NUR 1141 Pharmacology Assignment: Isotretinoin Concept Map, Otic Drops in Children, Immunity Types, Cyclosporine and Timolol

NUR 1141 Pharmacology: Dermatologic, otic, immunologic and ophthalmic medications (5 questions, 20 points each)

Question 1. Create a concept map for one of the dermatologic medications in the Lesson Plan, using the NUR 1141 Pharmacology Concept Map template.

Question 2. A 2-year-old girl has irritability, poor sleep, ear tugging, low-grade fever and decreased appetite. She is diagnosed with acute otitis media and prescribed antibiotic otic drops. What is the purpose of antibiotic otic drops, and what positioning technique should be used to give ear drops to a young child, and why?

Question 3. Differentiate between antigens, antibodies, toxoids and immunoglobulins. Discuss natural active, artificial active, natural passive and artificial passive immunization, with an example of each.

Question 4. A liver transplant recipient admitted for an asthma exacerbation takes cyclosporine (Sandimmune), but the automated dispensing system stocks cyclosporine modified (Neoral). What is cyclosporine’s mechanism of action? What is the difference between Sandimmune and Neoral? What should the nurse do? What adherence teaching should be provided?

Question 5. A 62-year-old woman has an intraocular pressure of 23 mm Hg. After a topical anesthetic and tetracaine drops, she waits for mydriatic and cycloplegic effects. What are these effects and their purposes? She is prescribed “Timolol (Timoptic) two gtts AD daily HS.” What actions should the home health nurse take, and what teaching should be provided about timolol?

Original example for study purposes (about 1,600 words). Transfer Question 1 into the required course template and cite your pharmacology textbook.

Question 1: Medication Concept Map, Isotretinoin

I selected isotretinoin, an oral retinoid for severe acne. Confirm that it appears on your Lesson Plan list; if not, use the same headings for your assigned drug.

Question 2: Antibiotic Otic Drops for Acute Otitis Media

Purpose. Antibiotic otic drops, such as ofloxacin or ciprofloxacin with dexamethasone, deliver a high concentration of antibiotic directly to the ear to eradicate bacteria and reduce infection and inflammation, with fewer systemic side effects than oral antibiotics. Students should note an important clinical point: drops reach the middle ear only when there is an opening in the eardrum, such as a perforation with drainage (otorrhea) or tympanostomy tubes. For a child with an intact eardrum, the American Academy of Pediatrics recommends oral high-dose amoxicillin as first-line therapy when antibiotics are needed, along with pain management (Lieberthal et al., 2013). The nurse should clarify the order if the child has no drainage or tubes.

Positioning technique.

• Warm the bottle in the hands for a few minutes, because cold drops can cause dizziness and pain.
• Lay the child on her side with the affected (right) ear facing up, with a caregiver helping to keep her still.
• For a child under 3 years old, gently pull the pinna (earlobe) down and back. For children over 3 and adults, pull the pinna up and back.
• Instill the prescribed drops without touching the dropper to the ear, gently press the tragus a few times to move the drops inward, and keep the child on her side for 2 to 5 minutes. A cotton ball may be placed loosely at the opening.

Why: a young child’s ear canal is shorter and directed upward, so pulling the pinna down and back straightens the canal and lets the medication reach the eardrum. Keeping the ear up prevents the drops from leaking out.

Question 3: Immunity Terms and Types of Immunization

Active immunity occurs when the body produces its own antibodies and memory cells; it takes time to develop but lasts long. Passive immunity occurs when ready-made antibodies are received; it works immediately but lasts only weeks to months.

• Natural active: immunity after having the disease. Example: a child who recovers from chickenpox develops lasting immunity to varicella.
• Artificial active: immunity from a vaccine or toxoid. Example: the MMR vaccine or tetanus toxoid.
• Natural passive: maternal antibodies passed to the baby. Example: IgG crossing the placenta and IgA in breast milk.
• Artificial passive: injected antibodies. Example: tetanus immune globulin after a contaminated wound or hepatitis B immune globulin for an infant born to a mother with hepatitis B.

Question 4: Cyclosporine (Sandimmune vs. Neoral)

Mechanism of action. Cyclosporine is a calcineurin inhibitor. It binds to the intracellular protein cyclophilin, and this complex inhibits calcineurin, which prevents activation of the transcription factor NFAT. As a result, T lymphocytes cannot produce interleukin-2 and other cytokines needed for their activation and proliferation, which suppresses the T-cell-mediated immune response that would reject the transplanted liver.

Sandimmune vs. Neoral. Both contain cyclosporine, but they are different formulations. Neoral (cyclosporine modified) is a microemulsion that is absorbed more consistently and more completely than Sandimmune, so it produces higher and more predictable blood levels. The two products are not bioequivalent and cannot be substituted for each other without a prescriber’s order and close blood-level monitoring. Switching without adjustment could cause toxicity, such as nephrotoxicity, hypertension and neurotoxicity, or, in the other direction, subtherapeutic levels and organ rejection.

Nursing actions.

1. Do not give Neoral in place of Sandimmune.
2. Notify the prescriber and pharmacist immediately so the correct formulation can be ordered and supplied; ask whether the patient’s own supply may be used according to policy.
3. Avoid missing or delaying the dose; immunosuppressants should be given at consistent times.
4. If the prescriber changes the formulation, expect orders for cyclosporine trough levels, serum creatinine, BUN, potassium, magnesium and blood pressure monitoring.
5. Check interactions with asthma treatment. Systemic corticosteroids add immunosuppression, and drugs such as macrolide antibiotics can raise cyclosporine levels.
6. Document the discrepancy and report it through the facility’s safety reporting system.

Adherence teaching. Take cyclosporine every day at the same times, with the same relationship to meals, and never skip or stop doses, because missed doses can cause rejection. Use only the same brand and formulation; check refills and report any change. Do not take grapefruit or grapefruit juice, St. John’s wort or new medicines without asking the transplant team. Keep appointments for blood levels and kidney tests, practice infection prevention, check blood pressure, report signs of rejection or infection (fever, jaundice, dark urine, abdominal pain) and use sun protection because of skin cancer risk.

Question 5: Mydriasis, Cycloplegia and Timolol

Mydriatic and cycloplegic effects. Mydriasis is dilation of the pupil, and cycloplegia is paralysis of the ciliary muscle, which prevents accommodation (focusing). Dilation lets the ophthalmologist see the optic nerve and retina to look for glaucomatous damage, which matters here because an intraocular pressure of 23 mm Hg is above the usual normal range of about 10 to 21 mm Hg. Cycloplegia prevents the eye from focusing, allowing accurate refraction and examination, and relieves ciliary spasm. These effects are produced by drugs such as tropicamide, cyclopentolate (anticholinergics) and phenylephrine (an adrenergic). Tetracaine itself is a topical anesthetic used to numb the cornea for tonometry; it does not dilate the pupil, so students should identify the dilating drops separately. The patient should expect blurred vision and light sensitivity for several hours, should wear sunglasses and should not drive herself home.

Nursing actions for the timolol order. The order “Timolol (Timoptic) two gtts AD daily HS” contains several problems, so the nurse should not give it as written and should contact the prescriber to clarify:

• Wrong site: “AD” means right ear (auris dextra). Timolol ophthalmic solution is used for glaucoma and belongs in the eye; the prescriber probably meant OD (right eye) or OU (both eyes). The Institute for Safe Medication Practices lists AD, AS, AU, OD, OS and OU as error-prone abbreviations that should be written out, such as “right eye” (Institute for Safe Medication Practices [ISMP], 2021).
• Dose: timolol is usually given as one drop; two drops increases systemic absorption without improving effect.
• Frequency: “daily HS” should be clarified, since standard timolol solution is usually given twice daily and the gel-forming solution once daily. “HS” is also an error-prone abbreviation.
• Confirm the strength (0.25% or 0.5%), screen for contraindications such as asthma, COPD, bradycardia, heart block and heart failure, and document the clarified order.

Patient teaching about timolol.

• Timolol is a beta-blocker that lowers eye pressure by decreasing aqueous humor production; glaucoma has no symptoms, so it must be used every day for life even if her eyes feel “fine.”
• Wash hands, tilt the head back, pull down the lower lid, instill one drop into the pocket without touching the tip, close the eye and press on the inner corner (nasolacrimal occlusion) for 1 to 2 minutes to reduce absorption into the body.
• Wait at least 5 to 10 minutes between different eye drops, and remove contact lenses before use.
• Expect brief stinging. Report slow pulse, dizziness, fainting, shortness of breath or wheezing, swelling of the feet, fatigue or depression, because the drug can cause systemic beta-blocker effects.
• If she has diabetes, timolol can mask signs of low blood sugar such as a fast heartbeat.
• Keep follow-up appointments for pressure checks and tell all providers she uses timolol.

References

Institute for Safe Medication Practices. (2021). ISMP list of error-prone abbreviations, symbols, and dose designations. https://www.ismp.org/recommendations/error-prone-abbreviations-list

Lieberthal, A. S., Carroll, A. E., Chonmaitree, T., Ganiats, T. G., Hoberman, A., Jackson, M. A., Joffe, M. D., Miller, D. T., Rosenfeld, R. M., Sevilla, X. D., Schwartz, R. H., Thomas, P. A., & Tunkel, D. E. (2013). The diagnosis and management of acute otitis media. Pediatrics, 131(3), e964–e999. https://doi.org/10.1542/peds.2012-3488

[Your NUR 1141 pharmacology textbook, in APA format.]

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