NR 565 Week 5 Study Guide

NR 565 Week 5 Study Guide Chapter 26: Drugs used in treating eye & ear disorders Contraindications for topical beta blockers Beta blockers • Suppress conduction through the atrioventricular (AV) node; therefore, topical beta blockers are contraindicated in patients with bradycardia or advanced AV block. • Do not use in patients with compromised ventricular dysfunction, cardiogenic shock, or with systolic congestive HF • D/c at first sign of cardiac failure • Contraindicated with hypotension • Use with caution: poorly controlled DM and hyperthyroidism • Surgical patients should be monitored closely for cardiac failure o Withdraw before surgery 2 days prior • Contraindicated with Raynaud’s disease or PVD, CVD • Preg cat C: fetal anomalies and fetotoxicity in animal studies 2 Prophylaxis for opthalmia neonatorum • Common patient group: infants younger than 1 month who presents with conjunctivitis should have Gram's stain, antigen detection tests, and cultures of the eye discharge to rule out gonococcal, chlamydial, or HSV origin. • Chlamydia is the most common cause of neonatal conjunctivitis • Gonococcal conjunctivitis is the most serious cause of ophthalmia neonatorum owing to concerns about the bacteria causing blindness • Prophylaxis: Administration of antibiotic eye medication within 1 hour of delivery • Erythromycin ointment 0.5% (0.25 to 0.5-inch ribbon in each eye) • Chlamydial conjunctivitis is not prevented by prophylactic use of erythromycin at birth therefore any mucopurulent eye discharge in the first few weeks of life should be evaluated for chlamydia. Glaucoma: Treatment, dosing, and patient education: • IOP damages the optic nerve • Leading cause of blindness worldwide • 6-8 times more likely in African Americans than Caucations • Antiglaucoma medications are prescribed by ophthalmologists. Dosage is determined by the clinical condition of the patient. Treatment and dosing • Current medical therapies are aimed at o decreasing the production of aqueous humor at the ciliary body and o Increasing the outflow of this fluid from the angle structures • Requires evaluation and treatment by an ophthalmologist o FNPs need to be aware of the medications prescribed, drug interactions, and ADRs • Antiglaucoma agents are prescribed by ophthalmologists and dosage is determined by the clinical condition of the patient • Four categories: Beta Blockers, adrenergic agonists, miotics, and carbonic anhydrase (CA) inhibitors o Beta Blockers: ▪ Betaxolol, carteolol, metipranolol, levobunolol, timolol o Adrenergic Agonists ▪ Apraclonidine, brimonidine o Miotics ▪ Carbachol, pilocarpine, echothiophate o Carbonic Anhydrase Inhibitors ▪ Acetazoleamide, brinzolamide, dorzolamide, methazolamide Patient education • The patient should be instructed to administer the medication exactly as the ophthalmologist has prescribed • Abruptly stopping the medication can increase adverse effects. • The patient should have been instructed by the ophthalmologist regarding the adverse effects of the medication. o Reinforcement may be necessary. If the patient is experiencing adverse effects from the medication, the primary care provider can facilitate a referral back to the ophthalmologist. Allergic or Vernal conjunctivitis: Treatment, dosing, and patient education • Occurs in response to a variety of allergens • Vernal conjunctivitis refers to conjunctivitis that occurs primarily in the spring, usually because of an allergen. • The mast cell stabilizers (lodoxamide, cromolyn sodium) may be used to treat vernal conjunctivitis and may be used safely for up to 3 months. Treatment and Dosing • Ketotifen (H1 blocker) for allergic conjunctivitis and ocular pruritus. o The dose used in adults and children over age 3 is 1 drop in the affected eye every 8 to 12 hours • Levocabastine (H1 blocker): allergic conjunctivitis and ocular pruritis o 1 drop in the affected eye 4 times a day. • Mast Cell Stabilizers: o Cromolyn sodium (1-2 gtt, 4-6 times/day) o Pemirolast (Alamast), 1-2 gtts QID o Nedocromil (Alocril), 1-2 gtts in each eye bid at regular intervals • Antihistamines o Antazoline-naphazoline (Vasocon-A), 1-3 gtts Q3-4 hours o Azelastine (Optivar) 1 gtt each eye bid o Epinastine (Elestat) 1 gtt each eye bid o Emedastine (Emadine) 1 gtt QID • OTC products o Combine a decongestant with an antihistamine o Products that combine antazoline and naphazoline (Vasocon-A) or o Naphazoline and pheniramine (Opcon-A, Naphcon-A) 1-2 gtt q3-4 hrs • Patient education o Administration: use exactly as prescribed, overuse or underuse can adversely affect outcomes o Avoid touching the dropper to the ey or other surfaces that may contaminate the medication o Do not share medications o Transient stinging and burning may occur o If severe or prolonged contact provider Bacterial conjunctivitis: Treatment, dosing, and pt education • Children between ages 3 months and 8 years are most likely to have staphylococcal, streptococcal, or Haemophilus conjunctivitis. • Non-typable H. influenzae is seen more in warmer climates between May and October o Most common in children younger than 7 • S. pneumoniae is seen in colder climates and during the winter (elderly) • S. aureus shows no geographic or seasonal pattern (elderly) • Although bacterial conjunctivitis is considered a self-limited disease (unless caused by gonorrhea), patients who receive topical antibiotic therapy have faster clinical improvement. • Treatment and Dosing: Uncomplicated conjunctivitis treated with o Sulfacetamide 10% solution or ointment: ▪ 1-2 gtts q2-3 hrs during the day, less often at night ▪ Or Ointment small amount tid-qid and qhs ▪ Not recommended for infants 2 months ▪ Sulfacetamide gives no coverage against H. influenzae and stings with application, a consideration in choosing an antibiotic o Erythromycin ointment ▪ 0.25-0.5 inch ribbon 2-3 times/day ▪ Safe in infants o Trimethoprim/polymyxin B (Polytrim) ▪ 1 gtt q3h for 7-10 days, up to 6 doses/day ▪ Not recommended for infants 2 months old o bacitracin/polymyxin B (Polysporin) ▪ 0.5 inch ribbon q 3-4 hours ▪ May be used safely in children o Other treatment options: tobramycin, gentamicin, azithromycin, or any fluoroquinolones o If caused by dacryostenosis (s. pneumonia or H. influenzae: treated with: erythromycin, tobramycin, or fluoroquinolones • Patient Education o Administration: Keep tip of dropper or tube from touching the eye, fingertips, or any other surface o Moist cotton swab for application, one swab per eye o Hold bottle of solution with dominant hand using the pointer finger of the other hand to gently pull down on the lower lid to form a pocket for the solution to be dropped into o Methods for children (3) ▪ School aged children can assist by pulling down their own eyelid, care provider instills drops ▪ Lay down on back and close eyes, keeping the head still, a drop of the medication is placed on the inner canthus after placed child slowly opens the eye without moving the head. Medication instills ▪ Immobilize the patient one person holding and one person instilling o Transient burning or stinging, if sever or prolonged, contact provider Viral Conjunctivitis: Treatment, dosing, and patient education • Viral conjunctivitis is usually caused by an adenovirus, HSV, or herpes zoster. • Simple viral conjunctivitis caused by adenovirus is treated with sulfacetamide 10% solution or ointment 4 times a day or a broad-spectrum antibiotic, such as tobramycin, to prevent secondary bacterial infection. • The course of the conjunctivitis runs 12 to 15 day • Herpes keratitis is a potentially serious consequence of HSV infection o If suspected referral to an ophthalmologist for Dx and Tx is indicated • Commonly used agents: gancyclovir, trifluridine, and vidarabine o Trifluridine (Viroptic), 1 gtt every 2 hours while awake, max 9 gtts per day. o After reepithelialization, 1 gtt q4h x 7 days