Antiviral Drugs Nursing Considerations & Management

Notes

Description

Antivirals are agents used to treat the diseases caused by viruses such as warts and common colds.

Table of Common Drugs and Generic Names

Here is a table of commonly encountered antivirals, their generic names, and brand names:

Classification	Generic Name	Brand Name
Influenza A and Respiratory Viruses Drugs	amantadine	Symmetrel
	oseltamivir	Tamiflu
	ribavirin	Rebetron, Virazole
	rimantadine	Flumadine
	zanamivir	Relenza
Herpes and Cytomegaloviruses (CMV)	acyclovir	Zovirax
	cidofovir	Vistide
	famciclovir	Famvir
	foscarnet	Foscavir
	ganciclovir	Cytovene
	valacyclovir	Valtrex
	valganciclovir	Valcyte
Agents for HIV and AIDS
Non-nucleoside Reverse Transcriptase Inhibitors	delavirdine	Rescriptor
	efavirenz	Sustiva
	etravirine	Intelence
	nevirapine	Viramune
	rilpivirine	Edurant
Nucleoside Reverse Transcriptase Inhibitors (NRTI)	abacavir	Ziagen
	didanosine	Videx
	emtricitabine	Emtriva
	lamivudine	Epivir
	stavudine	Zerit XR
	tenofovir	Viread
	zidovudine (AZT)	Retrovir, Aztec
Protease Inhibitors	atazanavir	Reyataz
	darunavir	Prezista
	fosamprenavir	Lexiva
	indinavir	Crixivan
	lopinavir	Kaletra
	nelfinavir	Viracept
	ritonavir	Norvir
	saquinavir	Fortovase
	tipranavir	Aptivus
Fusion Inhibitor	enfuvirtide	Fuzeon
CCR5 Coreceptor Antagonist	maraviroc	Selzentry
Integrase inhibitors	raltegravir	Isentress
*Antihepatitis B Agents*
Anti-Hepatitis B	adefovir	Hepsera
	entecavir	Baraclude
	telbivudine	Tyzeka
Anti-Hepatitis C	boceprevir	Victrelis
Anti-Hepatitis C	telaprevir	Incivek
Locally Active Antiviral Agents	docosanol	Abreva
	ganciclovir	Vitrasert
	imiquimod	Aldara
	penciclovir	Denavir
	trifluridine	Viroptic

Disease Spotlight: Viral Diseases

Viruses are composed of a single DNA or RNA inside a protein coat. Viruses must enter a cell in order for them to carry on with their metabolic processes.
Upon successful entry, viruses inject their DNA or RNA to the cell and the cell is altered in such a manner that it is now “programmed” to control the metabolic processes that the virus needs to survive.
Because viruses are contained in the cells, researchers find it difficult to develop vaccines. However, viruses respond to some antiviral therapy including influenza A viruses, herpes viruses, CMV, HIV, hepatitis B and C viruses, and some viruses that cause warts and eye infections.

Agents for Influenza A and Respiratory Viruses

Description

These agents are used to treat the signs and symptoms of respiratory flu caused by influenza A and B viruses as well as respiratory syncytial viruses (RSV). While vaccines are available, drug therapy would be the best option if patients manifest the viral infection and spontaneous resolution does not occur.

Therapeutic Action

The desired and beneficial action of agents for respiratory viruses is:

Unknown. However, the belief is that these agents prevent shedding of the viral protein coat and entry of the virus into the cell. This prevents replication and therefore causes viral death.

Indications

Agents for respiratory viruses are indicated for the following medical conditions:

Respiratory flu, especially in health care workers and high-risk individuals
Oseltamivir is the only antiviral agent that has been shown to be effective in treating H1N1 and avian flu.
Zidovudine has been safely used in pregnant women.

Here are some important aspects to remember for indication of agents for respiratory viruses in different age groups:

Children

This age group is very sensitive to the effects of most antivirals and therefore more severe reactions can be expected.
In addition, many antivirals do not have proven safety and efficacy in children.
Caution must be applied and smaller doses are given for children.

Adults

This age group should be educated about the dangers of using antibiotics for viral diseases.
Emphasis is given on patients with HIV about the limitations of antiviral drugs with regards to the curative aspect of the disease.

Pregnant women

Generally, pregnant women are not given antivirals unless the benefits clearly outweigh the risks to the fetus or neonate.
Women of childbearing age should be advised to use barrier contraceptives if they take any of these drugs.
The Centers for Disease Control and Prevention (CDC) advises that women with HIVinfection should not breast-feed to protect the neonate from the viruses.

Older adults

Older patients are more susceptible to adverse effects of antiviral therapy, particularly those with hepatic and renal dysfunctions.

Pharmacokinetics

Here are the characteristic interactions of agents for respiratory viruses and the body in terms of absorption, distribution, metabolism, and excretion:

Route	Onset	Peak	Duration
Oral	Slow	6 h	N/A
T1/2: 25.4 h Metabolism: none Excretion: kidney (urine); unchanged

Contraindications and Cautions

The following are contraindications and cautions for the use of agents for respiratory viruses:

Renal impairment. Alters metabolism and excretion of drugs, particularly amantadine, zanamivir, and oseltamivir.
Pregnancy and lactation. Amantadine, rimantadine, and oseltamivir should only be used for treatment if benefits outweigh the risks.

Adverse Effects

Use of agents for respiratory viruses may result to these adverse effects:

CNS: adverse effects that may be related to possible effects of dopamine levels in the brain, like light-headedness, dizziness, insomnia
CV: orthostatic hypotension
GU: urinary retention

Interactions

The following are drug-drug interactions involved in the use of agents for respiratory viruses:

Anticholinergics: increased atropine-like effects with amantadine or rimantadine
Acetaminophen and aspirin: loss of these drugs’ effectiveness with rimantadine
Antacids: reduced effectiveness of ribavirin
NRTIs: reduced effectiveness of ribavirin
Isoniazid: increased incidence of rifampin-related hepatitis
Antiarrhythmics, hormonal contraceptives, corticosteroids, antifungals, CNS depressants: decreased effectiveness of these drugs if combined with rifampin
St. John’s wort: decreased serum levels of protease inhibitors; increased metabolism of antivirals metabolized through cytochrome P450 system

Nursing Considerations

Here are important nursing considerations when administering antiviral agents for influenza A and other respiratory viruses:

Nursing Assessment

These are the important things the nurse should include in conducting assessment, history taking, and examination:

Assess for the mentioned cautions and contraindications (e.g. drug allergies, hepatorenal impairment, pregnancy and lactation, etc.) to prevent any untoward complications.
Perform a thorough physical assessment (other medications taken, orientation and reflexes, vital signs, etc.) to establish baseline data before drug therapy begins, to determine effectiveness of therapy, and to evaluate for occurrence of any adverse effects associated with drug therapy.

Nursing Diagnoses

Here are some of the nursing diagnoses that can be formulated in the use of these drugs for therapy:

Acute pain related to GI, CNS, or GU effects of the drug
Disturbed sensory perception (kinesthetics) related to CNS effects of the drug

Implementation with Rationale

These are vital nursing interventions done in patients who are taking antiviral agents for respiratory viruses:

Administer drug as prescribed as soon after exposure to the virus is possible to enhance effectiveness and decrease the risk of complications due to viral infection.
Administer influenza A vaccine before the flu season begins, if at all possible, to decrease the risk of contracting the flu and decrease the risk of complications.
Instruct the patient about the appropriate dosage scheduling regimen; safety precautions, including changing position slowly and avoiding driving and hazardous tasks that should be taken if CNS effects occur; the need to report any adverse effects such as difficulty walking or talking to enhance the patient knowledge about drug therapy and to promote compliance.
Educate client on drug therapy to promote understanding and compliance.

Evaluation

Here are aspects of care that should be evaluated to determine effectiveness of drug therapy:

Monitor patient response to therapy (prevention of respiratory flu-like symptoms and alleviation of flu-like symptoms).
Monitor for adverse effects (e.g. changes in orientation and affect, blood pressure, urinary output, liver or renal function test changes, etc).
Evaluate patient understanding on drug therapy by asking patient to name the drug, its indication, and adverse effects to watch for.
Monitor patient compliance to drug therapy.

Agents for Herpes and Cytomegaloviruses

Description

These agents are used to the infections caused by herpes (e.g. cold sores, encephalitis, shingles, and genital infections) and CMV (e.g. infections affecting the eyes, respiratory tract, and liver).

Therapeutic Action

The desired and beneficial action of agents for herpes virus and CMV is:

Inhibiting viral DNA replication by competing with viral substrates to form shorter, noneffective DNA chains.

Indications

Agents for herpes virus and CMV are indicated for the following medical conditions:

Infections caused by DNA viruses herpes simplex, herpes zoster, and CMV
Effective in immunocompromised individuals (e.g. patients with AIDS and multiple infections)
Acyclovir is the drug of choice for children with herpes virus or CMV infections.

Pharmacokinetics

Here are the characteristic interactions of agents for herpes virus and CMV and the body in terms of absorption, distribution, metabolism, and excretion:

Route	Onset	Peak	Duration
Oral	Varies	1.5-2 h	Not known
IV	Immediate	1 h	8 h
Topical	Not generally absorbed systematically
T1/2: 2.5-5 h Metabolism: none Excretion: kidney (urine); unchanged

Contraindications and Cautions

The following are contraindications and cautions for the use of agents for herpes virus and CMV:

Known allergy to drug. Prevent hypersensitivity reactions
Renal impairment. Alter drug excretion
Pregnancy and lactation. Prevent adverse effects to fetus or neonate
Severe CNS disorders. Drugs can cause headache, neuropathy, paresthesias, confusion, and hallucinations
Children with AIDS. Cidofovir has potential carcinogenic effects and effects on fertility. Caution must be applied.
Children. Foscarnet, ganciclovir, and valganciclovir can affect bone development and growth. Also, safety of use in children younger than 18 years has not been established for famciclovir.

Adverse Effects

Use of agents for herpes virus and CMV may result to these adverse effects:

CNS: headache, depression, paresthesias, neuropathy
GI: nausea, vomiting
GU: renal dysfunction and failure
IV and topical site: rash, inflammation, burning sensation
Cidofovir is associated with severe renal toxicity and granulocytopenia.
Ganciclovir and valganciclovir are associated with bone marrow suppression.
Foscarnet has been associated with seizures, especially in patients with electrolyte imbalance.

Interactions

The following are drug-drug interactions involved in the use of agents for herpesvirus and CMV:

Aminoglycosides: increased renal toxicity
Zidovudine: increased risk of drowsiness

Nursing Considerations

Here are important nursing considerations when administering antiviral agents for herpesvirus and CMV:

Nursing Assessment

These are the important things the nurse should include in conducting assessment, history taking, and examination:

Assess for the mentioned cautions and contraindications (e.g. drug allergies, hepatorenal impairment, pregnancy and lactation, severe CNS disorders, etc.) to prevent any untoward complications.
Perform a thorough physical assessment (other medications taken, orientation and reflexes, skin color, temperature, and lesions, etc.) to establish baseline data before drug therapy begins, to determine effectiveness of therapy, and to evaluate for occurrence of any adverse effects associated with drug therapy.
Evaluate renal function tests to determine baseline function of the kidneys and to assess adverse effects on the kidney and need to adjust the dose of the drug.

Nursing Diagnoses

Here are some of the nursing diagnoses that can be formulated in the use of these drugs for therapy:

Acute pain related to GI, CNS, or local effects of the drug
Disturbed sensory perception (kinesthetics) related to CNS effects of the drug

Implementation with Rationale

These are vital nursing interventions done in patients who are taking antiviral agents for respiratory viruses:

Administer drug as prescribed as soon after exposure to the virus is possible to enhance effectiveness and decrease the risk of complications due to viral infection.
Ensure good hydration to decrease the toxic effects on the kidneys.
Ensure patient takes the complete course of the drug regimen to improve effectiveness and decrease the risk of emergence of resistant viruses.
Wear protective gloves when applying the drug topically to decrease the risk of exposure to the drug and inadvertent absorption.
Provide safety precautions (e.g. use of side rails, appropriate lighting, orientation, assistance) if CNS effects occur to protect the patient from injury.
Monitor renal function tests periodically during treatment to ensure prompt detection and early intervention should renal toxicity develop.
Educate client on drug therapy to promote understanding and compliance.
Provide the following patient teaching:
- Avoid sexual intercourse if genital herpes is being treated because these drugs do not cure the disease.
- Wear protective gloves when applying topical agents.
- Avoid driving and hazardous tasks if dizziness or drowsiness occurs.

Evaluation

Here are aspects of care that should be evaluated to determine effectiveness of drug therapy:

Monitor patient response to therapy (alleviation of signs and symptoms of herpes or CMV).
Monitor for adverse effects (e.g. orientation and affect, GI upset and renal function).
Evaluate patient understanding on drug therapy by asking patient to name the drug, its indication, and adverse effects to watch for.
Monitor patient compliance to drug therapy.

Agents for HIV and AIDS (Antiretroviral Drugs)

Nonnucleoside Reverse Transcriptase Inhibitors

Description

This antiretroviral drug has direct effects on HIV activities within the cell.

Therapeutic Action

The desired and beneficial action of this antiretroviral drug is:

Binding directly to HIV reverse transcriptase to block both RNA- and DNA-dependent DNA polymerase activities. They prevent the transfer of information that would allow the virus to carry on the formation of viral DNA. Consequently, replication becomes impossible.

Indications

Nonnuceloside reverse transcriptase inhibitors are indicated for the following medical conditions:

Treatment of patients with documented AIDS or ARC who have decreased numbers of helper T cells and evidence of increased opportunistic infections in combination with other antiviral drugs.

Pharmacokinetics

Here are the characteristic interactions of nonnucleoside reverse transcriptase inhibitors and the body in terms of absorption, distribution, metabolism, and excretion:

Route	Onset	Peak	Duration
Oral	Rapid	4 h	N/A
T1/2: 45 h, then 25-30 h Metabolism: liver Excretion: kidney (urine)

Contraindications and Cautions

The following are contraindications and cautions for the use of nonnucleoside reverse transcriptase inhibitors:

Pregnancy. No adequate studies of nonnucleoside reverse transcriptase inhibitors so use should be limited only in which benefits clearly outweigh any risks.
Children. Safety for the use of delavirdine is not established.

Adverse Effects

Use of nonnucleoside reverse transcriptase inhibitors may result to these adverse effects:

CNS: dizziness, blurred vision, headache
GI: dry mouth, constipation or diarrhea, nausea, abdominal pain, dyspepsia
Flu-like syndrome may occur but this may also be because of the underlying disease.

Interactions

The following are drug-drug interactions involved in the use of nonnucleoside reverse transcriptase inhibitors:

Delavirdine should not be combined with antiarrhythmics, clarithromycin, dapsone, antituberculosis drugs, calcium-channel blockers, warfarin, quinidine, indinavir, saquinavir, or dapsone.
Efavirenz should not be combined with midazolam, rifabutin, triazolam, or ergot derivatives.
Hormonal contraceptives and protease inhibitors: lack of effectiveness of nevirapine
St. John’s wort: decreased antiviral effects

Nucleoside Reverse Transcriptase Inhibitors (NRTIs)

Description

This antiretroviral drug was the first class of drug developed to treat HIV infections. This competes with the naturally occurring nucleosides within a human cell that the virus would need to develop.

Therapeutic Action

The desired and beneficial action of this antiretroviral drug is:

Competing with the naturally occurring nucleosides within the cell that the virus would use to build DNA chain. These nucleosides, however, lack a substance needed to extend the DNA chain. Consequently, chain cannot lengthen and insert itself into the host DNA.

Indications

NRTIs are indicated for the following medical conditions:

Combination therapy for the treatment of adults and children with HIV
Lamivudine as an oral solution can be used in treatment of chronic hepatitis B
Zidovudine is used in prevention of maternal transmission of HIV.

Pharmacokinetics

Here are the characteristic interactions of nonnucleoside NRTIs and the body in terms of absorption, distribution, metabolism, and excretion:

Route	Onset	Peak	Duration
Oral	Varies	30-90 min	N/A
IV	Rapid	End of infusion	N/A
T1/2: 30-60 min Metabolism: liver Excretion: kidney (urine)

Contraindications and Cautions

The following are contraindications and cautions for the use of NRTIs:

Pregnancy. No adequate studies of NRTIs so use should be limited, except for zidovudine, which has been proven to be safe.
Hepatic dysfunction, severe renal impairment. Caution with use of tenofovir, zidovudine, and emtricitabine.
Bone marrow suppression. Can be aggravated by zidovudine.

Adverse Effects

Use of NRTIs may result to these adverse effects:

Abacavir: serious-to-fatal hypersensitivity reactions (fever, chills, rash, fatigue, GI upset, flu-like symptoms) can occur and drug must be discontinued immediately and listed with the Abacavir Hypersensitivity Registry
Didanosine: serious pancreatitis, hepatomegaly, and neurological problems
Emtricitabine, tenofovir: severe and fatal hepatomegaly with steatosis
Zidovudine: severe bone marrow suppression
Tenofovir: changes in body fat distribution, with loss of fat from arms, legs, and face and deposition of fat on the trunk, neck, and face.

Interactions

The following are drug-drug interactions involved in the use of NRTIs:

Tenofovir: increase serum level of didanosine; if in combine therapy, administer 2 hours before or 1 hour after didanosine was given
Alcohol: severe toxicity with abacavir
Antibiotics, antifungals: decreased effectiveness of these drugs if combined with didanosine
Cyclosporine: severe drowsiness and lethargy if combined with zidovudine
Lamivudine and zalcitabine inhibit the effects of each other.

Protease Inhibitors

Description

Protease inhibitors block protease activity within the HIV virus.

Therapeutic Action

The desired and beneficial action of this antiretroviral drug is:

Rendering the virus immature and noninfective by blocking protease which is essential for the maturation of an infectious virus.
As a result, the virus is unable to fuse with and inject itself into a cell.

Indications

Protease inhibitors are indicated for the following medical conditions:

Combination therapy for the treatment of HIV infections.

Pharmacokinetics

Here are the characteristic interactions of nonnucleoside NRTIs and the body in terms of absorption, distribution, metabolism, and excretion:

Route	Onset	Peak	Duration
Oral	Varies	1.5-4 min	N/A
T1/2: 7.7 h Metabolism: liver Excretion: kidney (urine)

Contraindications and Cautions

The following are contraindications and cautions for the use of protease inhibitors:

Pregnancy, lactation. Only saquinavir is not teratogenic. However, it can cross into breast milk.
Hepatic dysfunction. Increased toxicity especially with fosamprenavir and darunavir
Patients taking antidiabetic drugs. Darunavir can cause diabetes mellitus and/or hyperglycemia; dose adjustment is required.
Darunavir is associated with mild to severe dermatologic reactions including Steven Johnson syndrome.
Safety of indinavir for use in children younger than 12 years has not been established.
Darunavir should not be used in children younger than 3 years of age because of the potential for toxic effects.

Adverse Effects

Use of protease inhibitors may result to these adverse effects:

GI: nausea, vomiting, diarrhea, anorexia, changes in liver function (elevated cholesterol and triglyceride)
Skin: rashes, pruritus, Steven Johnson syndrome

Interactions

The following are drug-drug interactions involved in the use of protease inhibitors:

Pimozide, rifampin, triazolam, midazolam: severe toxic effects with nelfinavir
Nonsedating antihistamines, sedatives/hypnotics, antiarrhythmics: many potentially serious toxic effects with ritonavir

Fusion Inhibitor

Description

This antiretroviral drug was introduced in 2003.
Acts on different site than do other HIV antivirals.

Therapeutic Action

The desired and beneficial action of this antiretroviral drug is:

Preventing the fusion of the virus with the human cellular membrane, thereby preventing entry of HIV-1 virus into the cell.

Indications

Fusion inhibitors are indicated for the following medical conditions:

Combination therapy for the treatment of adults and children older than 6 years who have evidence of HIV-1 replication despite ongoing antiretroviral therapy.

Pharmacokinetics

Here are the characteristic interactions of fusion inhibitors and the body in terms of absorption, distribution, metabolism, and excretion:

Route	Onset	Peak	Duration
Subcutaneous	Slow	4-8 h	N/A
T1/2: 3.2-4.4 h Metabolism: liver; tissues recycle the amino acids Excretion: N/A

Contraindications and Cautions

The following are contraindications and cautions for the use of fusion inhibitors:

Pregnancy and lactation. Potential adverse effects to the fetus and neonate.
Known hypersensitivity to the drug.

Adverse Effects

Use of fusion inhibitors may result to these adverse effects:

CNS: insomnia, depression, peripheral neuropathy
GI: nausea, diarrhea
Respiratory: pneumonia
Local: injection-site reactions

Interactions

No reported drug interactions, but caution should be used when it is combined with any drug.

CCR5 Coreceptor Antagonist

Description

This antiretroviral drug was introduced in 2007.

Therapeutic Action

The desired and beneficial action of this antiretroviral drug is:

Blocking the receptor site on the cell membrane to which the HIV virus needs to interact to enter the cell.

Indications

CCR5 coreceptor antagonists are indicated for:

Combination therapy with other antivirals.

Pharmacokinetics

Here are the characteristic interactions of CCR5 coreceptor antagonists and the body in terms of absorption, distribution, metabolism, and excretion:

Route	Onset	Peak	Duration
Oral	Slow	0.5-4 h	N/A
T1/2: 14-28 h Metabolism: liver Excretion: kidney (urine), colon (feces)

Contraindications and Cautions

The following are contraindications and cautions for the use of CCR5 coreceptor antagonists:

Pregnancy, lactation, known hypersensitivity to drugs.
Renal impairment. Increased risk of toxicity.
Safety of use for children not established.

Adverse Effects

Use of CCR5 coreceptor antagonists may result to these adverse effects:

CNS: dizziness, changes in consciousness
Severe hepatotoxicity has been reported with maraviroc, often preceded with systemic allergic reaction with eosinophilia and rash.

Interactions

The following are drug-drug interactions involved in the use of CCR5 coreceptor antagonists:

Cyctochrome P450 CYP3A inhibitors (ketoconazole, lopinavir/ritonavir, saquinavir, ritonavir, atazanavir, delavirdine): risk of increased serum levels and toxicity of maraviroc.
CYP3A inducers (nevirapine, rifampin, efavirenz: decreased serum levels and loss of effectiveness of maraviroc
St. John’s wort: loss of antiviral effect of maraviroc

Integrase Inhibitors

Description

This antiretroviral drug was released in late 2007.

Therapeutic Action

The desired and beneficial action of this antiretroviral drug is:

Inhibiting the activity of the virus-specific enzyme integrase, an encoded enzyme needed for replication. Blocking integrase prevents the formation of HIV-1 provirus leading to decreased viral load and increased active CD4 cells.

Indications

Integrase inhibitors are indicated for:

Reserved for use in patients who have been treated with other antivirals and have evidence of a return to viral replication.

Pharmacokinetics

Here are the characteristic interactions of integrase inhibitors and the body in terms of absorption, distribution, metabolism, and excretion:

Route	Onset	Peak	Duration
Oral	Rapid	3 h	N/A
T1/2: 9 h Metabolism: liver Excretion: kidney (urine), colon (feces)

Contraindications and Cautions

The following are contraindications and cautions for the use of integrase inhibitors:

It is contraindicated with known hypersensitivity to any component of the drug, as initial treatment for adults, for use in children, and for nursing mothers.
Caution should be used if the patient is at risk for rhabdomyolysis or myopathy and during pregnancy.

Adverse Effects

Use of integrase inhibitors may result to these adverse effects:

CNS: headache, dizziness
Musculoskeletal: rhabdomyolysis, myopathy

Interactions

The following are drug-drug interactions involved in the use of integrase inhibitors:

Rifampin: decreased serum levels of raltegravir
St. John’s wort: reduced effectiveness of antiviral

Nursing Considerations for Antiretroviral Drugs

Here are important nursing considerations when administering antiretroviral drugs:

Nursing Assessment

These are the important things the nurse should include in conducting assessment, history taking, and examination:

Assess for the mentioned cautions and contraindications (e.g. drug allergies, hepatorenal impairment, pregnancy and lactation, etc.) to prevent any untoward complications.
Perform a thorough physical assessment (other medications taken, orientation and reflexes, vital signs, skin color, temperature, and lesions, etc.) to establish baseline data before drug therapy begins, to determine effectiveness of therapy, and to evaluate for occurrence of any adverse effects associated with drug therapy.
Evaluate hepatic and renal function tests to determine baseline function of the kidneys and liver.
Check results of CBC with differential to monitor bone marrow activity and helper T cell number to determine the severity of the disease and indicate the effectiveness of the drugs.

Nursing Diagnoses

Here are some of the nursing diagnoses that can be formulated in the use of these drugs for therapy:

Acute pain related to GI, CNS, or dermatological effects of the drug
Disturbed sensory perception (kinesthetics) related to CNS effects of the drug
Imbalanced nutrition: less than body requirements related to GI effects of the drug

Implementation with Rationale

These are vital nursing interventions done in patients who are taking antiretroviral drugs:

Monitor renal and hepatic function before and during therapy to detect changes requiring dose adjustments or additional treatment as needed.
Ensure patient takes the complete course of the drug regimen and takes all drugs included in a particular combination to improve the effectiveness of the drug and decrease the risk of emergency of resistant viral strains.
Administer the drug round the clock, if indicated, to provide the critical concentration needed for the drug to be effective.
Stop drug if sever rash occurs, especially if accompanied by blisters, fever, and other signs, to avert potentially serious reactions.
Provide safety precautions (e.g. use of side rails, appropriate lighting, orientation, assistance) If CNS effects occur, to protect patient from injury.
Educate client on drug therapy to promote understanding and compliance.

Evaluation

Here are aspects of care that should be evaluated to determine effectiveness of drug therapy:

Monitor patient response to therapy (alleviation or reduction of signs and symptoms of AIDS or ARC and maintenance of helper T cell levels).
Monitor for adverse effects (e.g. changes in orientation and affect, GI upset, renal and hepatic function, skin, levels of blood components, etc).
Evaluate patient understanding on drug therapy by asking patient to name the drug, its indication, and adverse effects to watch for.
Monitor patient compliance to drug therapy.

Anti-Hepatitis B and C Agents

Description

Hepatitis B is a serious-to-potentially fatal viral infection of the liver. It can be spread by blood or blood products, sexual contact, or contaminated needles or instruments. Individuals affected may develop a chronic condition or become a carrier.
Hepatitis C is the leading cause of most liver transplants due to progressive liver disease. After initial infection with HCV, most people develop chronic hepatitis C while some will develop cirrhosis of the liver. Mode of transmission is similar with HBV.

Therapeutic Action

The desired and beneficial action of this anti-hepatitis drug is:

Anti-hepatitis B agents inhibit reverse transcriptase in hepatitis B virus and cause DNA chain termination, leading to blocked viral replication and decreased viral load.

Indications

Anti-hepatitis agents are indicated for:

Treatment of adults with chronic hepatitis B and C who have evidence of active viral replication and either evidence of persistent elevations in serum aminotransferase or histologically active disease.

Pharmacokinetics

Here are the characteristic interactions of anti-hepatitis agents and the body in terms of absorption, distribution, metabolism, and excretion:

Route	Onset	Peak	Duration
Anti-hepatitis B: oral	Rapid	0.6-4 h	Unknown
T1/2: 7.5 h Metabolism: liver Excretion: kidney (urine)

Contraindications and Cautions

The following are contraindications and cautions for the use of anti-hepatitis agents:

Anti-hepatitis B: known allergy to drugs, to prevent hypersensitivity reactions; lactation, to prevent potential toxicity to the infant; renal and liver impairment, because of increased risk of toxicity.
Anti-hepatitis C: pregnancy, hepatitis B, and HIV infections, as safety is not established.

Adverse Effects

Use of anti-hepatitis agents may result to these adverse effects:

Anti-hepatitis B: should not be stopped immediately because of potential risk of hepatitis B exacerbation

CNS: headache, dizziness, nausea
GI: diarrhea, elevated liver enzymes, severe hepatomegaly with steatosis
GU: lactic acidosis and renal impairment

Anti-hepatitis C
- CNS: headache, fatigue
- GI: nausea, diarrhea
- Immunological: bone marrow suppression, severe skin reactions

Interactions

The following are drug-drug interactions involved in the use of anti-hepatitis agents:

Nephrotoxic drugs: increased risk of renal toxicity

Nursing Considerations

Here are important nursing considerations when administering anti-hepatitis drugs:

Nursing Assessment

These are the important things the nurse should include in conducting assessment, history taking, and examination:

Assess for the mentioned cautions and contraindications (e.g. drug allergies, hepatorenal impairment, pregnancy and lactation, etc.) to prevent any untoward complications.
Perform a thorough physical assessment (other medications taken, orientation and reflexes, vital signs, etc.) to establish baseline data before drug therapy begins, to determine effectiveness of therapy, and to evaluate for occurrence of any adverse effects associated with drug therapy.
Evaluate hepatic and renal function tests to determine baseline function of the kidneys and liver.

Nursing Diagnoses

Here are some of the nursing diagnoses that can be formulated in the use of these drugs for therapy:

Acute pain related to GI and CNS effects of the drug
Imbalanced nutrition: less than body requirements related to GI effects of the drug

Implementation with Rationale

These are vital nursing interventions done in patients who are taking anti-hepatitis drugs:

Monitor renal and hepatic function before and during therapy to detect changes requiring dose adjustments or additional treatment as needed.
Withdraw the drug and monitor the patient if he or she develops signs of lactic acidosis or hepatotoxicity because these adverse effects can be life threatening.
Caution patient to not run out of this drug but to take it continually because acute exacerbation of hepatitis B can occur when the drug is stopped.
Advise patients that these drugs do not cure the disease and there is still a risk of transferring the disease, so the patient should continue to take appropriate steps to prevent transmission of hepatitis B.
Provide the following patient teachings:
- Have regular blood tests and medical follow-up.
- Realize that GI upset, with nausea and diarhea, is common with this drug.
- Report severe weakness, muscle pain, palpitations, yellowing of the eyes or skin, and trouble breathing.
Educate client on drug therapy to promote understanding and compliance.

Evaluation

Here are aspects of care that should be evaluated to determine effectiveness of drug therapy:

Monitor patient response to therapy (decreased viral load).
Monitor for adverse effects (e.g. liver or renal dysfunction, headache, nausea, diarrhea, etc).
Evaluate patient understanding on drug therapy by asking patient to name the drug, its indication, and adverse effects to watch for.
Monitor patient compliance to drug therapy.

Exam

Welcome to your Pharmacology: Antiviral Drugs! This exam is carefully curated to help you consolidate your knowledge and gain deeper understanding on the topic.

✔ Exam Details

Number of Questions: 8 items
Mode: Practice Mode

✔ Exam Instructions

Practice Mode: This mode aims to facilitate effective learning and review.
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💡 Hint

Think about which protease inhibitor is considered safer for use in pregnant patients due to its non-teratogenic profile.

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1. Nurse Jessica is reviewing antiviral medications, particularly protease inhibitors, to determine which one is safe for use during pregnancy. Which of the following is the only protease inhibitor that is not teratogenic?

A. Fosamprenavir

B. Indinavir

C. Saquinavir

D. Darunavir

EXPLANATION

✔Correct answer:

Saquinavir. Saquinavir is the protease inhibitor that is considered safe for use during pregnancy and is not teratogenic. Teratogenicity refers to the capability of a substance to cause birth defects during fetal development. Among protease inhibitors, saquinavir has been studied more extensively and is generally regarded as safe to use in pregnant women with HIV to prevent maternal-fetal transmission of the virus.

Protease inhibitors are a class of antiretroviral drugs used in the management of HIV infection. They work by inhibiting the protease enzyme, which is crucial for the maturation of the virus. In pregnant women, controlling HIV viral load is essential to reduce the risk of transmitting the virus to the fetus. While some protease inhibitors carry risks of teratogenic effects, saquinavir is preferred because it does not exhibit these effects and is effective in maintaining viral suppression during pregnancy.

Think of saquinavir as a carefully designed tool that can effectively lock a door (protease enzyme) to prevent a problem (HIV replication) without damaging the surrounding structure (fetal development).

When caring for pregnant patients on antiretroviral therapy, nurses should monitor both maternal and fetal health closely, ensuring that the chosen medication regimen effectively controls the HIV infection while minimizing any potential risks to the developing fetus.

Monitor viral load and CD4 counts regularly to ensure effective suppression of the virus during pregnancy.
Educate the patient on the importance of medication adherence to prevent viral resistance and reduce the risk of mother-to-child transmission.
Collaborate with obstetricians to provide comprehensive prenatal care, including regular fetal monitoring.

✘Incorrect answer options:

Darunavir. Darunavir is another protease inhibitor used in HIV treatment, but it is generally avoided during pregnancy because of potential teratogenic effects, particularly in the first trimester.

Indinavir. Indinavir is a protease inhibitor that has also been associated with potential risks during pregnancy, including teratogenicity and other adverse effects such as nephrolithiasis (kidney stones), making it less favorable for use in pregnant women.

Fosamprenavir. Fosamprenavir is metabolized to amprenavir, another protease inhibitor that is not recommended during pregnancy due to potential teratogenic effects and concerns about fetal safety.

References

Panel on Treatment of HIV During Pregnancy and Prevention of Perinatal Transmission. (2022). Recommendations for the Use of Antiretroviral Drugs During Pregnancy and Interventions to Reduce Perinatal HIV Transmission in the United States. Retrieved from https://clinicalinfo.hiv.gov/en/guidelines/perinatal/whats-new-guidelines.
Hinkle, J. L., & Cheever, K. H. (2018). Brunner & Suddarth's Textbook of Medical-Surgical Nursing. Wolters Kluwer.

💡 Hint

Consider the antiviral that is specifically used to treat and prevent influenza, including strains like H1N1.

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2. Nurse Carol is reviewing medication options for a patient diagnosed with H1N1 influenza. Which of the following antiviral agents should she recognize as an effective treatment for this condition?

A. Acyclovir

B. Zidovudine

C. Selzentry

D. Oseltamivir

EXPLANATION

✔Correct answer:

Oseltamivir. Oseltamivir (commonly known by the brand name Tamiflu) is an antiviral medication specifically effective against influenza viruses, including H1N1. It is a neuraminidase inhibitor, which means it blocks the function of the viral neuraminidase enzyme. This enzyme is crucial for the release of new viral particles from infected cells. By inhibiting this enzyme, oseltamivir reduces the spread of the virus within the body, shortens the duration of illness, and helps to alleviate symptoms. It is most effective when administered within 48 hours of symptom onset.

H1N1 influenza is a type of viral infection caused by the influenza A virus. The virus infects the respiratory tract, leading to symptoms such as fever, cough, sore throat, body aches, and fatigue. Neuraminidase inhibitors like oseltamivir are important in the treatment and prophylaxis of influenza as they interfere with the replication of the virus, thus limiting its ability to infect additional cells.

Think of the influenza virus as a band of thieves trying to escape a building (the infected cell) after robbing it. Oseltamivir acts like a security system that locks the doors, preventing the thieves from escaping and causing more damage elsewhere (infecting other cells).

Nurses should ensure that oseltamivir is administered as soon as possible after the onset of influenza symptoms for optimal effectiveness. Additionally, patients should be educated on the importance of completing the full course of the medication to prevent resistance.

Monitor for potential side effects, such as nausea, vomiting, and headache.
Educate the patient on the importance of early treatment initiation for better outcomes.
Ensure the patient is aware of the need for supportive care, including hydration and rest.
Encourage the patient to receive an annual flu vaccine as preventive care.

✘Incorrect answer options:

Zidovudine Zidovudine is an antiretroviral medication used to treat HIV, not influenza. It works by inhibiting the reverse transcriptase enzyme, which is necessary for the replication of HIV, not the influenza virus. Therefore, it is not effective against H1N1 or other influenza viruses.

Acyclovir Acyclovir is an antiviral medication primarily used to treat infections caused by herpes viruses, such as herpes simplex virus (HSV) and varicella-zoster virus (VZV). It works by inhibiting viral DNA synthesis, but it is not effective against the influenza virus, including H1N1.

Selzentry Selzentry (maraviroc) is another antiretroviral medication used in the treatment of HIV. It works by blocking the CCR5 co-receptor on T-cells, preventing HIV from entering and infecting the cells. Like zidovudine, it is not effective against the influenza virus.

References

Ignatavicius, D. D., Workman, M. L., Rebar, C. R., & Heimgartner, N. M. (2018). Medical-Surgical Nursing: Concepts for Interprofessional Collaborative Care. Elsevier.
Centers for Disease Control and Prevention (CDC). (2021). Influenza Antiviral Medications: Summary for Clinicians. Retrieved from https://www.cdc.gov/flu/professionals/antivirals/summary-clinicians.htm.

💡 Hint

Consider the common side effects of both drugs, particularly those affecting blood cell counts.

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3. A senior nurse is advising her colleague on the key parameters to monitor in patients who are receiving both cyclosporine and zidovudine. Which of the following should the nurse focus on?

A. Flu-like symptoms.

B. Level of consciousness.

C. Skin lesions, temperature, and color.

D. CBC with differential count.

EXPLANATION

✔Correct answer:

CBC with differential count. CBC with differential count is the key parameter to monitor in patients receiving both cyclosporine and zidovudine. Cyclosporine is an immunosuppressant used primarily in organ transplantation to prevent rejection, and zidovudine is an antiretroviral medication used in the treatment of HIV. Both of these drugs can have significant hematological side effects, making it essential to monitor the complete blood count (CBC) with differential.

Cyclosporine can lead to bone marrow suppression, resulting in leukopenia (low white blood cell count) and thrombocytopenia (low platelet count).
Zidovudine is well known for causing anemia and neutropenia (a reduction in neutrophils, which are a type of white blood cell). Monitoring the CBC with differential will help in early detection of these conditions, allowing for timely interventions to prevent complications such as infections, anemia, or bleeding.

Both drugs can impact the bone marrow's ability to produce blood cells. Cyclosporine can suppress the immune system to prevent organ rejection, but this suppression can also reduce the production of essential blood cells. Zidovudine’s effect on bone marrow suppression can further compound this, leading to significant risks if not monitored appropriately.

Think of the bone marrow as a factory that produces essential products (blood cells). Cyclosporine and zidovudine can slow down this factory, leading to a shortage of products. Monitoring the CBC is like checking the factory's output to ensure it's still meeting demand.

Nurses should routinely monitor the CBC with differential in patients on these medications and be vigilant for signs of bone marrow suppression, such as increased susceptibility to infections (due to low white blood cells), fatigue (due to anemia), and easy bruising or bleeding (due to low platelets).

Monitor for signs and symptoms of infection, such as fever and sore throat, which could indicate neutropenia.
Assess for signs of anemia, including fatigue, pallor, and shortness of breath.
Watch for any unusual bruising or bleeding, which could suggest thrombocytopenia.
Collaborate with the healthcare provider to adjust dosages or provide supportive therapies like blood transfusions if necessary.

✘Incorrect answer options:

Skin lesions, temperature, and color. While monitoring skin lesions, temperature, and color can be relevant in certain conditions (e.g., infections, drug reactions), they are not the most critical parameters to monitor for patients receiving cyclosporine and zidovudine. The primary concern is hematological side effects, which are best assessed through CBC.

Flu-like symptoms. Flu-like symptoms could suggest an adverse reaction or an infection, which is possible in immunocompromised patients. However, they are nonspecific and do not directly monitor the key hematologic risks associated with these drugs.

Level of consciousness. Altered level of consciousness can be a sign of severe adverse effects or complications, such as infection-related sepsis, but it is not the primary focus when monitoring the combined use of cyclosporine and zidovudine. It is more crucial to monitor the CBC to prevent such severe complications from occurring.

References

Lehne, R. A., Rosenthal, L., & Collins, S. R. (2019). Pharmacology for Nursing Care. Elsevier.
Hinkle, J. L., & Cheever, K. H. (2018). Brunner & Suddarth's Textbook of Medical-Surgical Nursing. Wolters Kluwer.

💡 Hint

This severe side effect is related to mitochondrial dysfunction and is a serious concern with certain antiviral medications.

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4. Nurse Ella is educating a patient who is starting therapy with an anti-hepatitis B agent. She warns the patient about the most severe potential adverse effect of this medication. What is the most severe adverse effect?

A. Lactic acidosis

B. Severe skin reactions

C. Steatosis

D. Bone marrow suppression

EXPLANATION

✔Correct answer:

Lactic acidosis. The most severe potential adverse effect of anti-hepatitis B agents, particularly nucleoside analogs like tenofovir and entecavir, is lactic acidosis. Lactic acidosis is a rare but life-threatening condition characterized by the buildup of lactic acid in the body, leading to a decrease in blood pH. This can occur because these medications can affect mitochondrial function, leading to impaired oxidative phosphorylation and a subsequent accumulation of lactic acid.

Lactic acidosis occurs when the body's cells produce lactic acid faster than it can be metabolized. This condition can be caused by a variety of factors, but in the context of anti-hepatitis B therapy, the drugs may impair mitochondrial DNA polymerase, leading to mitochondrial dysfunction. This dysfunction can disrupt normal cellular respiration, causing anaerobic metabolism to take over, which produces excessive lactic acid as a byproduct. If not recognized and treated promptly, lactic acidosis can lead to multi-organ failure and death.

Imagine your cells are like factories that need energy to operate, and they usually get it from oxygen (like clean energy). When something goes wrong with their power system (mitochondrial dysfunction), they switch to a backup generator that burns fuel inefficiently (anaerobic metabolism), producing harmful exhaust fumes (lactic acid). Too much of this can overwhelm the body, leading to severe consequences.

When starting a patient on anti-hepatitis B therapy, it's crucial for nurses to educate them on the symptoms of lactic acidosis, which can include unexplained fatigue, weakness, abdominal pain, shortness of breath, and muscle pain. Nurses should also ensure regular monitoring of the patient's blood lactate levels, liver function, and renal function.

Educate the patient to report symptoms such as severe fatigue, muscle pain, or difficulty breathing immediately.
Monitor liver and renal function tests, as these can provide early indicators of mitochondrial toxicity.
Regularly assess the patient’s acid-base balance and lactate levels, especially if symptoms suggest lactic acidosis.
Collaborate with the healthcare team to consider dose adjustment or discontinuation of therapy if signs of lactic acidosis emerge.

✘Incorrect answer options:

Bone marrow suppression. Bone marrow suppression is a severe adverse effect associated with some antiviral agents, particularly those used in HIV treatment (e.g., zidovudine), but it is not the primary concern with anti-hepatitis B agents.

Steatosis. Steatosis, or fatty liver, can be associated with long-term use of some antiviral medications, particularly those affecting mitochondrial function. However, it is not typically the most acute or severe concern compared to lactic acidosis.

Severe skin reactions. Severe skin reactions, such as Stevens-Johnson syndrome or toxic epidermal necrolysis, can occur with certain antiviral medications, but they are not the most common or severe adverse effect associated with anti-hepatitis B agents.

References

Lehne, R. A., Rosenthal, L., & Collins, S. R. (2019). Pharmacology for Nursing Care. Elsevier.
Terrault, N. A., & Lok, A. S. (2018). Treatment of Hepatitis B: A Clinical and Molecular Approach. Springer.

💡 Hint

Focus on the enzyme responsible for processing viral proteins into their functional forms during viral replication.

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5. Nurse Alex is studying the process of viral maturation and infection. He learns that a specific enzyme is crucial for the maturation of infectious viruses. Which enzyme is this?

A. Reverse transcriptase

B. CCR5-ase

C. Protease

D. Nucleosidase

EXPLANATION

✔Correct answer:

Protease. Protease is the enzyme crucial for the maturation of infectious viruses, particularly in the context of HIV (Human Immunodeficiency Virus). In the viral lifecycle, protease plays a vital role in processing the viral polyproteins into functional viral proteins. After the viral RNA is transcribed and translated into long chains of polyproteins, protease cleaves these polyproteins into smaller, functional units that are essential for the assembly of mature viral particles. Without protease, these polyproteins would remain unprocessed, and the virus would not be able to assemble properly or become infectious.

Protease is integral to the lifecycle of many viruses, including HIV. After a virus infects a host cell, its genetic material is replicated, and viral proteins are synthesized as large precursor polyproteins. The protease enzyme cleaves these polyproteins at specific sites to produce the individual proteins needed to form a mature, infectious virus. Inhibiting protease prevents the virus from maturing, rendering it non-infectious.

Imagine you're baking a cake (representing the virus), and you have all the ingredients mixed together in one large batter (the polyprotein). Protease acts like a knife that slices the cake into individual pieces, each representing a functional part of the virus. Without the knife (protease), the cake can't be properly divided, and the pieces (viral proteins) can't be used to build the finished product (a mature virus).

In clinical practice, protease inhibitors (PIs) are a class of antiviral drugs used to treat infections such as HIV by inhibiting the protease enzyme. This prevents the maturation of the virus, reducing its ability to infect new cells. Nurses should be aware of potential side effects of protease inhibitors, such as metabolic changes, and educate patients on adherence to their medication regimen to prevent resistance.

Educate patients on the importance of strict adherence to protease inhibitors to prevent HIV resistance.
Monitor for metabolic side effects, including hyperlipidemia and insulin resistance, in patients taking protease inhibitors.
Ensure that patients are aware of possible drug interactions with protease inhibitors.

✘Incorrect answer options:

Reverse transcriptase Reverse transcriptase is an enzyme used by retroviruses like HIV to convert their RNA into DNA, allowing them to integrate into the host cell's genome. While crucial in the early stages of the viral lifecycle, it is not directly involved in the maturation of infectious viral particles.

Nucleosidase Nucleosidase is not a relevant enzyme in the context of viral maturation. It refers to enzymes involved in nucleotide metabolism, not viral protein processing or maturation.

CCR5-ase CCR5-ase does not exist as an enzyme. CCR5 is a co-receptor used by HIV to enter host cells, and drugs that block CCR5 (like maraviroc) are used to prevent viral entry, but CCR5 itself is not an enzyme involved in viral maturation.

References

Lehne, R. A., Rosenthal, L., & Collins, S. R. (2019). Pharmacology for Nursing Care. Elsevier.
Hinkle, J. L., & Cheever, K. H. (2018). Brunner & Suddarth's Textbook of Medical-Surgical Nursing. Wolters Kluwer.

💡 Hint

Focus on the drug's action at the DNA level, particularly how it interferes with viral replication.

6 / 8

6. During clinical rounds, a student nurse administering acyclovir is asked by the instructor to explain how the drug works. Which response from the student nurse would be correct?

A. It competes with viral receptors present in host cells.

B. It deprives viruses of the necessary substances required to form DNA chains.

C. The exact mechanism is unknown, but it is thought to disrupt the protein coat of the virus.

D. It traps and directly disintegrates the viruses.

EXPLANATION

✔Correct answer:

It deprives viruses of the necessary substances required to form DNA chains. Acyclovir is an antiviral medication primarily used to treat infections caused by herpes viruses, including herpes simplex virus (HSV) and varicella-zoster virus (VZV). The correct mechanism of action for acyclovir is that it mimics the structure of the nucleoside guanosine and gets incorporated into the viral DNA during replication. Once incorporated, acyclovir acts as a chain terminator, meaning that it prevents the addition of further nucleotides, thereby halting the elongation of the viral DNA chain. This disruption prevents the virus from replicating and spreading within the host.

Viruses, unlike bacteria, cannot replicate on their own and must hijack the host's cellular machinery to reproduce. By interfering with viral DNA synthesis, acyclovir effectively limits the replication and proliferation of the virus within the infected cells, helping to control the spread and reduce the severity of the infection.

Imagine a zipper (representing viral DNA) that is being zipped up. Acyclovir is like a broken zipper tooth—once it is inserted, the zipper can no longer close properly, stopping the virus from fully assembling its DNA and continuing its replication process.

When administering acyclovir, nurses should ensure that patients are well-hydrated, as the drug can crystallize in the kidneys, potentially leading to nephrotoxicity. It's also essential to educate patients on the importance of taking the medication as prescribed and completing the full course, even if symptoms improve early.

Monitor renal function, especially in patients with preexisting renal conditions.
Encourage patients to maintain adequate hydration during the course of treatment.
Educate the patient on recognizing early signs of renal impairment, such as reduced urine output or back pain.

✘Incorrect answer options:

The exact mechanism is unknown, but it is thought to disrupt the protein coat of the virus. This option is incorrect because the mechanism of acyclovir is well understood. It does not disrupt the viral protein coat but rather interferes with DNA synthesis by acting as a chain terminator.

It competes with viral receptors present in host cells. This answer is incorrect because acyclovir does not function by competing with viral receptors. Medications like maraviroc, used in HIV treatment, work by blocking viral receptors on host cells, but this is not the mechanism of acyclovir.

It traps and directly disintegrates the viruses. This option is incorrect as well. Acyclovir does not trap or directly disintegrate viruses. Instead, it interrupts the virus's ability to replicate its DNA, effectively preventing the virus from multiplying.

References

Lehne, R. A., Rosenthal, L., & Collins, S. R. (2019). Pharmacology for Nursing Care. Elsevier.
Hinkle, J. L., & Cheever, K. H. (2018). Brunner & Suddarth's Textbook of Medical-Surgical Nursing. Wolters Kluwer.

💡 Hint

Consider which antiviral drug is known to potentially exacerbate electrolyte imbalances, particularly hypokalemia.

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7. Nurse Rachel is reviewing the medication list for a patient who has been diagnosed with severe hypokalemia. Which of the following prescribed antiviral drugs should she question?

A. Valganciclovir

B. Foscarnet

C. Nevirapine

D. Cidofovir

EXPLANATION

✔Correct answer:

Foscarnet. Nurse Rachel should question the prescription of foscarnet for a patient with severe hypokalemia. Foscarnet is an antiviral medication used primarily to treat cytomegalovirus (CMV) infections, especially in immunocompromised patients, and acyclovir-resistant herpes infections. One of the significant adverse effects of foscarnet is that it can cause electrolyte imbalances, including hypokalemia (low potassium levels). Given that the patient is already experiencing severe hypokalemia, administering foscarnet could exacerbate this condition, leading to potentially life-threatening complications such as cardiac arrhythmias.

Potassium is a crucial electrolyte involved in maintaining the electrical activity of cells, particularly in cardiac muscle cells. Severe hypokalemia can disrupt normal heart function, leading to arrhythmias or even cardiac arrest. Foscarnet's ability to further lower potassium levels makes it a risky choice in patients who are already hypokalemic.

Think of potassium in the body like fuel for a car engine (the heart). If the fuel level is already low (hypokalemia), adding a substance that further reduces the fuel (foscarnet) could cause the engine to sputter or stop (cardiac arrhythmia).

For patients with hypokalemia, it's crucial to monitor electrolyte levels closely before and during the administration of medications that can affect potassium balance. Nurse Rachel should question the use of foscarnet in this patient and consult with the healthcare provider about alternative antiviral treatments or strategies to correct the hypokalemia before continuing treatment.

Ensure frequent monitoring of electrolyte levels, particularly potassium, in patients receiving foscarnet.
Consider preemptive potassium supplementation or correction of hypokalemia before initiating foscarnet therapy if it's deemed necessary.
Monitor cardiac function closely due to the increased risk of arrhythmias associated with hypokalemia.

✘Incorrect answer options:

Cidofovir Cidofovir is an antiviral medication also used to treat CMV infections, particularly in patients with AIDS. While cidofovir can cause nephrotoxicity and requires monitoring of renal function, it is not specifically known to exacerbate hypokalemia.

Valganciclovir Valganciclovir is another antiviral agent used to treat CMV infections. Although it can cause neutropenia and anemia, it does not have a direct impact on potassium levels and would not be as concerning in a patient with hypokalemia.

Nevirapine Nevirapine is a non-nucleoside reverse transcriptase inhibitor (NNRTI) used in the treatment of HIV. It is not associated with causing hypokalemia, and thus, it would not be immediately concerning in the context of a patient with severe hypokalemia.

References

Lehne, R. A., Rosenthal, L., & Collins, S. R. (2019). Pharmacology for Nursing Care. Elsevier.
Ignatavicius, D. D., & Workman, M. L. (2016). Medical-Surgical Nursing: Patient-Centered Collaborative Care. Elsevier.

💡 Hint

Think about which antiviral drug is commonly used to treat or prevent influenza.

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8. Nurse Megan is preparing to administer medication to a 15-year-old patient who has been diagnosed with a severe case of respiratory flu. Which of the following drugs is the nurse most likely to anticipate being prescribed?

A. Amantadine (Symmetrel)

B. Ganciclovir (Cytovene)

C. Acyclovir (Zovirax)

D. Abacavir (Ziagen)

EXPLANATION

✔Correct answer:

Amantadine (Symmetrel) Amantadine is an antiviral medication that is commonly used to treat or prevent respiratory infections caused by the influenza A virus. It works by interfering with the viral replication process, thus reducing the severity of the infection. Given that the patient is diagnosed with a severe case of respiratory flu, which is often caused by the influenza virus, Amantadine is the most appropriate medication among the choices provided. It is particularly useful when administered within the first 48 hours of symptom onset.

Influenza viruses, particularly influenza A, cause respiratory infections by invading and replicating within the respiratory tract epithelial cells. Amantadine blocks the M2 protein on the virus's surface, which is necessary for the uncoating and release of the viral RNA into host cells. By inhibiting this process, Amantadine reduces viral replication and shortens the duration of symptoms.

Think of the influenza virus as a key that needs to enter a lock (the host cell) to cause infection. Amantadine works like glue that jams the keyhole, preventing the key (virus) from unlocking and entering the cell to cause damage.

When administering Amantadine, it is important for nurses to:

Monitor the patient for any side effects, particularly central nervous system effects such as dizziness, confusion, or insomnia.
Educate the patient and their family on the importance of taking the medication as prescribed, especially within the first 48 hours of symptom onset.
Assess for any history of renal impairment, as Amantadine dosage may need to be adjusted in patients with renal issues.
Encourage fluid intake to help manage flu symptoms and facilitate the body's response to the medication.

✘Incorrect answer options:

Acyclovir (Zovirax) Acyclovir is an antiviral medication primarily used to treat infections caused by herpes viruses, such as herpes simplex and varicella-zoster. It is not effective against the influenza virus and would not be appropriate for treating respiratory flu.

Abacavir (Ziagen) Abacavir is an antiretroviral medication used in the treatment of HIV infection. It works by inhibiting the reverse transcriptase enzyme, which is crucial for HIV replication. It has no efficacy against the influenza virus, and thus, it would not be prescribed for a case of respiratory flu.

Ganciclovir (Cytovene) Ganciclovir is an antiviral medication used to treat cytomegalovirus (CMV) infections, especially in immunocompromised individuals. Similar to Acyclovir, Ganciclovir is not effective against the influenza virus, making it unsuitable for treating respiratory flu.

References

Ignatavicius, D. D., Workman, M. L., Rebar, C. R., & Heimgartner, N. M. (2018). Medical-Surgical Nursing: Concepts for Interprofessional Collaborative Care. Elsevier.
McCance, K. L., & Huether, S. E. (2018). Pathophysiology: The Biologic Basis for Disease in Adults and Children. Elsevier.

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