Pharm Final

subjective data

information provided verbally by the patient, family members, friends, or other sources.

objective data

what the nurse directly observes about the patient’s health status.

* physical health assessment
* lab and diagnostic test
* data from physician’s notes
* measurement of vital signs
* patients body language

What does evaluating a patient always involve?

critical thinking

What is the purpose of the federal legislation?

it attempts to protect the public from drugs that are impure, toxic, ineffective or not tested before public scale: the primary purpose of the legislation is to ensure safety

Food and Drug Act of 1906

set the standards for drug quality and purity in addition to strength and gave birth to the FDA. however, the law did not apply to “false claims of therapeutic efficacy”

The federal food, drug, and cosmetic act of 1938

Empowered the FDA to ensure a drug was safe before marketing. it is the FDA’s responsibility to ensure that all drugs are tested for harmful effects; it is also required that drugs be labeled with accurate information and have detailed literature in the drug packaging that explains adverse effects.

Kefauver-Harris Drug Amendment to the 1938 act

tightened controls on drug safety, especially experimental drugs, and required that adverse reactions and contraindications be labeled and included in literature.

Pediatric Research Equity Act of 2003

authorizes the FDA to require that drug manufacturers test certain drugs and biologic products for their safety and activeness in children, noting that “children are not small adults”.

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What does phase 1 of pharmaceutical research consist of?

a new drug is tested within a small group of people for the first time to evaluate its safety, determine a safe dosage, and identify side effects.

What does phase 2 of pharmaceutical research consist of?

the drug/treatment is given to a larger group of people to see whether it is effective and to further evaluate its safety.

What does phase 4 of pharmaceutical research consist of?

studies are done after the drug/treatment has been marketed to gather information on the drug’s effect sin various populations and to assess any side effects associated iwht long-term use

why weren’t drugs as effective towards women, children, and minorities in the 80s?

Medications were only tested on middle age white men

what do patients typically call the name of a drug by?

trade name (proprietary)

how is the trade name recognized?

It is recognized by the trademark sign

What is the generic name also known as?

the nonproprietary name

What is the chemical name made up by?

It is made up by the molecular makeup

What is the heaviest safety level/warning that a drug can have for marketing?

black box warning

What is the primary purpose of federal legislation?

The primary purpose of federal legislation is to ensure safety

Pharmacokinetics

what the body does to the drug/medication - it describes the movement of the drug through the body - 4 processes: absorption, distribution, metabolism, and excretion

The study of genetic factors that influence an individual’s response to a specific drug ; how genomes affect their response to medications

What is pharmacodynamics

what the drug/medication does to the body - involves receptor binding, post-receptor effects, and chemical reactions - a biologic or physiologic response results from the pharmacodynamic phase

the study of the effect of drugs on the body; the drugs act within the body to mimic the actions of the body’s own chemical messengers.

Phase 1 - absorption

The movement of the drug into the bloodstream after administration.

Phase 2 - distribution

The movement of the drug from the circulation to body tissues

Phase 3 - Metabolism (biotransformation)

The process by which the body chemically changes drugs into a form that can be excreted

Phase 4 - Excretion (elimination)

The main route of elimination of drugs from the body is through the kidneys

Distribution of Absorption

Blood flow, pain, stress, hunger, fasting, and H affect drug absorption

Where does absorption occur and how?

absorption happens across the mucosal lining of the small intestine and it occurs through active and passive transport, as well as pinocytosis

What factors influence drug distribution?

vascular permeability, permeability of cell membranes, reginal blood flow and pH, cardiac output, tissue perfusion, the ability of the drug to bind tissue and plasma proteins, and the drugs lipid solubility.

What conditions affect drug excretion?

* prerenal - reduce blood flow to kidneys and result in decreased glomerular filtration
* intrarenal - affect glomerular filtration and tubular secretion and reabsorption
* postrenal - obstruct urine flow adversely affect glomerular filtration

What is the main organ that metabolizes

the liver

What are other forms of drug excretion?

bile, the lungs, saliva, sweat, and breast milk

What organ secretes drugs?

Often secreted through the kidneys

What are the 7 patient rights?

* right patient
* right drug
* right dose
* right route
* right time
* right document

What is a just culture?

A just culture encourages individuals to report drug errors so the system can be repaired and problem can be fixed.

What is a medication error?

A preventable event that leads to inappropriate drug use or patient harm

What factors or failures play a role in medication errors?

* interruptions are responsible for 45% of medication errors
* have a quiet atmosphere to dispense meds
* look-alike & sound-alike drugs

What are the preparation guidelines for medication administration?

* hand hygiene
* access the MAR or EHR
* check drugs with health care provider’s order
* obtain the drug and check the 6 patient rights
* check for drug allergies
* prepare drugs one at a time
* calculate the drug dose and double-check it
* check the expiration date
* check against the MAR for accuracy
* open the package at patient’s bedside
* if it is liquid, use calibrated syringe then put into drug cup
* never leave drugs unattended

What are the types of injections?

intradermal, subcutaneous, intramuscular

What are the IM injection sites?

* ventrogluteal - place heel of hand over greater trochanter. point thumb toward groin, index finger to anterior superior iliac spine, and middle finger along iliac crest toward buttock. inject in the V-shaped triangle - this is preferred site for most injections given to adults and all children including infants
* Deltoid - 1-2 inches under acromion process, under 4 fingers across deltoid muscle. injection site is 3 finger widths below acromion process
* vastus lateralis - divide the thigh into three parts - commonly used in infants less than 12 months

What are the easiest drugs to reverse?

PO (by mouth) / oral

What onset do IV’s have?

Rapid onset

What is the needle size for an intramuscular injection?

18-25 guage, 5/8 - 1 1/2 inches long

How do you administer an IM injection?

90 degree angle

needle gauge and length are chosen based on patient weight and size

What is the needle size for a subcutaneous injection?

25-27 gauge; 3/8 to 5/8 inches long

How is a subcutaneous injection given?

45 or 90 degree angle

How is an intradermal injection given?

10-15 degree angle

What do you avoid when taking St John’s Wart?

antidepressants and anticoagulants

Why should patients with diabetes avoid milk thistle?

It can cause low blood sugar; hypoglycemia

What herbs interfere with anticoagulants?

Garlic

Ginseng

Ginger

Ginkgo

St. John’s Wart

What pharmacokinetic changes do older adults experience in absorption?

* there is a decrease in small bowel surface area
* reduced gastric blood flow
* a 5-10% decrease in gastric acid production

What pharmacokinetic changes do older adults experience in distribution?

* decline in muscle mass, 20-40% increase in fat
* lipid-soluble drugs gave a greater volume of distribution, increased drug storage, reduced elimination, and prolonged period of action
* decreased protein binding
* increased free drug available to exert therapeutic effects, also increases the risk for drug toxicity

What pharmacokinetic changes do older adults experience in metabolism?

* hepatic blood flow may be decreased by 40%
* 15-30% decrease in liver size
* reduction in hepatic metabolism can decrease first-pass metabolism and can prolong drug half-life, resulting increased drug levels and potential drug toxicity

What pharmacokinetic changes do older adults experience in excretion?

* changes in kidney function such as decreased renal size and volume (differs for each individual)
* changes in kidney function require dosage adjustment, especially if the drug has a narrow therapeutic range

What factors contribute to polypharmacy in the older adult?

* advanced age
* female sex
* multiple health care providers - lack of communication,
* use of herbal therapies and OTC drugs
* multiple chronic disease
* number of hospitalizations and care transitions

Why do older adults have an increased incidence of experience adverse drug effects?

* older adults are twice as likely as younger adults to visit the ED with ADEs and are 7x more likely to be hospitalized
* CAUSES : reactions to blood thinners, drugs used to treat diabetes and seizures, cardiac drugs, and drugs used for pain control.
* cognitive impairment, polypharmacy
* a decreased kidney function because a lack of elimination

Which receptor does Naltrexone block?

it affects the opioid receptor - can treat opioid abuse and alcoholism

* if someone comes in with alcohol toxicity, you must make sure they don’t have an opioid addiction if starting naltrexone because it can send them into a violent withdrawal

How is alcohol toxicity treated?

* airway management and supplemental oxygenation
* correction of hypoglycemia if present
* intravenous hydration - isotonic solution
* IF CHRONIC ALCOHOL USE : thiamine 100 mg may be administered intramuscularly to prevent neurologic damage

What is the procedure for reporting medication diversion by a fellow nurse?

share observations and concerns with the nurse and supervisor to provide the means for rehabilitation.

What is the acute treatment for overdose?

NARCAN (naloxone) is a short-acting opioid antagonist that is competitively attaches to opioid receptors in the CNS, thereby blocking activation by opioid drugs

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Potassium Electrolyte Levels

3\.5-5.0 mEq/L

Magnesium Electrolyte Level

1\.5-2.5 mEq/L

Sodium Electrolyte Level

135-145 mEq/L

Chloride Electrolyte Level

95-110 mEq/L

Calcium Electrolyte Level

8\.6-10.2 mEq/L

Phosphorus Electrolyte Level

24-4.4 mEq/L

Isotonic Solutions

Expand ECF

0\.9% Sodium Chloride

Lactated ringers (LR)

5% Dextrose in water (D5W)

* cells stay the same
* corrects dehydration

Hypotonic Solutions

* cause a shift from extracellular to intracellular and interstitial spaces
* decreased intravascular volume
* 1/2NS or 0.45% Sodium Chloride (Saline)
* 0.33% NaCl (1/3 NS)
* 0.225% NaCl (1/4 NS)
* Cells swell
* replaces cellular fluid by treating intracellular dehydration
* monitor for signs of FVD and worsening hypovolemia

Hypertonic Solutions

* replace electrolytes and shift fluid from interstitial spaces into extracellular fluid
* 3% sodium chloride (NaCL)
* 5% NaCl
* 5% dextrose in 0.45% NaCl
* 5% Dextrose and 0.9% NaCl
* 5% Dextrose in LR
* 10% Dextrose in water (D10W)
* cells shrink
* corrects serve hyponatremia, decreases ICP in patients with cerebral edema

Colloid Solutions

contain protein or other large molecular substances that increase osmolarity without dissolving in the solution

Colloid solutions - dextran

treatment of shock caused by hemorrhage, burns, or trauma

Colloid solutions - albumin

regulates plasma volume and tissue-fluid balance

Sodium - Hypernatremia

* above 145 mEq/L
* restlessness and agitation
* extreme thirst
* increased reflexes

Sodium - Hyponatremia

* less than 135mEq/L
* neurologic changes - lethargic
* orthostatic hypotension
* decrease in deep tendon reflexes

Sodium

* found in most bodily fluids
* major role in fluid volume balance and is primary determinant of plasma osmolality
* combines with chloride or bicarbonate to promote acid-base balance

Potassium - hyperkalemia

* above 5.0 mEq/L
* EKG changes; T wave changes (peaked and narrow)
* fatigue, drowsiness, irritability, confusion
* muscle cramps (early or mild), weakness starting in lower extremities (late/severe)

Potassium - hypokalemia

* less than 3.5 mEq/L
* flatten or inverted T wave; appearance of an enlarged T wave ST depression
* fatigue, weakness, heaviness in legs
* decreased bowl motility

How do you properly administer IV K+?

* use 10 mEq/h to not exceed 220 mEq/in 24 hr
* do not administer undiluted
* 10 in a peripheral line
* 20 in a central line
* IF IV IS PAINFUL YOU ASSES FIRST SO YOU CAN MAKE A PLAN

Magnesium - hypermagnesemia

* above 2.5 mEq/l
* flushing
* increased perspiration
* diminished deep tendon reflexes

Magnesium - hypomagnesemia

* less than 1.5 mEq/L
* neuromuscular irritability, twitches, tremors, leg and feet cramps
* nystagmus - messes with eyes and disorientation
* disorientation

Calcium - hypercalcemia

* above 10.2 mEq/L
* fatigue, muscle weakness, depressed deep tendon reflexes
* decreased heart rate
* confusion, impaired memory

Hypocalcemia

* less than 8.6 mEq/l
* anxiety, irritability, and tetany; twitching, hyperactive deep tendon reflexes
* decreased cardiac output
* positive Chvostek’s sign (facial nerve right in front of the ear twitches) and Trousseau’s sign (involuntary muscle contractions in the arm from inflated sphygmomanometer cuff)

What do you asses for on the IV site?

You need to make sure there is no infiltration

What are fat soluble vitamins?

They are metabolized slowly; can be stored in fatty tissue, liver, and muscle in significant amounts; and are excreted in the urine at a slow rate

Vitamin A,D,E,K

What are water soluble

Vitamin C, Folic Acid, Vitamin B12

Which dietary sources are rich in vitamin K and should be carefully monitored by patients receiving the anticoagulant, warfarin?

dark green leafy vegetables; be very limited in diet because they are high in vitamin K and reverse action of anticoagulants

Which vitamin is given to an infant at birth to prevent hemorrhaging?

Vitamin K; livers are immature so they don’t have the clotting factors that they need

The patient asks the nurse whether any side effects are associated with taking iron. What is an appropriate response?

Yes there are; stomach ulcers; stomach irritation is one of the main side effects of taking iron. Do NOT take iron on an empty stomach and also take it with Vitamin C

Nasogastric Tube

Goes through the nose and into the stomach

Nasal Duodenal

tube goes through the nose, passes through the stomach and into the duodenal area of the small intestine

Peg Tube

surgical incision that goes through the abdominal wall into the stomach

Jejunostomy tube

surgical incision passed the stomach into the first section of the jejunum into the first portion of the small intestine

How do you check gastric residual of a patient with a feeding tube? What could gastric content / residual greater than 150mL indicate?

Keep pulling back content until it stops coming or until its greater than 150

greater than 150 means they have delayed gastric emptying

What is the most common complication of enteral therapy? What precautions must the nurse take to avoid the complication?

* Aspiration; pneumonia
* elevate the head of the bed above 30 degrees (30-45 at all times) ; if below content could go back into the esophagus causing aspiration
* another complication could be dehydration

What is the recommended frequency for changing the tubing of parenteral nutrition?

Every 24 hours to prevent any potential growth of microbes and introductions of infection

What is a potential complication of parenteral nutrition?

* IV site complication
* pneumothorax; when placing you could nick the top the lung
* nurse needs to monitor for hypovolemia (fluid volume overload or excess)

Alpha 1 adrenergic agonists

Increases force of heart contraction; vasoconstriction increases blood pressure, mydriasis (dilation of pupils) occurs; secretion in salivary glands decreases; urinary bladder relaxation and urinary sphincter contraction increases

Alpha 2 adrenergic agonists

inhibits release of norepinephrine; dilates blood vessels, produces hypertension, decreases GI motility and tone

Beta1 adrenergic agonists

Increases heart rate and force of contraction, increases renin secretion, which increases blood pressure

Beta2 adrenergic agonists

dilates bronchioles, promotes GI and uterine relaxation; promotes increase in blood glucose through glycogenolysis in the liver; increases blood flow in skeletal muscles

Alpha1 Adrenergic blockers

Vasodilation; decreases bp, reflex tachycardia might result; mydriasis (constriction of pupil) occurs; suppresses ejaculation, reduces contraction of smooth muscle in the bladder neck and prostate gland.

Beta1 Adrenergic blockers

decreases heart rate; reduces force of contractions