1. PYRAMID POINTS CHAPTER 62: RENAL MEDICATIONS

2. ADULT HEALTH: Renal Medications Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc.62-2 PYRAMID POINTS I. Urinary Tract Antiseptics  Description Inhibit growth of bacteria in urine Inhibit growth of bacteria in urine  Side effects and nursing considerations Cinoxacin (Cinobac) Cinoxacin (Cinobac)  Dosages should be reduced in clients with renal impairment. Methenamine (Mandelamine, Hiprex, Urex) Methenamine (Mandelamine, Hiprex, Urex)  Requires acidic urine with pH of 5.5 or lower  Increasing fluids reduces antibacterial effects  Should not be combined with sulfonamides  Clients should avoid alkalinizing agents, including antacids

3. ADULT HEALTH: Renal Medications Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc.62-3 PYRAMID POINTS I. Urinary Tract Antiseptics (continued)  Nalidixic acid (NegGram) May produce intracranial hypertension in pediatric clients May produce intracranial hypertension in pediatric clients Can intensify effects of orally administered anticoagulants Can intensify effects of orally administered anticoagulants  Nitrofurantoin (Furadantin, Macrodantin, Macrobid) May cause pulmonary reactions, including dyspnea, chest pain, alveolar infiltrates May cause pulmonary reactions, including dyspnea, chest pain, alveolar infiltrates May produce harmless brown color in urine May produce harmless brown color in urine Contraindicated in clients with renal impairment Contraindicated in clients with renal impairment

4. ADULT HEALTH: Renal Medications Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc.62-4 PYRAMID POINTS II. Fluoroquinolones  Description Suppress bacterial growth by inhibiting an enzyme necessary for DNA synthesis Suppress bacterial growth by inhibiting an enzyme necessary for DNA synthesis Are active against a broad spectrum of microbes Are active against a broad spectrum of microbes  Side effects and nursing considerations Administer with full glass of water Administer with full glass of water Ensure maintenance of urine output of at least 1200 to 1500 mL/day Ensure maintenance of urine output of at least 1200 to 1500 mL/day Advise client to report dizziness, visual disturbances, photophobia, feelings of depression Advise client to report dizziness, visual disturbances, photophobia, feelings of depression Instruct client of signs of hepatic, renal toxicity; if they occur, report to physician Instruct client of signs of hepatic, renal toxicity; if they occur, report to physician

5. ADULT HEALTH: Renal Medications Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc.62-5 PYRAMID POINTS III. Sulfonamides  Description Suppress bacterial growth Suppress bacterial growth Are active against a broad spectrum of microbes Are active against a broad spectrum of microbes Are used primarily to treat acute urinary tract infections Are used primarily to treat acute urinary tract infections  Side effects and nursing considerations Should be discontinued if rash is noted Should be discontinued if rash is noted Instruct client to complete entire course of antibiotics prescribed Instruct client to complete entire course of antibiotics prescribed Adults should maintain urine output of 1200 mL/day Adults should maintain urine output of 1200 mL/day IV doses should be administered over IV doses should be administered over 60 to 90 minutes, not mixed with other medications

6. ADULT HEALTH: Renal Medications Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc.62-6 PYRAMID POINTS IV. Urinary Tract Analgesic  Description Administered with an antibiotic Administered with an antibiotic  Side effects Nausea Nausea Headache Headache Vertigo Vertigo  Nursing considerations Instruct client that urine will turn red or orange Instruct client that urine will turn red or orange

7. ADULT HEALTH: Renal Medications Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc.62-7 PYRAMID POINTS V. Anticholinergics and Antispasmodics  Description Relax smooth muscles of the urinary tract Relax smooth muscles of the urinary tract Decrease bladder muscle spasms Decrease bladder muscle spasms Reduce urinary incontinence, urgency, and frequency by controlling bladder contractions Reduce urinary incontinence, urgency, and frequency by controlling bladder contractions  Side effects Anticholinergic effects Anticholinergic effects Dizziness Dizziness Drowsiness Drowsiness  Nursing considerations Do not administer oxybutynin (Ditropan) to clients with known hypersensitivity, gastrointestinal or genitourinary obstruction, glaucoma, severe colitis, myasthenia gravis Do not administer oxybutynin (Ditropan) to clients with known hypersensitivity, gastrointestinal or genitourinary obstruction, glaucoma, severe colitis, myasthenia gravis Monitor for signs of toxicity Monitor for signs of toxicity

8. ADULT HEALTH: Renal Medications Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc.62-8 PYRAMID POINTS VI. Cholinergic Medications  Description Increase bladder tone and function Increase bladder tone and function  Side effects Headache Headache Hypotension Hypotension Flushing and sweating Flushing and sweating Abdominal cramps Abdominal cramps Urinary urgency Urinary urgency  Nursing considerations Do not administer if client has urinary stricture or obstruction Do not administer if client has urinary stricture or obstruction Monitor intake and output Monitor intake and output Monitor for cholinergic overdose (excessive salivation, sweating, involuntary urination and defecation, bradycardia, and severe hypotension) Monitor for cholinergic overdose (excessive salivation, sweating, involuntary urination and defecation, bradycardia, and severe hypotension)

9. ADULT HEALTH: Renal Medications Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc.62-9 PYRAMID POINTS VII. Medications for Prevention of Organ Rejection  Include immunosuppressants, corticosteroids, cytoxic medications, antibodies

10. ADULT HEALTH: Renal Medications Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc.62-10 PYRAMID POINTS VII. Medications for Prevention of Organ Rejection (continued)  Cyclosporine (Sandimmune, Gengraf, Neoral) Most common adverse effects are nephrotoxicity, infection, hypertension, tremor, hirsutism Most common adverse effects are nephrotoxicity, infection, hypertension, tremor, hirsutism Client should be instructed to monitor for early signs of infection; report immediately Client should be instructed to monitor for early signs of infection; report immediately Instruct client to dispense oral liquid medication into glass container using specially calibrated pipette, mix well, drink immediately, rinse glass container with diluent, drink to ensure ingestion of complete dose Instruct client to dispense oral liquid medication into glass container using specially calibrated pipette, mix well, drink immediately, rinse glass container with diluent, drink to ensure ingestion of complete dose Instruct client to mix medication with milk, chocolate milk, orange juice just before administration Instruct client to mix medication with milk, chocolate milk, orange juice just before administration

11. ADULT HEALTH: Renal Medications Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc.62-11 PYRAMID POINTS VII. Medications for Prevention of Organ Rejection (continued)  Sirolimus (Rapamune) Increases risk of infection, renal injury, lymphocele, raises cholesterol, triglyceride levels Increases risk of infection, renal injury, lymphocele, raises cholesterol, triglyceride levels  Tacrolimus (Prograf) Adverse effects include nephrotoxicity, infection, hypertension, tremor, neurotoxicity, hyperkalemia Adverse effects include nephrotoxicity, infection, hypertension, tremor, neurotoxicity, hyperkalemia  Prednisone (Deltasone) Hyperglycemia, hypokalemia can occur Hyperglycemia, hypokalemia can occur  Azathioprine (Imuran) Can cause neutropenia, thrombocytopenia Can cause neutropenia, thrombocytopenia

12. ADULT HEALTH: Renal Medications Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc.62-12 PYRAMID POINTS VII. Medications for Prevention of Organ Rejection (continued)  Mycophenolate mofetil (CellCept) Major adverse effects include diarrhea, severe neutropenia, vomiting, sepsis Major adverse effects include diarrhea, severe neutropenia, vomiting, sepsis  Daclizumab (Zenapax), basiliximab (Simulect) Contraindicated in clients with allergy to protein Contraindicated in clients with allergy to protein  Antithymocyte globulin, equine (Atgam) Before first infusion, client should undergo intradermal skin test for hypersensitivity Before first infusion, client should undergo intradermal skin test for hypersensitivity  Muromonab-CD3 (Orthoclone OKT3) Adverse reactions include fever, chills, dyspnea, chest pain Adverse reactions include fever, chills, dyspnea, chest pain

13. ADULT HEALTH: Renal Medications Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc.62-13 PYRAMID POINTS VIII. Hematopoietic Growth Factors  Erythropoietic growth factors Major side effect is hypertension Major side effect is hypertension  Leukopoietic growth factors Can cause bone pain, leukocytosis, elevation of plasma uric acid, lactate dehydrogenase, alkaline phosphatase levels Can cause bone pain, leukocytosis, elevation of plasma uric acid, lactate dehydrogenase, alkaline phosphatase levels  Thrombopoietic growth factor Adverse effects include fluid retention, cardiac dysrhythmias, conjunctival infections, visual blurring, papilledema Adverse effects include fluid retention, cardiac dysrhythmias, conjunctival infections, visual blurring, papilledema

14. ADULT HEALTH: Renal Medications Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc.62-14 A client must begin medication therapy with mycophenolate mofetil (CellCept) to prevent organ rejection following renal transplantation. The nurse plans to teach the client which of the following teaching points? 1. Notify the physician if a fever develops. 2. Take the medication with an aluminum-based antacid. 3. Take the dose following meals. 4. Open the capsule and mix with food before use.