Intro to Patient Centered Care Exam II

Pharmacokinetics

• What happens to the drug in the body

• Absorption, distribution, metabolism, excretion of the drug

• Determines drug’s intensity and duration of action

Pharmacodynamics

• How the drug affects the body – its mechanism of action and effects

• How drug molecules interact with target cells for response

• Forms the basis for medication effectiveness

Absorption

Movement of drug from administration site into bloodstream

Factors affecting absorption

• Route of administration: suitability of route for patient

• Drug solubility: must be transformed to liquid for absorption

• pH/ionization: acidity/alkalinity affects GI absorption, stomach acid destroys some medications

• Blood flow: amount of blood flow affects absorption rate

- Vascular disease will impact effectiveness

- Bone infections are difficult to treat

- Walls of abscess can block antibiotic action

Distribution

Drug transport via blood to tissues and organs

Factors affecting distribution

Local blood flow must be adequate for distribution.

• Abscesses, bone infections, skin and toes more difficult

• Applying heat to vasodilate increases blood flow

Membrane permeability

• Drug molecules must cross capillary membranes to reach site

Protein-binding capacity

• Depends on chemical structure of drug

• Only free, unbound drugs can produce pharmacological

effects

Biotransformation

chemical inactivation of drug through conversion into metabolites that can be excreted

Factors affecting metabolism

• Liver function: most metabolism takes place in liver

• Health/disease status: metabolism can be slowed, increasing amount

of circulating drug to toxic levels

• First-pass effect: inactivation of oral drugs as they pass through GI tract

and liver to reach blood circulation

• The reason PO meds have larger doses than parenteral

Factors affecting excretion

• Organ function, especially the kidneys, liver, and lungs

• Exocrine - sweat and salivary glands

• Dermatitis from elimination of metabolites in sweat

Onset

Time needed for drug concentration level to be effective

Duration

Length of time the drug has pharmacological effect

Therapeutic range:

• Peak level – highest level (absorption rate = elimination rate)

• Trough level – lowest level, usually just before next dose

• Therapeutic level – drug concentration in blood produces the desired effect without toxicity

Half-life

Amount of time for half the drug to be eliminated

Therapeutic and secondary effects

• Pharmacodynamics

• Therapeutic effects: predicted, intended, desired

• All other effects are secondary (undesired)

• Both are dose-dependent

Antagonistic

• Drug-drug interaction decreases the effect of one or both

• Need higher dose of the affected drug

Synergistic

• Drug-drug interaction increases the effect of one or both

• Need lower dose of the affected drug

Incompatibilities

• When multiple drugs are mixed together and cause a chemical deterioration of one or both medications

• Common with IV medications – need to infuse separately

• IV potassium and IV heparin ALWAYS need their own IV line

Stock Supply of Drug

• Bulk quantity: Medication is supplied in a larger container with multiple doses

• Central location

• Not patient-specific

Unit Dose

• Individually packaged: Each package contains one dose ready for one administration

• Patient-specific drawers

• 24-hour supply

Automated Dispenser

• Password-accessible locked cart

• Computerized tracking

• Can combine stock and unit doses

Self-Administration

• Individual containers

• Kept at patient’s bedside

• Inhalers, nitroglycerin, topical cream

• Remind patients to report doses to RN

STAT order

needed immediately

Routine orders

given within 2 hours of being written and carried out on schedule

Standing order

written in advance carried out under specific circumstances

5 ways medication orders are communicated

1. CPOE: Computerized Provider Order Entry — Provider enters a medication order into the EHR

2. Handwritten

3. Pre-printed

4. Verbal

5. Telephone (For verbal/ telephone order, provider has to sign it within 24 hrs)

Three Checks

1. Before pouring or removing

• Compare medication to the MAR

2. After pouring or removing

• Verify the label with the MAR

3. At the bedside

• Check the medication again

• Verify with BCMA

• Verify with patient

Six Rights

• Right drug

• Right patient

• Right dose

• Right time

• Right route

• Right documentation

Other Rights

• Right reason

• Right to know

• Right to refuse

Acceptable patient identifiers

• Name

• Date of birth

• Medical record number (MRN)

• Facility account number

• Social Security number

• Address

Enteral (GI tract)

• Oral

• Rectal

• NG, Jpeg, G-tube

Once daily

q.d.

Twice daily

b.i.d.

Before meals

ac

After meals

pc

HS

at bedtime

Granules

small particles of medication to be dissolved in liquid

Effervescent

releases carbon dioxide gas when tablet is dissolved in water

Solutions

clear fluids free from precipitates (solid particles)

Suspensions

solutions that contain undissolved, solid particles

Emulsions

liquids suspended in another liquid in droplet form

Elixirs

clear solutions that have been flavored or sweetened

Syrups

contain high amounts of sugar

Liquid medications must be measured using a calibrated device

dosing cup, oral syringe, dropper, or a cylindrical spoon

Respiratory Inhalations

Absorption via alveoli and blood supply

• Atomizers

• Aerosol

• Metered dose inhaler

• DPI: dry powder inhaler

Needle

Length from 1/4 inch to 4 inches

• Short for ID and subcut injections

• 1-3 inches for IM injections

• Range in gauge (diameter of needle) from fine (31 gauge) to large (14 gauge).

Barrel

Contains a calibrated dosing scale

• Hub at one end and a flange at the other end.

• The hub of the syringe is either a slip-tip or luer-lock design.

• Luer-lock hubs are threaded to allow needles and other devices to be connected securely to the syringe.

• The barrel’s flange provides counter pressure for the plunger when injecting medication.

ID injections are limited to

0.1 mL

Subcut injections are limited to

1 mL

IM injections are limited to

4 to 5 mL

Parenteral Medication Administration

• IV push

• IV piggyback

• Medicated drips

• IV fluids for hydration

Anabolism

forming larger molecules from smaller ones, such as proteins formed from amino acids

Catabolism

breakdown of larger molecules into smaller ones

– releases energy

Carbohydrates

• CHO

• Stored in liver as glycogen

• Each gram of CHO has 4 calories

Proteins

• Needed for tissue building, immune function, fluid balance, acid-

  base balance, secondary energy source

• Breakdown of amino acids, nitrogen converted to ammonia and

  excreted in urine as urea

• Nitrogen balance reflects healthy maintenance of body tissues

• Each gram of protein has 4 calories

Lipids

• Essential for cell metabolism, cell membranes, precursor to

  steroid hormones

• Provide organ protection, thermoregulation, nerve impulse

  transmission

• Each gram of fat has 9 calories

Sterols

a steroid compound, needed for cell membranes, and building many hormones. Cholesterol is a sterol

Phospholipids

soluble in water, component of lipoproteins, transport lipids in bloodstream

• LDL: transport cholesterol to cells, excess stored as fatty deposits

• HDL: transport cholesterol from bloodstream to liver

Triglycerides

common dietary lipid

• Major energy source for activity

• Assists in absorption and transport of vitamins A,D,E,K

Fatty acids

saturated and unsaturated (with hydrogen)

• Unsaturated , poly- or monousaturated lighter, less dense

• Trans-fats have hydrogen added by food manufacturers, may be

more harmful than saturated fat

• Saturated: from animal sources, may increase risk of heart disease

Vitamins

Regulate body functions through biochemical reactions

• Cell and tissue growth

• Mineral and bone metabolism

• Support immune system

• Support blood clotting

Fat-soluble absorbed in GI tract with lipids: A,D, E, K

• Excess can be toxic

Water-soluble absorbed in GI tract with water

• Excess will be excreted in urine

Vitamin A

eye and bone development, immune function

• Yellow & orange fruits & vegetables, dark leafy greens, eggs, milk, liver

Vitamin D

Calcium absorption, promotes bone growth

• Dairy products, egg yolks, synthesized in skin from sunlight exposure

Vitamin E

Antioxidant

• Seeds, nuts, vegetable oils, avocados, wheat germ

Vitamin K

Blood clotting and bone health

• Dark green leafy vegetables, broccoli, Brussel sprouts, cabbage

Vitamin B6

Na+ and K+ balance, RBC synthesis, protein metabolism

• Potatoes, bananas, beans, seeds, nuts, meat, fish, poultry, soy, dark greens

Vitamin B12

Nerve cell function, RBC production

• Fish, meat, poultry, dairy products, eggs (ONLY from animal sources)

Vitamin C

Collagen production for connective tissue and teeth, wound healing

• Citrus fruits, red berries, peppers, tomatoes, broccoli, dark greens

Minerals

• Inorganic compounds that work with other nutrients for body function

• Assist in fluid regulation, nerve impulse transmission, energy

  production, removal of metabolic by-products, and disease

  prevention

• Calcium and phosphorous are most common, stored in bones

• Most minerals are ionized

• Excess can be toxic

Potassium

Nerve and muscle function

• Meats, some fish, dairy, legumes, fruits, vegetables

Sodium

Blood pressure, blood volume, muscle and nerve function

• Table salt, milk, beets, celery, processed foods

Calcium

Bone structure, nerve and muscle function

• Dairy, dark leafy veg, molasses, nuts, Brewer’s yeast, some fish

Iron

Oxygen transport in blood, production of ATP

• Meat, poultry, fish, legumes, nuts, seeds, whole grains, dark greens

Water

• Maintains body temperature, fills in spaces

• Check IV site

  • infiltrated (edema)

  • phlebitis (inflammation of a vein; red, corded)

Clear liquids

fluids for dehydration with some simple CHO

• Water, tea, broth, clear juices, popsicles, soda, gelatin (Jello)

Indications

• Rest GI tract

• Maintain fluid balance

• Immediate post-op

• Nausea, vomiting, diarrhea

• Pre-op for diagnostic testing

Full liquids

Includes foods that are liquid at room temperature, clear or opaque

• Soups, milk, milk shakes, pudding, custard, juices, yogurt, strained fruits & veg

Indications

• Has tolerated clear liquids

• Intolerance to solid foods

• Febrile illness

Mechanical soft diet

For difficulty chewing or fatigue

• Soft vegetables and fruit, chopped or ground meat, bread,

pastries, eggs, cheese, canned fruits, rice

• Many foods can be ground to accommodate

Indications

• Chewing or swallowing difficulty

• Head, neck, mouth surgery

• Intestinal stricture

• Post-CVA

Pureed

Food and fluids in thick liquid form, scrambled eggs

• Not palatable to many people

Indications

• Transition from liquid to regular

• Swallowing or chewing difficulty

• Oral or facial surgery

Regular diet

no restrictions, 2000 cal/day, balanced

NPO

nothing by mouth, including water

Sodium restricted

for fluid balance, BP, or Meniere’s disease

Fat restricted

for weight loss or high cholesterol/triglycerides

Consistent carb

to manage calories and CHO, diabetic

Renal diet

manages electrolytes and fluid, sometimes protein

Cardiac

usually the same as sodium restriction

Low Protein Diets

Indications

• Hepatic encephalopathy

• Hepatic coma

• Renal impairment

Increase

• CHO to meet nutritional needs

High Protein Diets

Indications:

• Tissue repair and building

• Burns

• Metabolic syndromes

• Pregnancy

Overweight

body mass index >25 but <29.9

Obesity

body mass index >30

Identifying Nutritional Imbalances

Complete Physical Examination

• General survey

• Alterations in vital signs

• Poor skin turgor, wound healing

• Concave abdomen/ascites

• Change in muscle mass

Laboratory Results

• Changes in blood glucose, serum albumin, creatinine, hemoglobin

• Albumin and pre-albumin levels can indicate adequacy of protein

stores. Pre-albumin better indicates acute changes

• Creatinine is end product of skeletal muscle metabolism, level

indicates renal function or loss of muscle mass

Under-nutrition depends on cause

• Malnutrition

• Anorexia

• Bulimia

G-Tubes

PEG tube, J-tube, G-button: surgically placed into stomach or jejunum for long-term tube feedings

Feeding Tube

Nasogastric (NG) or nasojejunal (NJ)

• Before first use: X-ray confirmation is generally the gold standard for confirming placement of a newly inserted feeding tube

• Before each use: Verify placement aspirate pH - acidic

• Never rely on injecting air and listening over the stomach (“whoosh test”)

• Hold feed if > half of prior bolus

• Tube feeds are hypertonic - Can cause diarrhea

• Change tubing every 24 hours

• Check for residual in stomach with 60 ml syringe- Refeed residual

Parenteral Nutrition

• Nutritional fluids administered intravenously through a

  large vein

• TPN: Total parenteral nutrition: through a central line due to high concentration of dextrose – monitor BG

• PPN: Partial parenteral nutrition: PICC (Peripherally Inserted Central Catheter) line, less dextrose

• MUST be confirmed with X-ray prior to infusion

Sliding Scale Insulin

A Sliding-Scale protocol involves administering a variable amount

of rapid- or short-acting insulin based upon blood glucose levels

drawn prior to meals

Insulin syringes

30, 50, and 100 units size

Upper Airway

• Above the larynx: nasal passages, mouth, pharynx

• Not considered sterile

Lower airway

• Below the larynx: trachea, bronchi, bronchioles

• Considered sterile

Inhalation

Lungs expand

Exhalation

Lungs compressed

Hypoxemia

Low Blood Oxygen Level

Hypoxia

Oxygen deficiency in body tissues