle relaxant, as is albuterol. There may be some duplication of this type of medication so although I wouldn’t hold this medication to verify, I would follow up with provider to confirm that taking two medicines in this category is acceptable. One is a short acting and one is a long acting.  Albuterol may interfere with blood glucose control and reduce effectiveness of insulin aspart  Linezolid may increase cardiovascular side effects such as heart palpitations and chest pains  Trazodone can increase the risk of an irregular heart rhythm  Promethazine can increase the risk of an irregular heart rhythm CNS: headache GI: tremors, anxiety, insomnia, headache, dizziness, stimulation, restlessness, hallucinations, flushing, irritability CV: palpitations, tachycardia, hypertension, angina, hypotension, dysrhythmias EENT: dry nose, irritation of nose and throat

Mechanism of Action

Dosage and Route Is this a Safe Dose? Drug/food Interactions

Side Effects / Adverse Reactions

GI: heartburn, nausea, vomiting MISC: flushing, sweating, anorexia, bad taste/smell changes, hypokalemia MS: muscle cramps RESP: cough, wheezing, dypnea, paradoxical bronchospasm, dry throat Lab / VS needed prior to administration of each dose

Nursing Considerations

Vital signs should be monitored with each dose to check for increased heart and breathing rate. Prior to starting treatment, obtain baseline potassium level, ABGs, lung sounds, and sputum culture. Monitor blood glucose, lung sounds. Assessment: Monitor vitals, lung capacity, ABGs, sputum cultures. Determine pt has not received theophylline therapy before giving dose; monitor for signs of allergic reactions, paradoxic bronchospasm. Implementation: For nebulizer, compressed air or oxygen flow should be 6-10L/min and a single treatment lasts about 10 minutes. Teaching: Teach pt: not to use OTC meds before discussing w/provider, limit caffeine Pharmacodynamics: Onset: 5-15min, Peak: 1.5-2hrs, Duration: 4-6 hrs

Why is this patient taking this? Is it effective? Provide the evidence.

Increase pt’s ability to breathe because of bronchodilation Yes, this medication has been effective and the pt is demonstrating increased ability to breath after each treatment.

Generic/Trade name Classification

Levamire/insulin detemir Functional class: antidiabetic, pancreatic hormone; chemical class: modified structures of endogenous human insulin Lower blood glucose by stimulating glucose uptake in skeletal muscle and fat, inhibiting hepatic glucose production. Other actions include inhibition of lipolysis and proteolysis, enhanced protein synthesis. Therapeutic effects: control hyperglycemia in diabetic pts. 10 units, Subcutaneous Qam Yes, this is a safe dose but usually a single dose regimen is done in the evening. 10 units could also be divided into a twice daily regimen.

Mechanism of Action

Dosage and Route Is this a Safe Dose?

Drug/food Interactions

Side Effects / Adverse Reactions

Lab / VS needed prior to administration of each dose Nursing Considerations

Individual drugs: alcohol, Dobutamine, epinephrine, sulfinpyrazone; Drug classifications: anabolic steroids, MAOIs, beta blockers, corticosteroids, Herb/food: glucosamine, fenugreek, chromium, coenzyme Q-10. *no specific food interactions but diet should be discussed with provider and Specific to this pt:  promethazine may interfere with blood glucose control and reduce effectiveness of insulin detemir  salmeterol may interfere with blood glucose control and reduce effectiveness of insulin detemir  albuterol may interfere with blood glucose control and reduce effectiveness of insulin detemir  linezolid may increase the risk of hypoglycemia EENT: blurred vision, dry mouth INTEG: flushing, rash, urticaria, warmth, lipodystrophy, lipohypertrophy, swelling, redness META: hypoglycemia, rebound hyperglycemia Misc: peripheral edema SYST: anaphylaxis Blood glucose every 6 hours; Hgb A1c should be monitored q3mo; CBC & metabolic panel to get baseline on potassium, calcium, liver and thyroid function Assessment: urine should be monitored for ketones during illness (such as w/this pt and pneumonia); monitor pt for s/s of hypoglycemia; monitor body weight periodically to determine if dosage is still appropriate Implementation: give after warming to room temp by rotating in palms to prevent injecting cold insulin; use only insulin syringes with marking or syringe matching units/ml; rotate inj sites w/in one area: abdomen, upper back, thighs, upper arm, buttocks; keep record of sites; use only insulin syringes; do not use if cloudy, discolored, or unusually viscous Teaching: Instruct pt on proper technique for administration; discuss importance of not changing brands; remind pt that medication controls hyperglycemia but does not cure diabetes; teach pt proper testing of serum glucose and ketones; teach pt and family importance of proper nutrition guidelines; teach pt s/s of hypoglycemia and hyperglycemia and what to do if either occur; teach pt and family to carry source of sugar (candy) and ID

describing their disease and treatment regimen at all times. Pharmacodynamics: Onset: 0.8-2hr, Peak: unknown, Duration: up to 24hrs depending on concentration Why is this patient taking this? Is it effective? Provide the evidence.

This pt has DM type II. Yes, this medication has been successful in decreasing blood glucose levels and pt has been compliant in taking as prescribed.

Generic/Trade name Classification

Novolog SQ/insulin aspart Functional class: antidiabetic, pancreatic hormone; chemical class: modified structures of endogenous human insulin Lowers blood glucose by stimulating glucose uptake in skeletal muscle and fat, inhibiting hepatic glucose production. Other actions: inhibition of lipolysis and proteolysis, enhanced protein synthesis. A rapid-acting insulin w/more rapid onset and shorter duration than human regular insulin and should be used w/intermediate or long-acting insulin. Therapeutic effects: control of hyperglycemia in diabetic pts Novolog per Mild Sliding Scale AC &HS Blood Sugar Dose Before Meals Dose at Bedtime 151-200 2 units SQ 2 units SQ 201-250 4units SQ 4 units SQ 251-300 6 units SQ 6 units SQ 301-350 8 units SQ 8 units SQ 351-3...