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Posted: August 20th, 2023

Myrtle, a 74-year-old female, is receiving IV gentamicin for pseudomonas

Scenario #1

Myrtle, a 74-year-old female, is receiving IV gentamicin for pseudomonas in her left heel wound. The physician orders a peak and trough to be drawn for gentamicin.

Discuss the mechanism of action and the adverse effects of gentamicin.
What are the differences between the two laboratory tests that are ordered?
During the antibiotic therapy, when would you draw these laboratory tests?
What other laboratory values would you monitor? Explain your rationale.

Scenario #2

M.R. is a patient who was in a major motor vehicle accident 48 hours ago, that resulted in a significant head injury. The patient was recovering without complications until he began to have increased urinary elimination. The urine volume over the past 12 hours has been 3000 mL. A urinalysis is performed, and the results include a specific gravity of 1.001. Symptoms of dehydration are present, and the patient complains of being “so thirsty.” The patient is diagnosed with diabetes insipidus. The patient’s family comes to visit the patient. One of the family members approaches the nurse and asks, “Will he need insulin now?”

How will the nurse respond to the family member’s question?
Which medication will be ordered for diabetes insipidus? Discuss the mechanism of actions and adverse effects of the prescribed medication.
What will the nurse assess and monitor while the patient is receiving the prescribed medication?
Discuss the patient teachings for the prescribed medication.

Scenario #3

Laura, a 20-year-old college student, went to health department for oral contraceptives. Laura asks the nurse how to take the medication and wants to know the adverse effects of oral contraceptives.

What should the nurse assess for prior to the physician prescribing oral contraceptives?
How would the nurse respond to Laura’s questions?
One month later, she started on oral antibiotics for acute bronchitis. She has taken her antibiotics for one week and she now has a vaginal yeast infection. She continues to take the oral contraceptives as scheduled.

How did Laura develop a vaginal yeast infection?
What medication might be prescribed for a vaginal yeast infection? Discuss the adverse effects of this medication?
What patient teachings should the nurse provide while the patient is taking these medications?

Scenario #4

Edna went to the emergency department complaining of shortness of breath, fever, and productive cough with green sputum. Chest x-ray results confirmed pneumonia and Edna was started on IV azithromycin.

The pneumonia was acquired in which setting? What do you call this type of infection?
Discuss the mechanism of action and the adverse effects of azithromycin.
What will you monitor for while Edna is receiving azithromycin?
During the hospital stay, Edna became weaker from the complications of pneumonia. She could not tolerate transferring from the bed to the chair and a Foley catheter was inserted. Three days later, the nurse noticed a foul-smelling odor when the Foley bag was being emptied. The nurse received orders to send the urine the lab and results came back positive for gram negative chains and clusters. Edna was immediately started on IV Bactrim.

The urinary tract infection was acquired in which setting? What do you call this type of infection?
Discuss the mechanism of action and the adverse effects of Bactrim.
What will you monitor for while Edna is receiving Bactrim?

Scenario #5

J.P. is diagnosed with Type 1 Diabetes is receiving NPH Insulin 10 units every morning. He does not want to self-inject and asks the prescriber for oral antidiabetic drugs, glipizide and metformin.

Differentiate between Type 1 and Type 2 Diabetes Mellitus.
Can the prescriber order oral antidiabetic drugs instead? Explain your rationale.
What instructions would be included in his discharge teaching regarding insulin? Be specific.

_______________________________
Scenario #1

Mechanism of Action and Adverse Effects of Gentamicin:

Gentamicin is an aminoglycoside antibiotic used to treat various bacterial infections. It works by inhibiting bacterial protein synthesis, primarily by binding to the bacterial 30S ribosomal subunit. This inhibitory action prevents the production of essential proteins, leading to bacterial cell death.

Although gentamicin can be effective in treating infections, it is associated with several adverse effects. These include:

Nephrotoxicity: Gentamicin can cause damage to the kidneys, leading to impaired kidney function. Monitoring kidney function is crucial during therapy.
Ototoxicity: This antibiotic can also cause damage to the inner ear, resulting in hearing loss or balance problems. It is important to monitor for any changes in hearing.
Neurotoxicity: Gentamicin may cause various neurological side effects, including dizziness, vertigo, and muscle weakness.
Allergic reactions: Some individuals may develop allergic reactions to gentamicin, such as rash, itching, or swelling.
Differences Between Peak and Trough Levels:

Peak and trough levels are laboratory tests used to monitor the therapeutic levels of gentamicin in the bloodstream.

Peak levels: These are drawn approximately 30 minutes after an intravenous dose is completed. Peak levels help determine the highest concentration of gentamicin in the blood, ensuring it is within the therapeutic range. This information helps to evaluate the effectiveness of the drug and minimize toxicity.
Trough levels: These are drawn immediately before the next dose of gentamicin is administered. Trough levels measure the lowest concentration of the drug in the blood, indicating how well the body clears the medication. Low trough levels may suggest the need for dose adjustment to maintain therapeutic levels.
Timing of Laboratory Tests:

During gentamicin therapy, peak and trough levels are typically drawn to ensure appropriate dosing and to prevent toxicity. The timing of these tests depends on the dosing schedule of the medication. Generally, the peak level is drawn about 30 minutes after completion of the intravenous infusion, while the trough level is drawn immediately before the next dose. These tests provide valuable information to guide dosing adjustments and optimize therapeutic outcomes.

Other Laboratory Values to Monitor:

In addition to peak and trough levels, other laboratory values should be monitored during gentamicin therapy:

Renal function tests: Gentamicin can potentially cause kidney damage. Monitoring serum creatinine, blood urea nitrogen (BUN), and urine output helps assess renal function and detect any signs of nephrotoxicity.
Complete blood count (CBC): Regular monitoring of the CBC can help identify any hematological abnormalities, such as leukopenia or anemia, which may be associated with gentamicin use.
Liver function tests: Although gentamicin primarily affects the kidneys, periodic liver function tests may be warranted due to potential hepatic side effects.
Rationale: Monitoring these laboratory values allows healthcare providers to promptly identify any drug-related adverse effects, adjust dosages if necessary, and ensure patient safety throughout the course of gentamicin therapy.

References:

Murray MT, Pizzorno JE, Pizzorno L. Aminoglycosides. In: Murray MT, Pizzorno JE Jr, Pizzorno L, eds. Handbook of Natural Medicine. 4th ed. Churchill Livingstone; 2016.
Lexi-Drugs Online. Hudson, OH: Lexicomp, Inc.; 2021.

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