Page 636 - Cardiac Nursing

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612 PA R T I V / Pathophysiology and Management of Heart Disease
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the most difficult to treat. Prophylactic regimes have been alter the metabolism of these drugs. It is extremely important for
shown to be effective in transplant recipients to prevent or at- nurses to know most of these interactions to avoid adverse side ef-
tenuate opportunistic infections. Trimethoprim–sulfamethoxa- fects, in addition to understanding the pharmacology of cal-
zole is used against Pneumocystis carinii. CMV prophylaxisis in- cineurin inhibitors. Patients are taught to take this drug after
cludes intravenous ganciclovir postoperatively for several days meals to decrease the possibility of gastrointestinal intolerance and
then oral ganciclovir for 6 weeks up to a year to atenuate acti- to promote absorption.
vation or reactivation. In addition, hyperimmune globulin Hypertension is a serious side effect that often is difficult to
(CMVIG) may be used in high risk patients who are CMV control. Patients need to monitor their hypertension and should
sero-negative recipients of a seropositive donor. 61,78 In addi- be taught how to take an accurate blood pressure. They are also
tion, antifungal mouth losengers are used to prevent oral can- sent home with an understanding of what symptoms, such as
didiasis, some centers have patients take oral antifungals to help headaches, may indicate their hypertension has become uncon-
prevent aspirgillious infections. trolled.
Hand washing and universal precautions are used as the main- Cyclosporine therapy does result in changed bodily appear-
stays of protection in the hospitalized patient. Infection is moni- ance, particularly diffuse increased hair growth. Changed bodily
tored for closely. Because the lungs are the primary site of infec- appearance was reported in 34% of 44 patients on cyclosporine
tion, daily chest radiographs are performed immediately after and corticosteroid protocols. Excessive hair growth was reported
83
surgery as well as chest auscultation are performed every 4 hours. in 45% of the patients. Nurses can coach patients to prepare
Good pulmonary assessment is extremely important. Incentive for this side effect and provide ideas for managing this problem.
spirometry, early mobility, and coughing and deep breathing are Cyclosporine can also cause neurotoxicity, and patients may
used to minimize atelectasis and possible infection. A temperature exhibit tremors and report headache.
rise over 37 C, changes on the chest radiograph, or development
of a cough are indications for obtaining sputum cultures. A tem- Tacrolimus. Tacrolimus (Prograf), formally referred to as
perature increase more than 38 C is an indication for blood cul- FK506, is a potent immunosuppressive macrolide antibiotic.
tures. Otherwise, routine laboratory screening for infection is per- Tacrolimus acts by inhibition of the earliest steps of T-cell activa-
formed on a weekly basis, except white blood cell counts, which tion in a manner similar to that of cyclosporine. It was initially
are performed daily. used in liver and kidney transplantation with successful results,
and it is now used as a frequent alternative to cyclosporine. It is
Monitoring for Immunosuppressive used as an effective agent for rescue therapy in refractory cardiac
Drug Side Effects rejection and as a primary immunosuppressant in many centers. 84
Specific adverse effects and clinical manifestations of common Tacrolimus has demonstrated that it is well tolerated in gen-
immunosuppressive drugs are outlined in Table 25-5. Several side eral. It is nephrotoxic, as is cyclosporine, and has a slightly higher
effects have implications for patient teaching and coaching and diabetogenic effect. Tacrolimus does not cause hirsutism, gingival
warrant further discussion. Nurses play a key role in providing pa- hyperplasia, or facial dysmorphism as cyclosporine can. Its pri-
tients with knowledge of drug side effects and methods of self- mary side effects are headache, nausea, and tremors. It is impor-
monitoring. It is important that patients are able to detect prob- tant to monitor patient blood levels, kidney function, and blood
lems that can be injurious to their health and know when to seek glucose. Tacrolimus is also similar to cyclosporine in that it is me-
medical attention. A knowledgeable patient also can take steps to tabolized through the P-450 system; therefore, similar drug inter-
minimize some of these problems. Some of the drug side effects actions are present. 82
may be particularly emotionally troublesome for patients. Nurses
can do much to prepare them for this and assist them with strate- Corticosteroids. The anti-inflammatory actions of corticos-
gies for coping with these side effects. teroids provide important protection of the transplanted heart
against damage from rejection. Steroids impair the sensitivity of T
Calcineurin Inhibitors cells to the foreign antigen, decrease proliferation of sensitized T
Cyclosporine. Cyclosporine (Sandimmune, Neoral, Gengraf, cells, and decrease macrophage mobility. Long-term corticosteroid
Eon) is a natural metabolite found in a fungus. It is a lymphokine- therapy may be associated with several side effects that require
synthesis inhibitor that profoundly inhibits cell-mediated immu- monitoring. Glucose intolerance may develop during hospitaliza-
nity. It also impairs interleukin secretion by macrophages. Cy- tion and persist long enough to require insulin therapy. Insulin
closporine selectively interferes in the immune system, specifically coverage is initiated for serum glucose levels in excess of 200 to
targeting T cells; this specificity allows the body to retain some 250 mg/dL, necessitating patient instruction on diet management
ability to protect itself from infection. 51,52 The drug must be used and self-administration of insulin. Weight gain is problematic for
cautiously and monitored closely. Cyclosporine is nephrotoxic, many patients. Diet instruction and initiation of exercise pro-
leading to a decrease in glomerular filtration rate, renal plasma, grams may help minimize this problem. Regular exercise is also
and blood flow. 79,80 Calcineurin inhibitor-induced arterial hyper- thought to be important in minimizing the calcium loss from
tension has been reported to be as high as 100% and is a difficult bone associated with long-term corticosteroid therapy. Stress ul-
problem to control in the long-term survivor. 81 It is important to ceration is a concern in patients on higher doses of corticosteroid
maintain a consistent administration time for cyclosporine. therapy for long periods. Patients are on H 2 blocker therapy for
Equally important is timely acquisition of blood specimens for cy- prevention of gastric ulcers. Nurses need to be aware of the possi-
closporine levels after the last dose of the drug. Cyclosporine and bility and be alert to signs or symptoms that may indicate a prob-
tacrolimus has numerous drug interactions with common med- lem. It is also necessary to teach the importance of good skin care.
ications. Cyclosporine and tacrolimus are metabolized by the cy- Fragile skin that heals poorly may become a problem with the
tochrome P-450 system, so drugs that affect the P-450 system long-term patient. Patients should be taught to monitor the