NURS 133 Methotrexate and Clomiphene

jasmine's version from 2016-06-12 03:15

Section 1

Question Answer
Rheumatrex, Trexall, Otrexup, Rasuvo Methotrexate (Methotrexate)Anti-neoplastic, anti-rheumatics (DMARDS), and immunosuppressants; pharmacologic is anti-metabolites; Used to treat certain types of cancer of the breast, skin, head and neck, or lung, and sickle cell disease also used to treat sever psoriasis; Also used to treat autoimmune diseases, ectopic pregnancy, and for the induction of medical abortions
Methotrexate actions Interferes with folic acid metabolism; Result is inhibition of DNA synthesis and cell reproduction (cell-cycle S-phase-specific); Also has immunosuppressive activity
Methotrexate therapeutic effects Death of rapidly replicating cells, particularly malignant ones, and immunosuppression
Metabolism and excretion of Methotrexate Excreted mostly unchanged by the kidneys
Contraindications of Methotrexate Hypersensitivity; OB, Lactation: pregnancy or lactation; Pedi: products containing benzyl alcohol should not be used in neonates
Adverse/Side effects of Methotrexate Arachnoiditis (chronic pain disorder caused by the inflammation of the arachnoid membrane and subarachnoid space that surround the nerves of the spinal cord); Pulmonary fibrosis; Hepatotoxicity, anorexia, diarrhea, nausea, stomatitis, vomiting; Erythema multiforme, stevens-johnson syndrome, toxic epidermal necrolysis; Aplastic anemia, anemia, leukopenia, thrombocytopenia; Nephropathy
Drug-drug interactions of Methotrexate The following drugs may increase hematologic toxicity: high-dose salicylates, NSAIDS, oral hypoglycemic agents (sulfonylureas), phenytoin, tetracyclines, probenecid, tri-methoprim/fulfamethoxazole, pryimethamine, proton pump inhibitors, and chloramphenicol; Increase hepatotoxicity with other hepatotoxic drugs including azathioprine, sulfasalazine, and retinoids; Increase nephrotoxicity with other nephrotoxic drugs; Increase bone marrow depression with other anti-neoplastics or radiation therapy; Radiation therapy increase risk of soft tissue necrosis and osteonecrosis; May decrease antibody response to live-virus vaccines and increase risk of adverse reactions
Food and natural product interactions of Methotrexate Concomitant use with Echinacea and melatonin may interfere with immunosuppression; Caffeine may decrease efficacy of methotrexate, and similar effect may occur with guarana
Route of Methotrexate PO and IM (trophoblastic neoplasms), IV (breast cancer, osteosarcoma), PO, IM, IV, and IT (Administration within the cerebrospinal fluid at any level of the cerebrospinal axis, including injection into the cerebral ventricles) (leukemia)-IT for children; PO, IM, subcut, IV (psoriasis); PO, subcut (rheumatoid arthritis); PO (polyarticular juvenile idiopathic arthritis) for children; PO, IM, subcut (mycosis fungoides)
Nursing assessment of Methotrexate Monitor vital signs periodically during administration; monitor for abdominal pain, diarrhea, or stomatitis; monitor for bone marrow depression; assess for bleeding (bleeding gums, bruising, petechiae, guaiac stools, urine, and emesis) and avoid IM injections and taking rectal temperatures if platelet count is low; Apply pressure to venipuncture sites for 10 min. Assess for signs of infections during neutropenia; anemia may occur; monitor for increased fatigue, dyspnea, and orthostatic hypotension; monitor intake and output ratios and daily weights; monitor for symptoms of pulmonary toxicity, which may manifest early as a dry, non-productive cough; monitor for symptoms of gout (increased uric acid, joint pain, edema); Encourage patient to drink at least 2 L of fluid each day; assess nutritional status; administer anti-emetic prior to and periodically during therapy and adjusting diet as tolerated may help maintain fluid and electrolyte balance and nutritional status; Assess for rash periodically during therapy; Discontinue therapy if steven-johnson syndrome severe or if accompanied with fever, general malaise, fatigue, muscle or joint aches, blisters, oral lesions, conjunctivitis, hepatitis and/or eosinophilia; lab test considerations: monitor CBC and differential prior to and frequently during therapy, and notify health care professional of any sudden drop in leukocyte and thrombocyte values; monitor renal (BUN and creatinine) and hepatic function (AST, ALT, bilirubin, and LDH) prior to and every 1-2 months during therapy; Urine pH should be monitored prior to high-dose and every 6 hr during leucovorin rescue; urine pH should be kept above 7.0 to prevent renal damage; may cause increase serum uric acid concentration, especially during initial treatment of leukemia and lymphoma
Nursing implementation of Methotrexate High Alert: fatalities have occurred with chemotherapeutic agents. Before administering, clarify all ambiguous orders; double-check single, daily, and course of therapy dose limits; have second practitioner independently double-check original order, calculations and infusion pump settings; Methotrexate for non-oncologic use is given at a much lower dose and frequency-often just once a week; Do not confuse non-oncologic dosing regimens with dosing regimens for cancer patients
Routing of Methotrexate Direct IV; Intermittent/continuous infusion; Y-site compatibility; IT (Administration within the cerebrospinal fluid at any level of the cerebrospinal axis, including injection into the cerebral ventricles)
Patient/family teaching of Methotrexate Instruct patient to take medication as directed; Instruct patient to notify health care professional promptly if rash, fever; chills; cough; hoarseness; sore throat; signs of infections; lower back or side pain; painful or difficult urination; bleeding gums; bruising; petechiae; blood in stools, urine, or emesis; increased fatigue; dyspnea; or orthostatic hypotension occurs; Caution patient to avoid crowds and persons with known infections; Instruct patient to use soft toothbrush and electric razor and to avoid falls; Caution patient not to drink alcoholic beverages or take medication containing aspirin or other NSAIDs; may precipitate gastric bleeding; Instruct patient to inspect oral mucosa for erythema and ulceration; Discuss the possibility of hair loss with patient and explore methods of coping; Caution patient to use sunscreen and protective clothing to prevent photosensitivity reactions; Advise patient medication may have teratogenic effects; Emphasize need for periodic lab tests to monitor for side effects
Evaluation/Desired outcomes of MethotrexateImprovement of hematopoietic values in leukemia; decrease in symptoms of meningeal involvement in leukemia; decrease in size and spread of non-Hodgkin’s lymphomas and other solid cancers; resolution of skin lesions in severe psoriasis; decreased joint pain and swelling; improved mobility in patients with rheumatoid arthritis; regression of lesions in mycosis fungoides
Potential nursing diagnoses of Methotrexate Risk for infection (adverse reactions); Imbalanced nutrition: less than body requirements (adverse reactions)

Section 2

Question Answer
Clomid, Milophene, and Serophene (Clomiphene) Promote follicular maturation and ovulation in selected infertile women
Clomiphene actions blocks receptors for estrogen; Receptor blockade in the hypothalamus and pituitary makes it appear to these structures that estrogen levels are low; In response, the pituitary increases secretion of gonadotropins (LH and FSH), and these hormones then stimulate the ovary, promoting follicular maturation and ovulation; Success is impossible in women with primary pituitary or ovarian failure, hence pituitary and ovarian function should be verified prior to therapy; If treatment produces follicular maturation yet ovulation fails to occur, it may be possible to induce ovulation by adding hCG to regime
Adverse/Side effects of Clomiphene Hot flashes, nausea, abdominal discomfort, bloating, and breast engorgement; blurred vision, visual flashes; multiple births (usually twins) occur in 8 percent to 10 percent of clomiphene-facilitated pregnancies; Some actions may interfere with conception; Luteal-phase defect may be induced, yet can be corrected by giving progesterone; Because it has anti-estrogenic actions, it may force the production of scant and viscous cervical mucus; estrogen therapy can render cervical secretions more hospitable to sperm. It should be avoided during pregnancy-although no human fetal defects have been reported, it has produced developmental abnormalities in animals
Monitoring of Clomiphene Effects on the ovary can be monitored with serial ultrasound exams; When treatment is successful, the scans will show progressive follicular enlargement, followed by conversion of the follicle to a corpus luteum after ovulation occurs
Route of administration of Clomiphene PO after 5th day of menses or anytime if no menses