Patho & Pharm Review (1-5)

Pathophysiology

The study of disease—the causes, the process, and how the body responds.

Etiology

The PRECISE cause of a disease (e.g., strep bacteria → strep throat).

Idiopathic

Cause is unknown. The disease has risk factors but no single trigger.

Risk Factor

A characteristic that makes a person MORE LIKELY to develop a disease.

Pathogenesis

The BEGINNING and progression of disease — cellular events leading to illness.

Comorbidity

A second disease present at the same time that increases overall risk.

Acute

Short. Resolves in less than 2 weeks.

Treat aggressively, expect resolution.

Examples: Strep throat, common cold, appendicitis.

Subacute

Lingers. 2 weeks to 6 months.

Monitor closely, watch for complications.

Examples: Subacute thyroiditis, long COVID, endocarditis (some forms).

Chronic

Long. More than 6 months — often lifelong.

Shift focus to long-term management, patient education, self-care, and quality of life.

Examples: Diabetes, HTN, COPD, heart failure, lupus.

Endemic

Regularly found in a specific population or region.

Epidemic

Widespread in a community at a particular time.

Pandemic

Spread globally at high rates (e.g., COVID-19, March 2020).

Prevalence

How many TOTAL cases exist right now.

Example: 607 million COVID-19 cases worldwide (Nov 2018–Sep 2022)

Incidence

How many NEW cases per time period (the rate).

Example: 163.8 new COVID cases per 100,000 people per week (April–May 2021).

Modifiable Risk Factors

We CAN change these

• Smoking and tobacco use

• Diet (sodium, saturated fat, sugar)

• Physical activity level

• Alcohol and substance use

• Sleep hygiene and stress management

• Vaccination status

• Body weight and BMI

Nonmodifiable Risk Factors

Fixed traits (We CAN’T change these)

• Age

• Biological sex assigned at birth

• Genetics and family history

• Race and ethnicity

• Personal history of prior disease

• Congenital conditions

Pathogenesis—How disease unfolds

1) Exposure—Patient encounters the pathogen or

trigger

2) Invasion—Agent enters cells and tissues

3) Cellular Injury—Cells damaged; biochemistry

disrupted

4) Tissue/Organ Response—Inflammation, immunity, dysfunction

5) Signs & Symptoms—Patient becomes clinically ill

*Steps 1-4 are usually invisible

Pharmacovigilance

Ongoing monitoring of medication safety after a drug is on the

market.

Medication Reconciliation

Comparing a client's full medication list across every transition of care.

Sentinel Event

An unexpected event resulting in death or serious harm — always investigated.

ISBARR

Introduction, Situation, Background, Assessment,

Recommendation, Read-back—standardized handoff.

Cultural Humility

A lifelong commitment to self-reflection and learning about others' cultures—not a checkbox.

PICOT

Population, Intervention, Comparison, Outcome, Time—the

framework for evidence-based questions.

The Medication-Use Process—PTDAM

1) Prescribe: Provider orders

2) Transcribe: Order entered into eMAR

3) Dispense: Pharmacy prepares

4) Administer: Nurse Delivers

5) Monitor: Effect & Side effects

The 10 Rights of Medication Administration

1) Right patient

2) Right medication

3) Right route

4) Right time

5) Right dose

6) Right reason/indication

7) Right education

8) Right to refuse

9) Right response

10) Right documentation

Medication Errors

Rule-based: Wrong rule applied or correct rule applied incorrectly.

Ex: Ignoring the "no abbreviation" policy and writing "U" instead of "units.

Knowledge-based: Lack of knowledge about the drug, dose, or client.

Ex: Administering a med without knowing it's contraindicated in renal

failure

Activity-based: Slip, lapse, or distraction during the task itself.

Ex: Grabbing the wrong vial during a busy med pass after being interrupted.

Adverse Drug Reactions (ADRs)—ALLERGIC REACTION

Immune-mediated • Type I-IV hypersensitivity

• Triggered by IgE or T-cell response to the drug

• Onset typically within minutes to hours of exposure

• Range: rash & pruritus → anaphylaxis (airway compromise, hypotension)

• Documented as a drug ALLERGY — banded, charted, communicated

Adverse Drug Reactions (ADRs)—IDIOSYNCRATIC REACTION

Unexpected • Non-immune • Often genetic basis

• Unusual response unrelated to the drug's known

pharmacology

• Onset may be delayed; mechanism often not well

understood

• Often linked to genetic factors (e.g., G6PD deficiency, slow

acetylators)

• Documented as an adverse drug reaction — NOT a true

allergy

DEA Drug Schedules (I–V)

I: No accepted medical use • High abuse • Heroin, LSD, marijuana (federal)

II: High abuse • Medical use accepted • Morphine, oxycodone, fentanyl, methylphenidate

III: Moderate abuse potential • Codeine combos, ketamine, anabolic steroids

IV: Lower abuse potential • Alprazolam, lorazepam, tramadol, zolpidem

V: Lowest abuse potential • Pregabalin, low-dose codeine cough syrups

The Four Pillars of Bioethics—ABNJ

Autonomy: Respect the client's right to choose — including the right to refuse.

Example: Client declines opioid → offer alternatives, document, do not coerce.

Beneficence: Act for the client's benefit; promote the best outcome.

Example: Advocate for adequate pain control in a postoperative client.

Nonmaleficence: Do no harm—including harm from inaction or commission.

Example: Hold a beta-blocker if HR is 48 and call the provider.

Justice: Treat clients fairly; distribute resources equitably.

Example: The uninsured client deserves the same pain assessment as the insured

Informed Consent & HIPAA

Informed consent—5 components:

• Disclosure of the procedure, drug, or treatment

• Comprehension — confirmed teach-back

• Voluntariness — no coercion, no pressure

• Competence — capacity to make this decision

• Consent — verbal or written agreement

HIPAA

Health Insurance Portability & Accountability Act (1996)

Protects all identifiable health information.

Applies in:

• Charting and EHR access

• Handoffs (no patient names in hallways)

• Phone calls (verify identity)

• Social media (never post about clients — even "anonymized"

stories can identify)

Penalties: civil fines up to $1.5 million; criminal penalties for willful

violations.

Social Determinants of Health

Conditions where people are born, live, learn, work, and age — they account for ~80% of health outcomes. Medication adherence cannot be understood without them.

Influences on Medication Adherence

• Cultural beliefs & values

• Health literacy & language

• Historical trauma & medical mistrust

• Religion & spirituality

• Cost & insurance coverage

• Access (pharmacy, transportation)

Cultural Communication: The LARA Method

L: Listen—Pause. Let the client speak without interruption. Watch nonverbals.

A: Affirm—Acknowledge their concern is valid: "I hear that you're worried about this medication.”

R: Respond—Address the specific concern with information — not assumption.

A: Add Information—Offer additional context or resources tailored to the client.

Clinical Judgment

The observed outcome of critical thinking and decision-making— what the nurse DOES at the bedside.

Beers List

Evidence-based list of medications that are potentially inappropriate for adults age 65 and older.

KIDs List

Evidence-based list of medications that are potentially inappropriate for pediatric clients.

PLLR

Pregnancy and Lactation Labeling Rule — replaces the old A/B/C/D/X categories with narrative risk summaries.

Polypharmacy

The concurrent use of multiple medications (often 5+), which raises the risk of interactions and adverse effects.

Therapeutic Index

Ratio comparing the dose that produces effect to the dose that produces toxicity — narrow = more dangerous.

Aging Changes the Drug — Even When the Dose Doesn't Change (R&H)

↓ Renal (kidneys) clearance—Drug stays in body longer → toxic levels even at "normal" doses

Examples: Digoxin (controls heart rate), gabapentin, many antibiotics

↓ Hepatic (liver) metabolism—First-pass effect drops → more active drug reaches circulation.

Examples: Benzodiazepines, opioids, beta-blockers (low blood pressure)

Aging Changes the Drug — Even When the Dose Doesn't Change (T&P)

↓ Total body water • ↑ body fat—Lipid-soluble drugs accumulate; water-soluble drugs hit higher peaks.

Examples: Diazepam stores in fat → prolonged sedation

↓ Plasma albumin (blood protein)—More free drug circulates → exaggerated effect from highly bound drugs.

Examples: Warfarin (blood thinner), phenytoin

Tanner Model—NIRR

Noticing → Interpreting → Responding → Reflecting

Nursing Process—ADPIE

Assess → Diagnose → Plan → Implement → Evaluate

NCSBN Action Model

Recognize cues → Analyze → Prioritize → Generate solutions → Take action → Evaluate outcomes

Six Steps, Six Questions

1) Recognize cues—What do I see, hear, measure?

2) Analyze cues—What does this mean — and what doesn't fit?

3) Prioritize hypotheses—Which possibility is most urgent or most likely?

4) Generate solutions—What could I do — and which is best for this client?

5) Take action—What do I do RIGHT NOW?

6) Evaluate outcomes—Did it work? What changed? What's next?

Medications Across the Lifespan—Pediatric

(Newborn → 17 yr)

• Dose by weight (mg/kg) or BSA (body surface area)

Immature kidneys/liver

• Liquid or chewable forms

Crushing tablets often unsafe

• Higher metabolism per kg

Some drugs need more, others less

• Family-centered teaching

Caregiver is the medication giver

Medications Across the Lifespan—Adult

(18 → 64 yr)

• Standard adult dosing reference

• Most drug studies done here

• Consider sex, weight, pregnancy

Use PLLR for pregnant/lactating

• Lifestyle: alcohol, smoking, OTC

Drug-drug and drug-food risks

• Adherence drops with complexity

Simplify when possible

Medications Across the Lifespan—Older Adult

(65 yr →)

• Start low, go slow

Pharmacokinetic changes (Lower renal function, hepatic metabolism, etc)

• Beers List medications

Avoid or use with caution

• Polypharmacy — review every visit

Each new drug adds interaction risk

• Fall risk, cognitive change

Often the first sign of toxicity

Pregnancy & Lactation Labeling Rule (PLLR)

• 8.1 Pregnancy—Risk to fetus • Dose adjustments • Maternal & fetal outcomes • Animal vs human data

• 8.2 Pregnancy—Drug presence in breast milk • Effect on infant • Effect on milk production

• 8.3 Pregnancy—Need for pregnancy testing • Contraception recommendations • Infertility risk

Drug-Drug Interactions

What happens inside the body

Synergistic: Two drugs amplify (make stronger) each other (warfarin + NSAID → bleeding ↑↑)

Antagonistic: One drug cancels the other (vitamin K cancels warfarin)

Additive: Effects add up (two BP meds → hypotension)

Altered metabolism: One drug changes how another is cleared (grapefruit ↑ statin levels)

Incompatibilities

What happens in the IV line or syringe

Physical: Precipitation, color change, gas formation in syringe or tubing

Chemical: Drugs degrade or form new compounds (often invisible to the eye)

Therapeutic: Drugs cancel or duplicate effects in vivo

Prevent: Flush IV lines between meds; check compatibility BEFORE administering

How to: Medication Reconciliation (OVCC)

1) Obtain—Gather the complete list — prescriptions, OTC, herbals, vitamins. Ask the client, family, pharmacy, prior records

2) Validate—Verify with at least two sources. Confirm dose, frequency, route, last dose taken.

3) Compare—Match the home list against the admit/transfer/discharge orders. Flag omissions, duplicates, interactions.

4) Communicate—Document & share the reconciled list with the client, family, and next care team.

Monitoring: Therapeutic vs Adverse

Therapeutic effect

"Is it working as intended?"

What to monitor:

• Targeted symptom (pain ↓? BP at goal?)

• Lab markers (INR, glucose, K⁺, drug level)

• Functional improvement (ambulation, sleep)

• Time to peak effect (route-specific)

Examples:

• Furosemide → urine output ↑, edema ↓

• Warfarin → INR 2-3 (target range)

• Antibiotic → fever ↓, WBC ↓

Adverse effect

“Is something going wrong?"

What to monitor:

• Common side effects (drug-specific)

• Allergic reaction (hives, swelling, SOB)

• Organ toxicity labs (renal, hepatic)

• Mental status, fall risk, vitals

Red flags:

• New confusion in older adult on meds

• Hypotension after first dose (alpha blocker)

• Bleeding on anticoagulant

Pharmacokinetics—ADME

What the BODY does to the DRUG (absorption, distribution, metabolism, excretion).

Pharmacodynamics

What the DRUG does to the BODY (receptor binding, dose-response, effects).

Half-life (t½)

Time for drug concentration to drop by 50%. Drives dosing frequency.

First-Pass Effect

Liver metabolizes a drug before it reaches systemic circulation.Affects PO dosing.

Receptor

A molecule (often a protein) the drug binds to in order to cause an effect.

ADME—A

Absorption—How does the drug get into the

blood?

• Crosses cell membranes from the site of administration into systemic circulation.

• GI tract (PO), muscle (IM), subQ tissue, lungs, skin

What changes it:

• Route (PO, IM, IV, SL)

• Food, antacids, calcium

• GI motility, surgery

• First-pass effect

ADME—D

Distribution—Where does it travel once in the

blood?

• Carried by blood to tissues.

• Affected by protein binding, blood flow, lipid solubility, and the blood-brain barrier.

What changes it:

• Albumin level (binding)

• Body fat vs water composition

• Blood flow to tissues

• Blood-brain barrier

ADME—M

Metabolism—How does the body BREAK IT DOWN?

• Primarily liver (CYP450 enzymes).

• Converts drug into water-soluble metabolites that can be excreted.

• First-pass effect happens here.'

What changes it:

• Liver function (LFTs)

• CYP450 inducers/inhibitors

• Genetics (CYP variants)

• Age (immature/aging liver)

ADME—E

Excretion—How does it LEAVE?

• Primarily kidneys (urine). Also bile/feces, lungs (anesthesia), sweat, breast milk

What changes it:

• Renal function (GFR, creatinine)

• Urine pH

• Bile/biliary disease

• Hydration status

Diseased Organs Change How Drugs Behave

Liver Disease—↓ Metabolism → Active drug accumulates → toxicity.

Watch for: Acetaminophen, opioids, benzodiazepines

Kidney Disease—↓ Excretion → Renally-cleared drugs accumulate.

Watch for: Many antibiotics, digoxin, gabapentin

GI disease / Surgery—↓ Absorption → Drugs reach systemic circulation in lower amounts or not at all.

Watch for: Levothyroxine, fat-soluble vitamins

Malnutrition / Chronic illness—↓ Albumin → MORE free drug circulates → exaggerated effect.

Watch for: Levothyroxine, fat-soluble vitamins

Drugs Bind to Receptors—(AAP)

Agonist—Turns the receptor ON

• Binds to a receptor and ACTIVATES it—mimics the body's natural signal

Examples:

• Albuterol → beta-2 receptors → bronchodilation

• Morphine → opioid receptors → analgesia

Antagonist—BLOCKS the receptor

• Binds to a receptor and BLOCKS the natural signal—no activation occurs.

Examples:

• Metoprolol → beta-1 blocker → ↓ HR

• Naloxone → opioid blocker → reverses overdose

Partial Agonist—SOME activation, lower ceiling

• Binds and activates the receptor but produces a SMALLER effect than a full agonist.

Examples:

Buprenorphine → opioid receptor → relieves pain with less respiratory depression

Dose, Response, and the Window of Safety

Narrow window drugs (high alert):

Warfarin (INR), digoxin (level), lithium, phenytoin, theophylline, insulin

Wide window drugs:

Most antibiotics, antihypertensives at typical doses

Tolerance, Dependence, Withdrawal—(TDW)

Tolerance—The SAME dose produces LESS effect over time. The body adapts

Dependence—The body has ADAPTED to the drug. Stopping it produces withdrawal symptoms.

Withdrawal—Physiological symptoms when a drug is stopped or reduced too quickly.

Two Ways to Classify a Drug—Therapeutic Classification

Groups drugs by WHAT THEY TREAT.

Examples:

• Antihypertensive → lowers BP

• Analgesic → relieves pain

• Antibiotic → treats infection

• Antidepressant → treats depression

• Diuretic → ↑ urine output

Useful for: matching a drug to a diagnosis at the bedside.

Two Ways to Classify a Drug—Pharmacologic Classification

Groups drugs by HOW THEY WORK.

Examples:

• ACE inhibitor → blocks angiotensin

• Opioid → binds opioid receptor

• Beta-1 blocker → blocks beta-1

• SSRI → blocks serotonin reuptake

• Loop diuretic → blocks Na-K-Cl pump

Useful for: predicting effects, interactions, adverse events.

Pattern Recognition—Drug-Name Suffixes

-pril → ACE inhibitors (lisino-pril, enala-pril)

-sartan → ARBs (Angiotensin II receptor blockers) (losartan, valsartan)

-olol → Beta blockers (metoprolol, atenolol)

-statin → HMG-CoA reductase inhibitors (atorvastatin)

-azole → PPIs (proton pump inhibitors) (omeprazole) OR antifungals (fluconazole)

-cillin → Penicillins (amoxicillin, ampicillin)

Drug Classes—ACE inhibitors & Beta Blockers

ACE inhibitors

• Lisinopril

Uses: HTN (hypertension), HF (heart failure), post-MI (after a heart attack (post-myocardial infarction)).

Adverse effects: Dry cough, hyperkalemia, angioedema

Beta Blockers

• Metoprolol

Uses: HTN, HF, angina (chest pain)

Adverse effects: Bradycardia, fatigue, bronchospasm (tightening of airways)

Drug Classes—Loop diuretics, PPIs, & Statins

Loop Diuretics

• Furosemide

Uses: Edema (swelling from excess fluid), HF

Adverse effects: Hypokalemia, dehydration, ototoxicity (ear poisoning)

PPIs

• Omeprazole

Uses: GERD (gastroesophageal reflux disease), PUD (Peptic ulcer disease)

Adverse effects: ↓ B12/Mg absorption (vitamin B), infection risk

Statins

• Atorvastatin

Uses: Hyperlipidemia

Adverse effects: Myalgia/rhabdomyolysis, ↑ liver enzymes

Drug Classes—SSRIs & Opioids

SSRIs

• Sertraline

Uses: Depression, anxiety

Adverse effects: GI upset, sexual dysfunction, ↑ suicidality

(youth)

Opioids

• Morphine

Uses: Moderate-severe pain

Adverse effects: Respiratory depression, constipation, dependence

Interactions Across Classifications

Warfarin (anticoagulant)— + NSAID, + antibiotic, + antifungal

Adverse effects: ↑ bleeding risk • Monitor INR closely

SSRIs— + tramadol, + MAOI, + St. John's wort

Adverse effects: Serotonin syndrome • Recognize early: HTN, hyperthermia, hyperreflexia

ACE inhibitor— + K-sparing diuretic, + K supplement

Adverse effects: Hyperkalemia • Check K⁺ regularly

Beta blocker— + Verapamil/Diltiazem (non-DHP CCB)

Adverse effects: Bradycardia, heart block • Avoid combo when possible

PPIs— + Levothyroxine, + Iron, + Calcium

Adverse effects: ↓ Absorption • Separate dosing by 4 hours

Monitoring & Labs by Class

Warfarin

Labs to monitor: INR (international normalized ratio)

TARGET: 2.0-3.0 most uses; 2.5-3.5 mechanical valve

Digoxin

Labs to monitor: Digoxin level + K⁺

TARGET: 0.5-2.0 ng/mL • Hypokalemia ↑ toxicity

Lithium

Labs to monitor: Lithium level

TARGET: 0.6-1.2 mEq/L • >1.5 = toxic

Heparin (unfractionated)

Labs to monitor: aPPT (activated partial thromboplastin time)

TARGET: 1.5-2.5× control

Insulin

Labs to monitor: Blood Glucose

TARGET: 70-180 (sliding scale varies)

Statin

Labs to monitor: LFTs (ALT/AST) (liver function)

TARGET: Baseline + with symptoms

Levothyroxine

Labs to monitor: TSH (thyroid stimulating hormone)

TARGET: 0.3-5.0 mU/L • recheck 6-8 weeks after

change

ACE inhibitor / ARB

Labs to monitor: K⁺, Cr (Chromium)

TARGET: K⁺ 3.5-5.0 • Cr trend baseline

OTC (Over-the-Counter)

Medications the FDA has determined are safe and effective for use

WITHOUT a prescription.

Drug Facts Label

The FDA-required label on OTC products listing active ingredients, uses, warnings, and dosing.

Dietary Supplement

Vitamins, herbs, minerals, amino acids. Regulated as FOOD by FDA—NOT held to drug safety standards.

CAM

Complementary And Alternative Medicine. Therapies used alongside (complementary) or instead of (alternative) conventional care.

Integrative Medicine

Combining evidence-based CAM with conventional medicine in a coordinated, client-centered plan.

Herb-Drug Interaction

Pharmacokinetic or pharmacodynamic effect of an herbal product on a prescription drug—often dangerous.

The OTC Landscape

Pain & Fever

• Acetaminophen, ibuprofen, naproxen, aspirin

Risks: Hepatotoxicity (APAP) • GI bleed, renal injury (NSAIDs)

Cough, Cold, & Allergy

• Diphenhydramine, dextromethorphan, pseudoephedrine, loratadine

Risks: Sedation, falls (older adults) • Hidden APAP in combos • ↑ BP

GI / Digestive

• Antacids, famotidine, omeprazole, loperamide, bisacodyl

Risks: Absorption interference • Long-term PPI: ↓ B12/Mg/Ca, ↑ infection

Sleep & Anxiety

• Diphenhydramine, doxylamine, melatonin

Risks: Anticholinergic burden in older adults • Daytime sedation

Topical / Derm

• Hydrocortisone, antifungals, antibiotics, sunscreens

Risks: Generally low — but systemic absorption possible (large surface, occlusion)

How to Read a Drug Facts Label

1) Check ACTIVE ingredient first—Many products share the same ingredient under different brand names.

2) Look for hidden duplicates—Cough/cold combos often contain acetaminophen too. Total daily dose adds up FAST.

3) Read every WARNING—Liver, kidney, BP, pregnancy warnings exist for a reason—they apply to YOUR patient.

4) Confirm the DIRECTIONS—Adult dose ≠ child dose. Frequency matters as much as amount.

Acetaminophen

Where APAP hides:

• Tylenol (all forms)

• Excedrin

• NyQuil / DayQuil

• TheraFlu

• Robitussin (some)

• Sudafed PE (some)

• Percocet, Norco (Rx)

The Math:

• Max adult dose: 4 g/day

• Safer target: 3 g/day

• Per dose: 325-650 mg

• Every 4-6 hours

Safer Practice

• Check ALL labels

• ≤ 3 g/day if alcohol use

• Avoid in liver disease

• Watch in malnourished

• Treat overdose w/ NAC

• Teach the limit by NAME

Other OTC risks

NSAIDs

Ibuprofen • Naproxen • Aspirin

How they work: Block prostaglandins → ↓ pain & inflammation BUT ↓ protective gastric mucus and ↓ renal blood flow

Watch for: GI bleeding • Acute kidney injury • ↑ BP and fluid retention • Avoid in HF, CKD, pregnancy (3rd trimester)

First-Gen Antihistamines

Diphenhydramine • Doxylamine • Chlorpheniramine

How they work: Block H1 histamine + significant anticholinergic effects (dry mouth, urinary retention, confusion)

Watch for: BEERS-listed in older adults • Sedation + falls • Often hidden in "PM" pain products and sleep aids

Decongestants

Pseudoephedrine • Phenylephrine

How they work: Alpha-adrenergic agonists → vasoconstriction of nasal mucosa → ↓ congestion

Watch for: Raises BP and HR • Avoid in HTN, CAD (coronary artery disease), hyperthyroidism, anxiety • Insomnia common

Why Acetaminophen Destroys the Liver

1) Normal dose acetaminophen reaches the liver and is metabolized — mostly by safe pathways (glucuronidation, sulfation).

2) A small portion is metabolized by CYP2E1 into NAPQI — a highly toxic intermediate that BINDS to liver cell proteins.

3) Normally, glutathione (GSH) neutralizes NAPQI quickly. At safe doses, no harm.

4) Overdose, fasting, alcohol use, or malnutrition DEPLETE glutathione. NAPQI accumulates → hepatocyte death → acute liver failure.

Acetaminophen Antidote—NAC

N-Acetylcysteine (NAC)

Replenishes glutathione → neutralizes NAPQI before more damage.

MOST EFFECTIVE: within 8-10 hours of ingestion.

The CAM Landscape

Natural Products

Examples: Herbs, vitamins, probiotics, minerals

Nurse note: HIGHEST drug-interaction risk

Mind-Body

Examples: Meditation, yoga, breathwork, guided imagery

Nurse note: Generally low risk; can support BP and anxiety

Manipulative / Body

Examples: Chiropractic, massage, osteopathic manipulation

Nurse note: Caution: anticoagulation, osteoporosis, recent surgery

Energy / Whole Systems

Examples: Reiki, healing touch, acupuncture, traditional Chinese medicine

Nurse note: Mostly low risk; needles → infection if non-sterile

Traditional healers

Examples: Curandera, herbalist, native medicine, faith healing

Nurse note: Honor cultural meaning; screen for interactions

Eight Herbs Your Patients Use—part 1

St. John's wort

Use: Depression

KNOW: Potent CYP3A4 inducer — lowers MANY drug levels

Ginkgo biloba

Use: Memory, circulation

KNOW: Anticoagulant effect — bleeding risk

Garlic (high-dose)

Use: Cardiovascular health

KNOW: Antiplatelet effect — bleeding risk

Ginseng

Use: Energy, immune support

KNOW: ↓ INR with warfarin; affects glucose

Eight Herbs Your Patients Use—part 2

Echinacea

Use: Cold/flu prevention

KNOW: Immune stimulation — avoid with immunosuppressants

Licorice root

Use: Digestion, sore throat

KNOW: ↑ BP, ↓ K⁺ — dangerous with HTN, diuretics, digoxin

Kava

Use: Anxiety, sleep

KNOW: Hepatotoxicity — banned in some countries

Valerian root

Use: Sleep, anxiety

KNOW: Sedation — additive with benzodiazepines, opioids

Three Interactions That Will Hurt Your Patient

St. John's wort

Interacts with: ↓ Levels of: warfarin, digoxin, oral contraceptives, cyclosporine, antiretrovirals

Mechanism: Induces CYP3A4 + P-glycoprotein. Speeds drug metabolism → treatment failure.

Nurse action: DO NOT add to patients on these meds. Educate: pregnancy on OCPs + SJW = real risk.

Ginkgo biloba + Garlic + Ginseng

Interacts with: + Warfarin, aspirin, NSAIDs, clopidogrel

Mechanism: Antiplatelet / anticoagulant effects ADD to the drug's effect.

Nurse action: Hold supplements 1-2 weeks before surgery. Check for bruising, bleeding, ↑ INR.

Licorice root

Interacts with: + Lisinopril, furosemide, digoxin, antihypertensives

Mechanism: Glycyrrhizin → Na⁺ retention + K⁺ loss → ↑ BP, hypokalemia, arrhythmias.

Nurse action: Screen ALL hypertensive patients.

Documentation & Reporting

What to document:

Product name (generic + brand if known) • Dose & frequency • Reason patient is taking it • Duration of use • Source (pharmacy, friend, online, traditional healer) • Reported effect

1) Chart-it

2) Flag-it

3) Reconcile

Enteral

Drug administered via the gastrointestinal tract—PO, NG, G-tube, J-tube. Safest, slowest.

Parenteral

Drug administered by injection or infusion—IV, IM, SubQ, ID, intrathecal. Faster, riskier.

Topical

Drug applied to skin or mucous membranes—including transdermal patches and inhaled

Bioavailability

Fraction of an administered dose that reaches systemic circulation. IV = 100%; PO is typically much lower.

Anaphylaxis

A SEVERE, life-threatening allergic reaction. Treated with epinephrine, IM into the lateral thigh.

Routes of Administration Roadmap

1) Enteral—Through the gut (~10 min)

2) Parenteral—By injection (~15 min)

3) Topical—Skin & Lungs (~5 min)

4) Safe Admin—Rights, checks, safety (~15 min)

Enteral Routes—Through the GI Tract

Oral (PO)

The most common route. Easy, safe, large surface area for absorption.

Limitations: slow onset (~30-60 min). Patient must be alert and able to swallow. NPO patients cannot take PO.

NG / G-tube / J-tube

For patients who can't swallow or who have GI access tubes already in place.

Limitations: must use LIQUID or finely crushed forms. Always flush before and after to prevent tube clogs.

REMEMBER: Enteral bypasses NOTHING — drugs go through stomach acid, first-pass liver metabolism. That's why oral doses are often LARGER than IV doses of the same drug.

Do NOT Crush, Open, or Chew

WHY IT MATTERS—Crushing a sustained-release tablet releases the FULL 24-hour dose at once. Patients have died from this exact error.

Suffix check: EC, ER, XR, SR, CR, CD, LA, XL = DO NOT CRUSH.

Examples: morphine SR/ER, metformin XR, venlafaxine XR, oxycodone CR (OxyContin).