chapter 26 Unit 5Medications Chapter 26 Affecting the Hematologic System Growth Factors Overview ●● ●● ●● Blood cells and platelets are produced in the body by the biological process hematopoiesis. In the body, this process is naturally controlled by hormones, also known as hematopoietic growth factors. Genetically engineered products are available for therapeutic purposes. ◯◯ Replacement of neutrophils and platelets after chemotherapy ◯◯ Hastening of bone marrow function after a bone marrow transplant ◯◯ Increase in red blood cell production for clients who have chronic renal failure There are three groups of hematopoietic growth factors. ◯◯ Erythropoietic growth factors ■■ ◯◯ Leukopoietic growth factors ■■ ◯◯ Biological name – erythropoietin Biological names ☐☐ Granulocyte colony stimulating factor (G-CSF) ☐☐ Granulocyte-macrophage colony-stimulating factor (GM-CSF) Thrombopoietic growth factor ■■ Interleukin-11 Medication Classification: Erythropoietic Growth Factors ●● Select Prototype Medication: epoetin alfa (Epogen, Procrit) ●● Other Medications ◯◯ Darbepoetin alfa (Aranesp) – long-acting erythropoietin ◯◯ Methoxy polyethylene glycol (MGEG)-epoetin beta (Mircera) – very long-acting erythropoietin Purpose ●● ●● Expected Pharmacological Action – Hematopoietic growth factors act on the bone marrow to increase production of red blood cells. Therapeutic Uses – Anemia related to chronic renal failure, use of zidovudine (Retrovir) in clients who have HIV infection, chemotherapy, and elective surgery RN Pharmacology for Nursing 341 CHAPTER 26 Growth Factors Complications Adverse Effects Nursing Interventions/Client Education ›› Hypertension secondary to elevations in hematocrit level ›› Monitor Hgb levels and blood pressure. If elevated, administer antihypertensive medications. ›› Risk for a thrombotic event, such as myocardial infarction or stroke if the client has a Hgb of 11 g/dL or higher, or an increase of more than 1 g in 2 weeks. Seizures may also occur with a too-rapid rise in the blood counts. ›› Decrease dosage when these limits are reached. Therapy may be resumed when Hgb drops to acceptable level, but dosage should be reduced. ›› Increased risk for deep-vein thrombosis in preoperative clients ›› Prophylactic use of an anticoagulant may be needed for preoperative clients. ›› Headache and body aches ›› Report headaches that are frequent or severe to provider. Hypertension may be the cause. Contraindications/Precautions ●● Pregnancy Risk Category C. ●● Contraindicated in clients who have uncontrolled hypertension. ●● Contraindicated in clients who have certain cancers because of possible increase in tumor growth. Nursing Administration ●● ●● ●● ●● Obtain baseline blood pressure. In clients who have chronic kidney injury, control hypertension before the start of treatment. Monitor blood pressure frequently, because adjustments in antihypertensive medication may also be required as treatment progresses. Administer by subcutaneous or IV bolus injection. Dosage is based on client’s weight. Do not agitate the vial of medication. Use each vial for one dose, and do not put the needle back into the vial when withdrawing the medication. ●● Do not mix medication with any other medication in syringe. ●● Dosing is usually three times/week, but may be once per week with some types of chemotherapy. ●● ●● ●● Monitor iron levels, and implement measures to ensure a normal iron level. RBC growth is dependent upon adequate quantities of iron, folic acid, and vitamin B12. Without adequate levels of these, erythropoietin is significantly less effective. Monitor Hgb and Hct twice a week until target range is reached. The longer-acting forms are administered less frequently (weekly or monthly), but can be prescribed for clients who have chronic kidney failure only. Nursing Evaluation of Medication Effectiveness ●● 342 Depending on therapeutic intent, effectiveness may be evidenced by Hgb level of 10 to 11 g/dL and maximum Hct of 33%. RN Pharmacology for Nursing CHAPTER 26 Growth Factors Medication Classification: Leukopoietic Growth Factors ●● Select Prototype Medication: filgrastim (Neupogen) ●● Other Medication: pegfilgrastim (Neulasta) Purpose ●● ●● Expected Pharmacological Action – Leukopoietic growth factors stimulate the bone marrow to increase production of neutrophils. Therapeutic Uses ◯◯ Decreases the risk of infection in clients who have neutropenia, from cancer and other conditions ◯◯ To build up numbers of hematopoietic stem cells prior to harvesting for autologous transplant Complications Adverse Effects Nursing Interventions/Client Education ›› Bone pain ›› Monitor for bone pain and notify the provider. ›› Administer acetaminophen or opioid analgesic if acetaminophen is not effective. ›› Leukocytosis ›› Monitor CBC two times per week during treatment. ›› Decrease dose or interrupt treatment if WBC is greater than 100,000/mm3 or absolute neutrophil count exceeds 10,000/mm3. ›› Splenomegaly and risk of splenic rupture with long‑term use ›› Evaluate reports of left upper quadrant abdominal pain or shoulder tip pain carefully and report to provider. Contraindications/Precautions ●● Contraindicated in clients who are sensitive to Escherichia coli protein. ●● Use cautiously in clients who have cancer of the bone marrow. Nursing Administration ●● ●● ●● ●● Administer filgrastim by intermittent IV bolus, continuous IV, subcutaneous infusion, or subcutaneous injection. Do not agitate the vial of medication. Use each vial for one dose, and do not combine with other medications. Do not put the needle back into the vial when withdrawing the medication. Monitor CBC two times per week. If client will be administering subcutaneous filgrastim at home, provide thorough instruction on self-administration procedures. RN Pharmacology for Nursing 343 CHAPTER 26 Growth Factors Nursing Evaluation of Medication Effectiveness ●● Depending on therapeutic intent, effectiveness may be evidenced by: ◯◯ Absence of infection. ◯◯ WBC count and differential within expected reference ranges. Medication Classification: Granulocyte Macrophage Colony Stimulating Factor ●● Select Prototype Medication: sargramostim (Leukine) Purpose ●● ●● Expected Pharmacological Action – This medication acts on the bone marrow to increase production of white blood cells (neutrophils, monocytes, macrophages, eosinophils). Therapeutic Uses ◯◯ Hastens bone marrow function after bone marrow transplant ◯◯ Used in the treatment of failed bone marrow transplant Complications Adverse Effects Nursing Interventions/Client Education ›› Diarrhea, weakness, rash, malaise, and bone pain ›› Monitor for adverse effects and notify the provider if they occur. ›› Leukocytosis, thrombocytosis ›› Monitor CBC two times per week during treatment. ›› Administer acetaminophen. ›› Reduce dose or interrupt treatment for absolute neutrophil count 20,000/mm3 or greater, WBC 50,000/mm3 or greater, or platelets 500,000/mm3 or greater. ›› First IV dose effect: tachycardia, hypotension, chills, fever, diaphoresis, dyspnea ›› Assess carefully for these effects and notify provider if they occur. Contraindications/Precautions ●● ●● ●● 344 Contraindicated in clients allergic to yeast products. Use cautiously in clients who have heart disease, hypoxia, peripheral edema, or pleural or pericardial effusion. Use cautiously in clients who have cancer of the bone marrow. RN Pharmacology for Nursing CHAPTER 26 Growth Factors Nursing Administration ●● ●● ●● Obtain baseline CBC, differential, and platelet count. Monitor periodically during treatment. When administered subcutaneously, reconstitute with sterile water. Mix contents gently, but do not shake vial. Administer by IV infusion, diluted and without an in-line membrane filter. Slow or discontinue infusion if client who has pre-existing heart failure or respiratory disorders experiences increase in dyspnea. Nursing Evaluation of Medication Effectiveness ●● Depending on therapeutic intent, effectiveness may be evidenced by: ◯◯ Absence of infection. ◯◯ WBC and differential within expected reference ranges. Medication Classification: Thrombopoietic Growth Factors ●● Select Prototype Medication: oprelvekin (Interleukin-11, Neumega) Purpose ●● ●● Expected Pharmacological Action – Increases the production of platelets. Therapeutic Uses – Decreases thrombocytopenia and the need for platelet transfusions in clients receiving chemotherapy. Complications Adverse Effects Nursing Interventions/Client Education ›› Fluid retention (peripheral edema, dyspnea on exertion) ›› Monitor I&O. ›› Cardiac dysrhythmias (tachycardia, atrial fibrillation, atrial flutter) ›› Use cautiously in clients who have a history of cardiac dysrhythmias. ›› Conjunctival injection, transient blurring of vision, papilledema (inflammation of the eye and eyelid) ›› Advise the client to observe for adverse effects. The medication should be withheld until notification of the provider. ›› Allergic reactions, possible anaphylaxis ›› Observe the client carefully for allergic reactions. Stop the medication and notify the provider if adverse effects occur. RN Pharmacology for Nursing ›› If adverse effects occur, stop the medication and notify the provider. ›› Monitor vital signs, heart rate, and rhythm. ›› If adverse effects occur, stop the medication and notify the provider. 345 CHAPTER 26 Growth Factors Contraindications/Precautions ●● ●● Generally contraindicated in clients who have cancer of the bone marrow, because they may stimulate tumor growth. Use cautiously in clients who have heart failure and pleural effusion. Nursing Administration ●● Obtain baseline CBC, platelet count, and electrolytes. ●● Oprelvekin should not be agitated and or combined with other medications. ●● Administer oprelvekin once daily by subcutaneous injection until platelet count reaches prescribed level. Nursing Evaluation of Medication Effectiveness ●● 346 Depending on therapeutic intent, effectiveness may be evidenced by platelet count greater than 50,000/mm3. RN Pharmacology for Nursing CHAPTER 26 Growth Factors Application Exercises 1. A nurse is caring for a client who is receiving daily doses of oprelvekin (Interleukin-11). Which of the following laboratory values should the nurse monitor to determine effectiveness of this medication? A. Hemoglobin B. Absolute neutrophil count C. Platelet count D. Total white blood count 2. A nurse is preparing to administer filgrastim (Neupogen) for the first time to a client who has just undergone a bone marrow transplant. Which of the following interventions is appropriate? A. Administer intramuscularly in a large muscle mass to prevent injury. B. Ensure that the medication is refrigerated until just prior to administration. C. Shake vial gently to mix well before withdrawing dose. D. Discard vial after removing one dose of the medication. 3. A nurse is monitoring a client who is receiving epoetin alfa (Epogen) for adverse effects. Which of the following is an adverse effect of this medication? A. Leukocytosis B. Hypertension C. Edema D. Blurred vision 4. A nurse is assessing a client who has chronic neutropenia and who has been receiving filgrastim (Neupogen). Which of the following actions should the nurse take to assess for an adverse effect of filgrastim? A. Assess for bone pain. B. Assess for right lower quadrant pain. C. Auscultate for crackles in the bases of the lungs. D. Auscultate the chest to listen for a heart murmur. RN Pharmacology for Nursing 347 CHAPTER 26 Growth Factors 5. A nurse is teaching a client who has chronic kidney injury and who is starting subcutaneous epoetin alfa (Epogen) three times weekly. What should the nurse teach the client about this medication? Use the ATI Active Learning Template: Medication to complete this item to include the following: A. Therapeutic Use: Identify for epoetin alfa in this client. B. Adverse Effects: Identify two the client should watch for. C. Diagnostic Tests: Describe two the nurse should monitor periodically. D. Nursing Actions: Describe two. 348 RN Pharmacology for Nursing CHAPTER 26 Growth Factors Application Exercises Key 1.A. INCORRECT: Hemoglobin levels should be monitored for a client receiving epoetin alfa (Epogen). B. INCORRECT: Absolute neutrophil count should be monitored for a client receiving filgrastim (Neupogen). C. CORRECT: The expected outcome for oprelvekin is a platelet count greater than 50,000/mm3. D. INCORRECT: A total WBC should be monitored for a client receiving sargramostim (Leukine). NCLEX® Connection: Pharmacological and Parenteral Therapies, Expected Actions/Outcomes 2.A. INCORRECT: Filgrastim is not administered by the IM route. B. INCORRECT: The nurse can allow the medication to reach room temperature prior to administration. C. INCORRECT: Before withdrawing a dose of filgrastim, the nurse should take care not to shake the medication vial. D. CORRECT: Only one dose of filgrastim should be withdrawn from the vial and the vial should then be discarded. NCLEX® Connection: Pharmacological and Parenteral Therapies, Medication Administration 3.A. INCORRECT: Leukocytosis is an adverse effect of filgrastim (Neupogen) rather than for epoetin alfa (Epogen). B. CORRECT: Hypertension is an adverse effect of epoetin alfa that the nurse should monitor for throughout treatment. C. INCORRECT: Edema is an adverse effect of oprelvekin (Interleukin-11) caused by fluid retention, rather than of epoetin alfa. D. INCORRECT: Blurred vision is an adverse effect of oprelvekin, rather than of epoetin alfa. NCLEX® Connection: Pharmacological and Parenteral Therapies, Adverse Effects/Contraindications/ Side Effects/Interactions RN Pharmacology for Nursing 349 CHAPTER 26 Growth Factors 4.A. CORRECT: Bone pain is a dose-related adverse effect of filgrastim. It can be treated with acetaminophen and, if necessary, an opioid analgesic. B. INCORRECT: Palpating gently for right lower quadrant pain may be a necessary part of the nurse’s assessment, but will not assess for an adverse effect of filgrastim. C. INCORRECT: Auscultating for crackles in the bases of the lungs may be a necessary part of the nurse’s assessment, but will not assess for an adverse effect of filgrastim. D. INCORRECT: Auscultating the chest to listen for a heart murmur may be a necessary part of the nurse’s assessment, but will not assess for an adverse effect of filgrastim. NCLEX® Connection: Pharmacological and Parenteral Therapies, Adverse Effects/Contraindications/ Side Effects/Interactions 5. Using the ATI Active Learning Template: Medication A. Therapeutic Use ●● B. Adverse Effects ●● Headaches and myalgia (body aches) ●● Thrombotic events, such as myocardial infarction and cerebral vascular accident ●● Hypertension (common, sometimes serious) ●● Erythropoietin, a substance that stimulates bone marrow to produce red blood cells, is produced by the kidney. In clients who have kidney failure, erythropoietin is no longer present and anemia results. Epoetin alfa stimulates production of red blood cells in these clients. A too-rapid increase (Hgb greater than 1 g/dL over 2 weeks, or Hgb above 10 to 11 g/dL) can worsen hypertension, increase risk of thrombosis, and cause seizures. C. Diagnostic Tests ●● Baseline iron levels, CBC with differential, and platelet count ●● Hgb and Hct twice weekly until blood counts stabilize D. Nursing Actions ●● ●● Calculate dosages carefully. Both subcutaneous and IV epoetin alfa have dosages based on the client’s weight. Do not shake the epoetin alfa vial, and discard vial after one dose is removed. Monitor blood pressure carefully and report increases to the provider. Question client about frequency and severity of headaches, which could be an indication of increasing BP or a simple adverse effect. NCLEX® Connection: Pharmacological and Parenteral Therapies, Medication Administration 350 RN Pharmacology for Nursing
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