Week 6 – CAM & Pharmacology Comprehensive Study Notes

Page 1 – Week 6 Overview

• Indicates week of course (Week 6) and that content begins here.

Page 2 – Complementary & Alternative Therapies (CAM)

• Title slide announcing focus on Complementary and Alternative Therapies.

Page 3 – Introduction to CAM

• Complementary = used with allopathic (Western) care.
• Alternative = used instead of allopathic care, often holistic.
• Integrative health care = complementary + alternative combined for mind-body-spirit wellness.
• CAM roots: Traditional Chinese Medicine (TCM), Ayurveda; emphasizes prevention, natural healing, client participation.
• NGN Cue: When client requests “natural” options or refuses meds, first determine whether approach is complementary or alternative.

Page 4 – Six Major CAM Categories

1. Whole Medical Systems – homeopathy, TCM, Ayurveda.
2. Biological-Based – herbs, vitamins, probiotics.
3. Manipulative/Body-Based – massage, chiropractic, acupressure.
4. Mind-Body – yoga, guided imagery, meditation, psychotherapy.
5. Energy – Reiki, therapeutic touch, magnets.
6. Movement – Pilates, dance, tai chi.

• NGN Cue: Document category + client response when charting CAM (e.g., “guided imagery … Mind-Body”).

Page 5 – Common Therapies & Clinical Implications

• Acupuncture/Acupressure: meridians, pain relief, functional stimulation.
• Chiropractic: spinal alignment, pain control.
• Homeopathy: “like cures like,” minute dilutions.
• Naturopathy: diet + herbal focus.
• Massage: muscle loosen, circulation, relaxation.
• Therapeutic Touch: hand-hover energy balancing.
• Biofeedback: sensors teach voluntary control of autonomic functions (HR, tension).
• Nursing note: differentiate those needing licensed specialist versus those an RN may integrate without certification.

Page 6 – Key Herbal Agents

• Assess self-prescribed use; reconcile in history.

Page 7 – CAM Assessment Questions

• “What vitamins, supplements, herbs do you take?”
• “Seen acupuncturist, chiropractor, herbalist?”
• “Use meditation, yoga or mind-body?”
• “Any cultural/spiritual healing practices important to you?”
• Direct, respectful inquiry because CAM seldom appears on med list.

Page 8 – Safety Concerns & Red Flags

• Possible supplement–drug interactions (garlic + warfarin → $\uparrow$ INR).
• Multiple modalities undisclosed to provider.
• Substituting CAM for critical therapy (e.g., chemo).
• Misconception “natural = safe”.
• Must include CAM in pre-op reconciliation.

Page 9 – Client Readiness & Behavioral Cues

Belief/Readiness Questions

• “What does healing mean to you?”
• “Open to combining natural & medical?”
• “Past experiences—effective/ineffective?”
  Signs of CAM Interest
• Declines meds: “I prefer natural remedies.”
• Brings own teas, oils, crystals.
• Frustration with Western care.
  Clinical Insight: Use recognize → reflect → reassess; educate without judgment.

Page 10 – CAM Classification Matching Exercise (Question)

• Homeopathy, Meditation, Reiki, Ginger, Acupuncture to be matched with categories.

Page 11 – CAM Classification Answer & Rationale

• Homeopathy → Whole Medical System.
• Meditation → Mind-Body Therapy.
• Reiki → Energy Therapy.
• Ginger → Biologic/Botanical.
• Acupuncture → crosses Whole Medical System + Mind-Body + Energy.

Page 12 – Diagnostic Tools for CAM Use

• Medication reconciliation: include vitamins, teas, oils.
• FICA tool for spiritual/cultural aspects.
• Facility CAM history forms.
• Precise documentation: product, dose, frequency, purpose (e.g., “valerian nightly for insomnia”).

Page 13 – Labs & Clinical Signs Affected by CAM

• INR/PT: garlic, ginseng, ginkgo.
• LFTs: kava, valerian.
• BP/HR: ginseng, licorice.
• Sedation: valerian, chamomile, CBD.
  NGN cue: Unexplained sedation or INR spike → ask about herbals.

Page 14 – Situations Requiring Vigilance

• Pre-surgery: stop garlic, ginkgo, ginseng 1–2 wks prior.
• New prescriptions: evaluate interactions.
• Organ dysfunction: altered metabolism/excretion.
• Polypharmacy: cumulative effects.

Page 15 – RN-Scope CAM Interventions (No Certification)

• Guided imagery, breathwork, meditation facilitation, therapeutic communication, supportive touch.
• NGN Teaching Cue: can reduce anxiety and promote client-centered care.

Page 16 – CAM Requiring Licensed Specialist

| Therapy | Why licensure? |
| Acupuncture/Acupressure | Infection/nerve injury risk |
| Chiropractic | Spinal manipulation expertise |
| Massage (clinical) | Incorrect technique injures tissue |
| Homeopathy/Naturopathy | Diagnostic/prescriptive authority |

• Refer via case management.

Page 17 – Teaching Safe Herbal Use

• Share evidence-based data.
• Stop high-bleed herbs 1 wk pre-op.
• Explain non-FDA regulation; potency varies.
• Interactions (St. John’s Wort ↓ OCP efficacy).

Page 18 – Integrating CAM in Care Plan

• Collaborate with provider; document effectiveness.
• Shared decision-making; uphold cultural practices if safe.

Page 19 – Medication Section Divider

• Transition to pharmacokinetics/pharmacology content.

Page 20 – Pharmacokinetics Definition & Phases

• Absorption, Distribution, Metabolism, Excretion (ADME).
• Clinical cue: drug failure may be due to ADME issue.
• Example: liver cirrhosis → poor metabolism → toxicity.

Page 21 – Absorption Essentials

• Influencers: route, solubility, GI pH/motility, food, formulation.
• Fastest: IV; slowest: enteric-coated PO.
• Pediatric example: liquid acetaminophen faster than tablet.
• NGN: gastroparesis delays oral absorption.

Page 22 – Oral Route Pitfalls

• Requires intact swallow, functional GI.
• Vomiting/diarrhea, food, altered pH hinder absorption.
• Assessment: gag reflex, LOC, sitting upright.
• NGN: vomiting soon after PO → reassess.

Page 23 – IM Injection Anatomy (Illustration)

• Depicts appropriate IM sites: deltoid, vastus lateralis, ventrogluteal; dorsogluteal discouraged.

Page 24 – SubQ & IM Absorption

• Water solubility & blood flow determine rate.
• Deltoid/ventrogluteal faster than dorsogluteal.
• Shock/cold extremities slow uptake.
• Heparin abdomen injection quick; rotate insulin sites.

Page 25 – Case: Mr. Tyler – Route Safety Matrix (Question)

• Evaluate LOC, first-pass avoidance, aseptic need for PO, SL, IV, topical.

Page 26 – Case Answer & Rationale

• PO & SL require LOC/gag.
• SL & IV bypass liver.
• IV & broken-skin topical need asepsis.
• Given dysphagia, IV safest for Mr. Tyler.

Page 27 – IV Route High-Alert Points

• $100\%$ bioavailability; immediate effect.
• Indications: emergencies, unconscious pts, GI-destroyed drugs.
• Risks: irreversible errors; monitor for phlebitis, infiltration, toxicity.
• Example: never IV push potassium.

Page 28 – Distribution Factors

• Circulation, membrane permeability (BBB, placenta), protein binding.
• Burn/shock = impaired distribution.
• Lipid-soluble drugs cross CNS.

Page 29 – Protein Binding & Albumin

• Low albumin $\rightarrow$ ↑ free drug $\rightarrow$ ↑ toxicity.
• Labs: albumin, LFTs; adjust dose.

Page 30 – Metabolism Basics

• Mainly hepatic; converts to inactive or water-soluble forms.
• First-pass effect inactivates some PO drugs; choose SL/IV.

Page 31 – Factors Altering Metabolism

• Slows: extremes of age, liver disease, malnutrition.
• Speeds: enzyme inducers, multi-drug competition.
• Example: warfarin + phenytoin interaction.

Page 32 – Excretion Pathways

• Kidneys primary; monitor Cr, GFR, urine output.
• Other: lungs, bile, sweat, breast milk.
• Impaired excretion $\rightarrow$ drug accumulation.

Page 33 – Half-Life Significance

• Time for $50\%$ plasma reduction.
• Short (4-8 h) needs frequent dosing; long (≥ 24 h) ↑ toxicity risk.
• Renal/hepatic impairment prolongs half-life.

Page 34 – Therapeutic Index (TI)

• $TI = \dfrac{LD<em>{50}}{ED</em>{50}}$.
• High TI = safer (amoxicillin); low TI = narrow window (digoxin, lithium, warfarin) ⇒ require serum levels.

Page 35 – Peak, Trough & Plateau

• Peak: IV 15–30 min; PO 1–3 h.
• Trough: just before next dose.
• Plateau reached after 4–5 half-lives; set patient expectations (SSRIs 2–4 wks).

Page 36 – Nurse Legal & Ethical Duties

• 5 rights; allergy check; post-admin assessment; prompt documentation.
• Error protocol: hold med, assess, notify provider; no concealment.

Page 37 – Pre-Administration Assessment

• Vitals, allergies, med history (incl. OTC/CAM), organ function.
• NGN: hold atenolol if HR < 60.

Page 38 – Medication-Specific & Route Assessments

• Diuretic → K⁺ & BP; Digoxin → apical HR & K⁺; Opioid → RR/LOC; Anticoag → INR.
• Route checks: PO (swallow), IM/SQ (site), IV (patency).

Page 39 – Case: Mrs. Chen – Monitoring Matrix (Question)

• Digoxin, warfarin, morphine; current vitals & INR provided.

Page 40 – Case Answer & Clinical Takeaways

• Digoxin: hold HR < 60, check level.
• Warfarin: INR 3.2; monitor bleeding.
• Morphine: monitor RR & BP; may worsen hypotension.

Page 41 – High-Risk Meds & Polypharmacy

• Warfarin, heparin, lithium, vancomycin require targeted labs.
• Polypharmacy ↑ interaction risk; scrutinize duplicates, OTC, herbals.

Page 42 – Pain & Teaching Assessments

• Use pain scales; reassess 30–60 min post opioid.
• Before teaching: evaluate cognition, language, literacy, cultural factors.

Page 43 – Post-Medication Evaluation & Adverse Effects

• Confirm therapeutic outcomes (BP ↓, pain ↓, BG controlled).
• Monitor common & severe reactions; tie labs to organ risk.

Page 44 – IV Site Assessment & Compatibility

• Inspect for infiltration/phlebitis; flush; verify fluid/med compatibility; monitor for speed shock.

Page 45 – Diagnostics to Validate Drug Action

• Labs, vitals, physical signs (e.g., edema reduction, lung sounds) confirm effectiveness.
• Example: ↓ HR + ↑ LOC with beta-blocker.

Page 46 – High-Yield Drug–Lab Pairs

• Warfarin → INR 2–3.
• Heparin → aPTT 1.5–2×.
• Digoxin → 0.5–2 ng/mL, K⁺.
• Lithium → 0.6–1.2 mEq/L, Na⁺/hydration.
• Vancomycin → trough 10–20 µg/mL, BUN/Cr.
• Acetaminophen → AST/ALT.
• Furosemide → electrolytes/daily weight; Insulin → capillary glucose; ACEi → Cr, K⁺; Opioids → RR.

Page 47 – Peak/Trough Ordering & Non-Lab Diagnostics

• Timing specifics for peak/trough.
• ECG/vitals for beta-blockers, antiarrhythmics.
• Diuretics: I&O, lung sounds.
• Neuromeds: watch gait/nystagmus.

Page 48 – Route Selection Principles

• PO: easy but slow, needs GI.
• SL/Buccal: fast, liver bypass.
• IM/SQ: depot potential.
• IV: fastest, greatest error risk.

Page 49 – Administration Techniques

Oral

• Upright $90^{\circ}$, water, assess swallow; do not crush enteric/ER.
  SubQ
• $25–27$ G, $3/8–5/8$ in, ≤$1.5$ mL; rotate.
  IM
• $22–25$ G, $1–1.5$ in, ≤$3$ mL (deltoid ≤ 2 mL); Z-track for irritants.

Page 50 – Discharge Teaching Scenario (Table Prompt)

• Lisinopril, prednisone, metformin: identify teaching points (grapefruit, orthostatic, rinse mouth, monitor BG).

Page 51 – Scenario Answer & Teaching Points

• Lisinopril: rise slowly; monitor BP (<90 systolic hold).
• Prednisone: rise slowly; if inhaled, rinse mouth; monitor BG.
• Metformin: monitor BG; avoid if renal impairment (risk $\uparrow$ lactic acidosis).
• Bonus reminders (furosemide hypokalemia, digoxin HR

Page 52 – IV & Transdermal Administration Steps

IV

• Confirm patency, dilution, rate; monitor for speed shock/infiltration; use pump.
  Transdermal
• Gloves, remove old patch, clean/rotate site, apply to hairless skin, date/time/initial.
• Warning: leftover fentanyl patches still active.

Page 53 – Inhalers & Suppositories

Inhaler (MDI/DPI)

• Shake MDI, exhale, slow deep inhale during actuation, hold 10 s, 1 min between puffs, rinse mouth post-steroid.
  Rectal/Vaginal
• Rectal: Sims’, insert past sphincter, stay 5 min.
• Vaginal: dorsal recumbent, insert to posterior wall, provide perineal care.

Page 54 – Safe Prep & Patient Teaching

• Double-check calculations; label syringes; no unattended meds; use filter needle for ampules.
• Teach med name, purpose, dose, schedule, storage, side-effects; employ teach-back.

Page 55 – Medication Error Protocol

• Assess patient first.
• Notify provider.
• Incident report (not in chart).
• Reflect to prevent recurrence; maintain transparency with client.

Page 56 – Skill-Building Video Links

• Insulin sliding scale, central-line blood draw/flush, SCD, Foley insertion, sterile urine collection, head-to-toe, med validation, IV insertion, bolus administration (URLs provided).

Page 57 – Supplemental Clinical Videos

• Topics: DVT pathophysiology, PCN allergy cross-sensitivity, allergic reactions, seizure care, beta-blocker use, advanced DVT treatment, clot removal, venous doppler, hemicolectomy, patient PE experience (URLs provided).