305 exam 2 Flashcards
1
Q
Understand the steps of the nursing process.
A
ADPIE
Assessment
- Collecting data
Diagnosis
- Analyze data, Identify health risks
Planning
- Prioritize problems
Implementation
- Implement nursing interventions
Evaluation
- Collected data related to outcomes
2
Q
What assessment would be important
A
Subjective Data: What patient Describes
Objective Data: Physical Assessment, Laboratory tests, other diagnostic sources
Health History
3
Q
What nursing diagnosis would pertain to medications
A
Deficient Knowledge:
*Patient not properly educated about medication
Noncompliance
*Patient properly educated but chooses not to take medication
4
Q
What outcome would you want to see for the patient depending on the medication?
A
Once pharmacotherapy is initiated, assessment focuses on reaction to medication. Watch for:
◦Desired response
◦Adverse effects
◦Patient capability of assuming responsibility for self-administration
5
Q
What interventions would you use for medication administration
A
Administer medication
Continue assessment of patient
Monitor drug effects
Carry out interventions in planning phase
Provide patient teaching
6
Q
How would you evaluate medication effectiveness
A
Reassess Patient
*Physical condition
*Vital signs
*Body weight
*Lab values
*Serum drug levels
Monitor for identified therapeutic effects
Monitor side effects or adverse reactions
7
Q
What is the most important step to the nursing process
A
Assessment
8
Q
Assessment of the Patient
A
Systematic collection, organization, validation, and documentation of patient data
Health history and physical assessment
Baseline data gathered; will be compared to later information from observations
9
Q
Nursing Diagnosis
A
Often most challenging part of nursing
Focus is on patients needs, not nurses
Three main areas of concern
*Promoting therapeutic drug effects
*Minimizing adverse drug effects and toxicity
*Maximizing patient ability for self-care (including knowledge, skills, and resources necessary for safe and effective drug administration)
10
Q
Risk Diagnosis
A
Diagnostic Statement
Related Factors
11
Q
Actual Diagnosis
A
Diagnostic Statement
Related Factors
As Evidence By
12
Q
Diagnoses for Drug Administration
A
Activity intolerance
Pain, acute or chronic
Risk for falls
Urinary incontinence
13
Q
Outcomes for patients receiving medications
A
Provide specific, measurable criteria
Evaluate degree to which goal is met
Focus on what patient will achieve or do
Discussed with patient and caregiver
Should be written and include
- Subject, Action required by subject, circumstances, expected performance, specific time frame
14
Q
Documentation of Medication Administration
A
Administration of medication
Therapeutic and adverse effects
Patient statements
Objective assessment data
15
Q
Patient education
A
Primary role for nurses
Think about individual learning styles related to what is being taught
Directly related to
◦Deficient knowledge
◦Noncompliance
16
Q
Evaluation
A
Begins new cycle
New assessment data are gathered and analyzed
Nursing diagnoses are reviewed or rewritten
Goals and outcomes are refined
New interventions are carried out
17
Q
Review what should be included for a medication reconciliation.
A
Complete List of Current Medications
- Name of all Meds, OTC meds, Supplements, Vitamins, Herbal products, Tea
- Frequency, Date, Last time taken
- Dosage and Route
- Reason for taking
- Place for provider to document review or for RN to document provider was notified
18
Q
What constitutes an error or a near miss
A
Omitting: One of the rights of drug administration
Failing: To perform an agency system check
Failing: To analyze patient variables such as age, body size, and renal or hepatic functions
Giving: Giving medication based on verbal orders or phone orders
Giving: Giving medication based on an incomplete order or an illegible order
Practicing: Practicing under stressful work conditions
19
Q
What should you do in the event of an error
A
First assess patient (Vital signs, monitor for adverse reactions)
Inform provider
Administer antidote (If available)
Document all the names of individuals who were notified
Patient must be informed of the error
20
Q
How can you prevent errors when preparing medications
A
Avoid use of abbreviations
*Pay special attention to
*Watch for look-alikes (TALL letters)
*Black box warnings
*Narrow therapeutic indexes
*Clarify any order you do not understand
*Do not accept verbal orders or phone orders if possible to avoid
*Limit distractions during med admin (vest)
*ALWAYS identify client using 2 means of identification
*Calculate dosages correctly (ask a peer or pharmacist to double check when needed)
21
Q
What are some methods hospitals use to prevent errors
A
*Look up the medication (dosage range, contraindications, …)
*Assess the patient (know the patient’s baseline findings)
*5 rights & 3 checks
*Follow the pharmaceutical instructions and RN Scope of Practice Standards for preparing and administering the medication
*Educate the client about the medication BEFORE administering the first dose
*Reassess the client after administration to determine if:
*Adverse reactions are occurring
*Therapeutic effectiveness is occurring
22
Q
Methods for reporting
A
*RN’s legal and ethical responsibility to report all errors
*The RN’s errors and near misses, and
*The errors and near misses the RN observes
*FDA coordinates the reporting of medication errors
*MedWatch
*NCC MERP
*DMEPA
Follow the healthcare facilities policy on reporting medication errors.
This policy will specify who to report the incident to and the documents that must be completed (example: incident report).
23
Q
Infant development stages and how to promote compliance (Discussion from Sakai)
A
Held upright and cuddled while administering medication
Often administered via drops into the eyes, ears, nose, or mouth
Oral meds should be directed to posterior portion of inner cheek, give time to swallow to avoid choking
If rectal suppository is used, hold buttocks together to prevent expulsion
Smaller needles for Parenteral meds, Vastus lateralis is most preferred
Rotate injection sites
Underdeveloped liver, possible risk for toxicity
24
Q
Toddler development stages and how to promote compliance (Discussion from Sakai)
A
Use fun colored equipment
Physical comfort: Hugging, touching, verbal praise
Mix medications with something more tasty if possible
Offer choices
25
Young and middle aged adult development stages and how to promote compliance (Discussion from Sakai)
Promote healthy lifestyle
providing information on what type of medication the client is taking and what they are taking it for. Advise clients of side effects and adverse effects of medication and possible polypharmacy.
Advise clients on drug-food interactions to prevent adverse medication effects.
Encouraging the client to attend regular doctor appointments and reaching out if things change
Suggest medication organization boxes for memorizing when to take medications
26
Older Adult development stages and how to promote compliance (Discussion from Sakai)
Pill storage due to memory loss
Regular allergy testing
Keep a list of medications
Bring all medications with them to the doctor
27
Preschool and school age development stages and how to promote compliance (Discussion from Sakai)
Stickers
Crush or mix meds into foods
Incorporate small choices when possible to give sense of autonomy
Provide education
High metabolism, higher risk for toxicity
Absorption reduced due to shorter intestinal transit time
High body water composition, low body fat
Increased hepatic blood flow affects metabolism
28
Adolescents development stages and how to promote compliance (Discussion from Sakai)
ADME peak, similar to young adults
Focus on education and self advocacy
Most common use of meds is for eating disorders, depression, headaches, skin issues, sports injuries
Set a good routine for taking meds
Understand recreational drug use can have serious adverse drug interactions
Heavily influenced by peers
29
Pregnancy development stages and how to promote compliance (Discussion from Sakai)
Embryonic Stages of development: 3-8 weeks post conception, Rapid development of internal structures occur during this stage and is the period of maximum sensitivity to teratogens
Absorptive Properties: Increase levels of progesterone can cause delayed gastric emptying, allowing longer time periods for absorption of oral meds. Reduced gastric acidity is also decreased affecting absorption.
Increased cardiac output, increased plasma volume and altered regional blood flow causes dilution of drugs and decreased plasma protein concentrations also affecting drug distribution
Drug metabolism increases in certain drugs, most noticeable in anticonvulsants (Phenytoin) Fat soluble drugs are passed in lipid rich breast milk and may be passed to a lactating infant
By third trimester blood flow to the mothers kidneys increases by 50% affecting glomerular filtration, renal absorption, and renal plasma flow which may increase the rate of excretion and doses may need to be adjusted
Instruct client to contact the provider before taking medications while pregnant
30
Lactating Patients development stages and how to promote compliance (Discussion from Sakai)
pharmacotherapy should be postponed until the infant is weaned
Try relaxing music for anxiety instead of medication
Try massage for pain instead of medication
Administer the drug immediately after breastfeeding
○ Reduces the concentration of drug before next feeding
Avoid illicit drugs, alcohol, and tobacco products during lactation period
Monitor lactating clients and infants for any signs of adverse effects.
31
Infant factors that may affect medication administration
Liver not fully mature, unable to breakdown drugs
IM injections- Use caution due to low body mass
32
Geriatric factors that may affect medication administration
Absorption slows
More body fat
Reduced plasma levels
Enzymes in liver is reduced
Reduced half lives of drugs
Decreased metabolism
Decreased Excretion (Drug stays in body longer)
33
What would you advise a breastfeeding woman who is taking medications while breastfeeding?
If medication is prescribed take it at a point of the day when the baby may be napping, or won't be feeding for a while
34
Trust vs Mistrust
(Infant-12 months)
Dependent on caregiver
35
Autonomy vs Shame and Doubt
(1-3 years)
Rapid motor development
More at risk for choking
Asserting independence
Limited ability to reason
36
Initiative vs Guilt
(3-5 years)
Gross and fine motor skills
New activities and socially involved
If walking for 1 year use ventrogluteal site for injections, if not vastus lateralis
Choking is less common
Poisonings are more common
37
Industry vs Inferiority
(5-12 years)
Rapid physical development, social growth
Sense of pride
Likes choices and praise
38
Identity vs Confusion
(12-18 years)
Rapid physical growth
Psychological maturity
Personality development
Sense of independence
Skin problems, menstrual problems, headaches, contraception, alcohol, sports injuries
Rely on peers for support
Peak metabolism
39
Intimacy vs Isolation
(18-40 years)
Minimal need for prescription drugs
Intimate loving relationships
Start families
Sexually active
Contraception, STD prevention
Substance abuse
40
Generativity vs Stagnation
(40-65 years)
Build lives with careers
Stressors
Sandwich generation
Health impairments around 45
41
Integrity vs Despair
(65-Death)
Polypharmacy (Multiple drugs)
Some may experience cognitive decline
Independence and dignity
Fulfillment, review accomplishments
Absorption slows
Reduced plasma levels
Enzymes in liver is reduced
Reduced half life of drugs
More body fat
42
Thalidomide
Used to reduce headaches and morning sickness, caused babies to be born with missing limbs
43
Hormones can affect ADME
Decreased absorption
Progesterone
Increased tidal volume = Increased effect, increased pulmonary vasodilation
Inhaled drugs absorbed to a greater extent
Increased blood supply to abdominal organs
Affects absorption (Accelerated)
Increased in blood volume
Diluting drugs affecting distribution
44
Drug Categories
Category A: Adequate well controlled studies have shown no risks in any trimester during the pregnancy
Category B: Animal studies have revealed no evidence of fetal harm
Category C: Animal studies have demonstrated risk to fetus
Category D: Observation in pregnant women demonstrated risks to fetus, but benefits may outweigh the risk
Category X: Contraindicated for pregnancy
45
Teratogen
Causes abnormality, permanent damage
Dose response relationship
Embryonic stage: Most risk for development issues
46
Mexican American
- Traditional diet high intake of fruit, vegetables, and fiber (such as grains and legumes),
- less meat intake
- Traditional meals usually include coffee, beans, meat, and rice is usually served first before the main meal
- Mexican American diet and meals typically eat more meat and less fruits and vegetables
- more likely to have pain underestimated by physicians
- family often plays significant roles in health care decisions
- Usually seek out a folk healer or practitioner before consulting Western medicine
- have increased CYP450 enzymes which effects metabolism of drugs and can reduce therapeutic concentration of a drug
47
Asian Americans
Family collectivism
Maintain strong ties to traditional medicine
High respect for medical providers
Diet heavy in seafood
Rice is main source of carbohydrates
Food is seasonally based
48
Review ways in which a nurse can be culturally aware.
Practice self awareness and examine personal attitudes related to various aspects of culture, identify possible bias
Be knowledgeable about cultures in your area
Apply culturally appropriate care
Understand and address entire culture
Do not impose your own cultural beliefs on others
49
Understand medication change that is needed for someone considered a slow acetylator, slow metabolizer, Fast metabolizer
Slow acetylator:
the rate at which a person acetylates certain drugs is slower than regular
Allows drugs to stay in the body longer increasing risk for toxicity
Slow Metabolizers
Slow metabolizers have a reduced ability to process and eliminate certain drugs, which means these drugs stay in the bloodstream for longer periods and can reach higher concentrations
Fast Metabolizers
This can lead to lower drug levels in the bloodstream and reduced drug efficacy, as the drug is cleared from the system before it has time to produce its full therapeutic effect.
50
Understand holistic care and incorporating it in caring for patients
Caring for the entire patient, physically, spiritually, emotionally
Use inclusive language
Provide resources for spiritual practice if appropriate
Active listening
Use of pharmacological and nonpharmacological practices
Cultural influences, Environmental factors, Psychosocial variables, Gender, Genetics
51
Genetic Polymorphism
*Two or more versions of the same enzyme
*Pharmacogenetics—study of genetic variations that cause differences in the way patients handle medications
*Enzyme function changes
51
What is a psychosocial influence of pharmacotherapy
Psychosocial: Ones psychological development in the context of one's social environment
Ill health, Suffering, Loneliness, Despair, Death
52
Barriers to culturally responsive nursing care
Language
Culturally inappropriate tests
Genetic polymorphism
Poor access to healthcare
Prejudice and Discrimination
Health disparities
53
Garlic:
Medicinal Part: Bulb
Primary Use: Reduce blood cholesterol, reduce blood pressure, anticoagulant
54
Ginger:
Medicinal Part: Root
Primary Use: Antiemetic, Antithrombotic, Diuretic, Promote gastric secretions, Antiinflammatory, Increase blood glucose, Stimulation of Peripheral circulation
55
Ginkgo:
Medicinal Part: Leaves and Seeds
Primary Use: Improve memory, Reduce Dizziness
56
Ginseng:
Medicinal Part: Root
Primary Use: Relieve stress, Enhance immune system, decrease fatigue
57
Echinacea:
Medicinal Part: Entire Plant
Primary Use: Enhance immune system, treat the common cold
58
Know how dietary supplements can support health
*Non Herbal dietary products are used to enhance a wide variety of body functions
*Occur naturally in the body
*Excessive amounts may have harmful effects
*Example—chondroitin and glucosamine (Reduces symptoms of arthritis and other joint problems)
*Link with benefits is unclear
59
Co-Q10:
Primary Use: Prevents heart disease, provides antioxidant therapy
60
Fish Oil:
Primary Use: Reduces cholesterol levels, enhance brain function, increase visual acuity (Due to presence of Omega-3 fatty acids)
61
Lactobacillus Acidophilus:
Primary Use: Maintains intestinal Health
62
Vitamin C:
Primary Use: Prevents Colds
63
Know the regulations on labels for dietary supplements
*Manufacturers of dietary supplements required to evaluate the identity, purity, potency, and composition of their products and report on label
Dietary Supplement and Nonprescription Drug Consumer Protection Act (2007)
Companies must
*Include contact information on product labels for reporting adverse events
*Notify the F D A of any serious adverse event reports within 15 days of receiving such reports
*Keep extensive records on reports
64
D S H E A Weaknesses
*Not necessary to demonstrate effectiveness prior to marketing
*Manufacturer not required to prove safety
*Labels not monitored for accuracy in product amounts or claims of benefits of product
64
Dietary Supplement Health and Education Act of 1994 (D S H E A)
*Regulatory act for dietary supplements
*Less rigid than the Food, Drug, and Cosmetic Act (F D & C Act)
*Dietary supplements are exempted from F D & C Act standards
*Gives Food and Drug Administration power to remove products considered harmful
65
Complementary, Alternative, Integrative medicine
*Complementary – non mainstream practice is used together with conventional medicine
*Alternative – non mainstream practice is used in place of conventional medicine
*Integrative medicine – traditional and complementary approaches are used together
66
Review gastric lavage and when it would be a good treatment option and when you should withhold the treatment.
*Used if patient has ingested a potentially life-threatening amount of poison
*Must be done within 60 minutes
It involves the introduction of a large volume of normal saline or water into the stomach through a tube, which is then aspirated to evacuate stomach contents.
Elevate head of bed to 20 degrees
Continuous setting until return is clear, then set to intermittent
Withhold if:
Client is throwing up
67
Single-Dose Activated Charcoal
*Used if poison is carbon-based (binds to substance to prevent absorption)
*Greatest benefit within 60 minutes
68
Whole Bowel Irrigation
*For potentially toxic ingestions of sustained-release or enteric-coated drugs
*For toxic ingestions of iron, lead, zinc, or illicit drugs
*Solutions such as GoLytely administered via NG tube
*May also have solutions ordered per rectum
69
Review nerve agents and antidotes
Can cause convulsions and loss of consciousness within seconds, respiratory failure within minutes
Blocks Ach E, increasing action of acetylcholine in the synaptic space
*G A (Tabun), G B (Sarin), G D (Soman), V X treatment
–Give atropine injection
–Flush eyes with water
–Apply sodium bicarbonate or 5% liquid bleach solution to skin
–Do not induce vomiting (Mix with stomach acids and form a gas)
69
Review the different levels of patient triage
Red: Patient requires immediate attention within 60 minutes or death will occur
Black: Patient is dead or will die, move on
Yellow: Delayed, Patient still requires treatment but is able to wait a few hours
Green: Minor, Walking wounded
70
Review role of nurse in emergency preparedness
*You will be called upon—duty to respond regardless of training
*virtually no resources and very long hours
*RN role in prevention for:
- self
- community: disaster plans, hospitals etc…
*1. mitigate, 2. Triage 3. treat 4. reassess
*Mitigation-Assessment of Populations at Risk
Education: *Current knowledge/understanding of emergency management
Resources: *Current list of contacts in health and law enforcement
Diagnosis and Treatment: *Awareness of signs, symptoms, and treatment of chemical/biologic agents
Planning: *Involvement in emergency-management plans
70
Know the different types of disasters
Natural Disasters:
Naturally occurring, Tornados, Hurricanes, Flood, Earthquake, etc
Bioterrorism:
Bioterrorism is the intentional use of biological agents—such as bacteria, viruses, toxins, or other microorganisms—to cause harm, fear, or disruption to individuals, communities, or governments
71
Biological Agents:
Category A: Agents-Highest priority, poses a risk to national security, Highly transmissible Ex. Anthrax, smallpox, botulism, ebola, plague
Category B: Agents-2nd highest priority, high morbidity rate, and low mortality rate Ex Typhus fever, E-coli, West nile virus and ricin toxin
Category C: 3rd highest priority, pathogens that are easy to produce and easily disseminated, high morbidity, mortality rate Ex. Hantavirus, TB, Influenza and Rabies
72
Know about the Strategic national stockpile
Also Known As: SNS
Managed by the U.S. Centers for Disease Control and Prevention (C D C)
Stockpile consists of antibiotics, vaccines, and medical, surgical, and patient supplies
Designed to ensure immediate deployment of essential medical materials in case of biologic or chemical attack
Two Components
First Component: Push Package
*Supplies and pharmaceuticals for unknown chemical or biologic threat
*Arrives within 12 hours after attack
Second Component: Vendor-Managed Inventory (VMI) Package
*Supplies and pharmaceuticals for specific chemical or biologic agent
*Arrives within 24 to 36 hours
73
Disaster Management Cycle
1)Mitigation-Prevention Phase
2)Preparedness Phase: Identify threats, create action plans, do drills
3)Response Phase: Different Agencies Respond and assess the situation
4)Recovery Stage: begins when there is no longer danger.
74
Basics of Anthrax
Carried by hooved animals
Inhalation anthrax, rare but has a near total mortality (Normally terrorism)
Cutaneous anthrax, most are cured (Naturally in animals)
Symptoms start after 1-6 days
Treatment- Ciprofloxacin for cutaneous anthrax
Treatment- Anthrasil for inhalation anthrax
75
Anthrax vaccine
5 part series over 18 months
Only for select personnel, military, those who work with imported meat
76
Signs of Anthrax
Cutaneous anthrax
Skin lesions that turn to black scabs
Gastrointestinal anthrax
Sore throat, difficult swallowing, abdominal cramping, diarrhea, abdominal swelling
Inhalation anthrax
Initially fatigue and fever for several days, followed by cough and shortness of breath
77
Ionization Radiation
Ionizing radiation causes
Nuclear Bombs
Nuclear Accidents
Symptoms can occur within hours or days of exposure
Immediate-Nausea, vomiting and diarrhea
Later symptoms-Wt loss, anorexia, fatigue and bone marrow suppression
Treatment: Symptomatic and Potassium Iodide tablets
78
Surface decontamination
*Remove clothes
*Flush with water
*Soap-and-water and alcohol washes for undamaged skin
*Remember to use personal protective equipment to prevent exposure to self
*Must decontaminate prior to entering facility to protect other patients and staff
–Most Emergency Departments have a decontamination room
–Emergency response agencies have portable decontamination structures
79
Basic Care for Toxicity
. Maintain airway, breathing, and circulation
*Airway – keep it open
*Breathing – monitor and provide supplemental O2
*Circulation – monitor and IV (2 large bore 18g if possible)
*Continuous vital signs!
2. Maintain proper blood glucose levels
*Monitor for early signs of hypoglycemia (irritability, confusion, shaking, weakness)
3. Provide treatment of developing seizures (Seizure Precautions)
*Pad siderails, maintain safety
4. Antidotes/treatments
*Is there an antidote
*If oral route, can lavage and/or charcoal be used
80
Specific Antidotes for Overdose
Acetylcysteine: Used for Acetaminophen overdose
Flumazenil: Benzodiazepines
Naloxone: Opioid agents, morphine
Protamine Sulfate: Heparin
Vitamin K: Coumadin, Warfarin
80
ADPIE Parts
-Assessment
-Diagnosis
-Planning
-Implementation
-Evaluation
81
Assessment
-Collection of health history data and physical assessment
-Med use, otc drugs, illicit drug use, lifestyle habits
-Most important step - reference for everything in the future
82
Reassessment
-After pharmacotherapy assess for response
-Desired response
-Adverse effects
-Patient capability of assuming responsibility
for self admin
83
Diagnoses (Nursing)
-Focus on patient needs
-3 main parts
1. Promote therapeutic drug effect
2. Minimize adverse effects and toxicity
3. Maximize patient ability for self care
84
Risk Diagnoses
1. Diagnostic statement
2. Related factor or inferred cause
85
Actual Diagnoses
1. Diagnostic statement
2. Related factor or inferred cause
3. Evidence to support statement
86
Planning
Goals for Patient Receiving Meds
-Bases on nursing diagnoses
-Focused on what pt will do/achieve
-Discussed with pt or caregiver
-Can be short or long term
Outcomes for Patient
-Provide specific and measurable criteria
-Evaluate level of completion of goal
-Focus on what patient will do
87
Implementation
1. Administer
2. Continue
3. Monitor
4. Carry out
5. Provide (education)
Monitoring Drug Effects
-Monitor for therapeutic effect
-Reassess patient (condition, vs, weight, labs)
-Monitor side/adverse effects
Document
-Admin of med
-Therapeutic/adverse effects
-Pt statements
-Objective assessment data
88
Evaluation
-Compares current status with goals
Evaluation Begins New Cycle When
-New assessment data gathered and analyzed
-Nursing diagnoses reviewed/rewritten
-Goals or outcomes are refined
-New interventions are carried out
89
Methods For Reporting
-RN's legal and ethical responsibility to report all errors (near misses and errors, near miss and errors the RN observes)
FDA coordinates the reporting of med errors
-MedWatch
-NCC MERP
-DMEPA
90
Factors that Contribute to Med Errors
1. Omitting (one of the rights)
2. Failing (to perform safety check)
3. Failing (to identify patient variables age, weight, liver function)
4. Giving (meds on verbal orders)
5. Giving meds (on incomplete/illegible orders)
6. Practicing (under stressful conditions)
91
Documenting Med Errors
-Med given
-Monitor VS
-Asses for Adverse Effects
-Notify Provider
-Admin antidote
-Document everyone notified
-Inform patient
92
Med Reconciliation
-Can reduce med errors
-Accurate collection of all meds and substances the client has taken within the past month
Done when:
-Proceeds form one provider to another
-On admission to a facility
-When transferring facilities or units
-When discharged
93
Electronic Health Records (EHR)
-Used to reduce med errors
e-prescribing
-Increase accuracy of orders
-Allows for accurate records keeping
-Increase efficiency in checking contraindications and drug-drug interactions
-Allows for electronic transmission of orders to pharmacy
93
Patient Teaching Reduces Med Errors
Every patient, every dose
-Patient must receive info/education prior to receiving first dose of a med
-Allows patient to decide if they want to take it
94
Reinforce Patient Education with Each Dose
Client should be able to state
-Name of med, why taking, dose, time route
-Adverse reactions and what to do
-Teach back
-Have patient demonstrate specific skill related to administering med
95
Erikson's Developmental Stages
1. Trust vs Mistrust ( birth-18mo)
2. Autonomy vs Shame and doubt (18mo-3yr)
3. Initiative vs Guilt (3-5yr)
4. Industry vs Inferiority (5-12yr)
5. Identity vs Confusion (12-18yr)
6. Intimacy vs Isolation (18-40yr)
7. Generativity vs Stagnation (40-65yr)
8. Integrity vs Despair (65-death)
96
Pregnancy Pharmacotherapy Considerations
-Drug therapy postponed until after pregnancy and lactation
-Non pharmacological alternatives used
-Only use pharmacotherapy in pregnant pt if preexisting condition exists (epilepsy, hypertension, psychiatric disorder)
96
Conditions That May Arise During Pregnancy That Need Treatment
-Gestational diabetes
-Gestational hypertension
-Acute UTI (use antibiotics)
-STI
-Estimated 90% of preg women take med and 70% take at least one prescription med
97
What Can Affect Absorption During Pregnancy
-Hormones
-Pressure of expanding uterus on blood supply to abdominal organs
-Gastric Acidity decreased
-Increase progesterone can delay gastric emptying (more absorption time)
-Progesterone causes greater tidal volume (inhaled drugs absorbed more)
98
What Can Affect Distribution and Metabolism During Pregnancy
Increased cardiac output, plasma volume, altered blood flow
-Dilution of drugs
-Decreased plasma protein concentration
Altered lipid levels
-Affect drug transport and distribution
-Fat soluble drugs ma be passed to infant via breast milk
99
What Can Affect Excretion During Pregnancy
Increased blood flow through kidneys by over 50%
-Drug excretion may increased
-Doses and med may need to be adjusted
100
Teratogen Definition
Substance, organism, or physical agent that can cause permanent abnormality in structure or function, causes growth retardation, or results in death
100
Thalidomide
Causes birth defects between days 35-48
35-37 days: No ears
39-41 days: No arms
41-43 days: no uterus
45-47 days: No tibia
47-49 days: Triphalangeal thumbs
101
Preimplantation Period
-Weeks 1-2
-"All or none" period
-Exposure to teratogen either causes death or has no effect
-Nicotine can cause intrauterine growth retardation
102
Embryonic Period
-Weeks 3-8
-Rapid internal development
-Maximum sensitivity to teratogens
-Teratogen exposure can lead to structural malformation or spontaneous abortion
103
Fetal Period
-Weeks 9-40
Blood flow to placenta increases and placental vascular membranes thin
-Max the transfer of substances to fetus
-Fetus can receive larger dose of med and substances
-Meds will have prolonged duration within fetus (lack metabolic enzymes and efficient excretion)
Teratogen exposure will cause slowed growth or impaired organ function rather than malformation
104
FDA Pregnancy Category Ratings
-A: No increased risk of fetal abnormalities
-B: No evidence of harm to fetus in animal studies
-C: Animal studies show no adverse effect. No well controlled studies in pregnant women
-D: Demonstrated risk to fetus in pregnant women. Benefits may outweigh risks
-X: No indication for use in pregnancy. Abnormalities and risks to fetus
105
Effective Pharmacotherapy Includes
-Culture
-Environment
-Genetics
-Gender
-Psychosocial
Nurse must take all of these into consideration
106
Psychosocial Influences on Pharmacotherapy
-Concerns when illness threatens health
-Ill health
-Suffering
-Loneliness
-Despair
-Death
107
Spiritual or Religious Beliefs Affecting Pharmacological Outcomes
-Meaning
-Hope
-Value
-Capacity to love, give, forgive
-Compassion and empathy
-Enjoyment of life
-Ability to find peace of mind
-Fulfillment of living
108
Ethnic Influences on Pharmacotherapy
-Biologic and genetic similarities
109
Cultural Influences on Pharmacotherapy
-Beliefs, values, and norms that provide meaning
110
Ethnic and Cultural Influences on Pharmacotherapy
-Influence on med outcomes
-Dietary considerations
-Alternative Therapies
-Beliefs about health and illness
-Genetic differences
111
Cultural Awareness
Aware of different cultures and beliefs
112
Cultural Sensitivity
Knowledgeable about relevant cultures
113
Cultural Appropriateness
Apply cultural knowledge to deliver care
114
Cultural Competence
Understand and address entire cultural context
115
Genetic Polymorphism
-2 or more versions of the same enzyme
-Caused by single base mutation in DNA
-Amino acid change in enzyme
-Enzyme functions change
Pharmacogenetics
-Study of genetic variations that cause differences in the way patients handle meds
-99.8% of DNA is that same
116
Cultural Imposition
Impose rules of your culture onto another
117
CAM
Complementary and Alternative Medicine
118
Complementary Medicine
Nonmainstream practice is used together with conventional medicine
119
Integrative Medicine
Traditional and complementary approaches are used together
119
Alternative Medicine
Nonmainstream practice is sued in place of conventional med
120
Alternative Healthcare Systems
-Naturotherapy, homeotherapy, chiropractic
-Native American Med (sweat lodge, med wheels)
-Chinese Traditional Medicine (acupuncture, Chinese herbs)
-Aurvita (ancient Indian therapy to balance mind, body, and spirit)
121
Biologic Based Therapies
-Herbal therapies
-Nutritional supplements
-Special Diets
122
Manual Healing
-Massage
-Physical therapy
-Pressure-point therapy
-Hand-mediated biofield therapies
123
Mind-Body Interventions
-Yoga, meditation, hypnotherapy
-Guided imagery, biofeedback
-Movement-oriented therapies (music, dance)
124
Other Therapies
-Bioelectromagnetics
-Detoxifying therapies
-Animal assisted therapies
125
Aloe Vera
-Use of leaves
-Topical application for minor skin irritation and burns
126
Cranberry
-Use of berries/juice
-Prevent UTI
127
Echinacea
-Use entire plant
-Increase immune system
-Treat common cold
128
Garlic
-Interacts with: Aspirin, NSAIDS, warfrin, insulin, oral antidiabetic drugs
-Used for: reduce blood cholesterol, decrease BP, use for anicoagulant
-Increase risk of bleeding
129
Ginger
-Interacts with: Aspirin, NSAIDS, heparin, warfin
-Used for: antiemetic, antithrombotic, diuretic, stimulate peripheral circulation, anti-inflammatory
-Increase risk of bleeding
130
Gingko
-Interacts with: anticonvulsants, aspirin, NSAIDS, heparin, warfarin, tricyclic antidepressants
-Used for: improve memory, reduce dizziness
-Increase risk of bleeding
131
Dietary Supplement Health and Education Act of 1994 (DSHEA)
-Regulatory act for dietary supplements
-Less rigid than Food, Drug, Cosmetic Act (FD&C)
-Dietary supplements are exempted from FD&C
-Dietary supplements are exempted from FD&C act standards
-Gives FDA power to remove products considered harmful
132
Dietary Supplement and Nonprescription Drug Consumer Act (2007)
Companies Must
-Include contact info on product labels for reporting adverse effects
-Notify FDA of any serious adverse event reports within 15 days of receiving report
-Keep extensive report records
133
Coenzyme Q10
-Prevents Heart Disease
-Provides antioxidant therapy
133
Other FDA Rules
Manufacturers of dietary supplements required to evaluate:
-Identity
-Purity
-Potency
-Composition
Must report on label
134
Fish Oil
-Reduces cholesterol levels
-Enhances brain function
-Increases visual acuity
135
Role of RN in Preparing and Responding to Bioterrorist Attack
Education
-Knowledge/understanding of emergency management
Resources
-Current list of contacts in health and law enforcement
Diagnosis and Treatment
-Awareness of signs, symptoms, and treatment of chemical/biologic agents
Planning
-Involvement in emergency-management plans
136
Disaster Management Cycle
1. Mitigation-Prevention Phase
2. Preparedness Phase
3. Response Phase
4. Recover Stage
137
Triage Categories
-Black: expected to die
-Red: Need treatment within 60 min
-Yellow: Can wait a few hours
-Green: Can wait a while for treatment
138
Category A Biologic Agents
-Highest priority
-Poses risk to national security
-Highly transmissible
Examples: Anthrax, smallpox, botulism, ebola, plague
139
Category B Biologic Agents
-2nd highest priority
-High morbidity rate
-Low mortality rate
Examples: Typhus fever, E-coli, West Nile virus, ricin toxin
140
Category C Biologic Agents
-3rd highest priority
-Pathogens that are easy to produce and easily disseminated
-High Morbidity
-Low mortality rate
Examples: Hantavirus, TB, influenza
141
Anthrax
-Carried by hoofed animals and animal products
-Inhalation: rare, but near total mortality
-Cutaneous: most are cured, "common"
-Symptoms start 1-6 days later
Treatment: Ciprofloxacin
-Use IV cipro
-PO cipro prophylaxis for 60 days
2015 FDA approved Anthrasil, an immune globulin from plasm of vaccinated folks (only good for inhalation)
142
Anthrax Vaccine
-5 part series over 18 months
-Only for select military and those who work with imported meat
-Used for 40 years
143
Cutaneous Anthrax Signs
Skin lesions that turn into black scabs
144
Gastrointestinal Anthrax Symptoms
-Sore throat
-Difficulty swallowing
-Abdominal cramping
-Diarrhea
-Abdominal swelling
145
Inhalation Anthrax
-Initially fatigue and fever for several days
-Cough and SOB develop
146
Push Package
-Supplies and pharmaceuticals for unknown chemical or biologic threat
-Arrives within 12 hours after attack
146
Strategic National Stockpile Packages
1. Push Package
2. Vendor-managed inventory
147
Vendor-managed Inventory
-Supplies and pharmaceuticals for specific chemical or biologic agent
-Arrives within 24-36 hours
148
Nerve Agents
-Cause: convulsions, loss of consciousness (within seconds), respiratory failure (within minutes)
-Overstimulates acetylcholine at central and peripheral sites in body
-Blocks Ach E, increasing action of acetylcholine in synaptic space
149
Nerve Agents and Treatment
GA (Tabun), GB (Sarin), GD (Soman), VX treatment
-Give atropine injection
-Flush eyes with water
-Apply sodium bicarbonate or 5% liquid bleach solution to skin
-Do not induce vomiting
150
Ionizing Radiation Causes
-Nuclear Bombs
-Nuclear Accidents
151
Ionizing Radiation Symptoms
-Can occur within hours or days
-Immediate: Nausea, vomiting, diarrhea
-Later: Weight loss, anorexia, fatigue, bone marrow suppression
-Treatment: Symptomatic and Potassium Iodide tablets
152
Surface Decontamination of Radiation
-Remove clothes
-Flush with water
-Soap and water and alcohol washes for undamaged skin
153
Basic Supportive Care for Toxicity
1. ABC
2. Maintain proper blood glucose
-Monitor for hypoglycemia
-Look for: irritability, confusion, shaking, weakness
3.Provide treatment of developing seizures
4. Antidotes/treatments
-If oral route: can lavage and/or charcoal be used
154
Treatments of Poisoning: Gastric Lavage and Aspiration
-If pt ingested life threatening amount of poison
-Treatment within 60min
155
Treatments of Poisoning: Single-dose Activated Charcoal
-Used if poison is carbon-based
(binds to substance to prevent further absorption)
-Greatest benefit within 60min
156
Treatments of Poisoning: Whole-bowel Irrigation
-For potentially toxic ingestions of sustained-release or enteric-coated drugs
-For toxic ingestions of iron, lead, zinc, or illicit drugs
-Solutions such as: GoLytely administered via NG tube
-May also have solutions ordered per rectum
157
Antidote: acetylcysteine
-Trade Name: Acetadote
-For Overdose of: Acetaminophen (nonopioid analgesic)
158
Antidote: flumazenil
-Trade Name: Romazicon
-For Overdose of: Benzodiazepines (sedative-hypnotic)
159
Antidote: naloxone
-Trade Name: Narcan
-For Overdose of: Opioid agents; morphine (opioid analgesic)
160
Antidote: protamine sulfate
-For Overdose of: Heparin (parenteral anticoagulant)
161
Antidote: vitamin K
For Overdose of: Coumadin; warfarin (oral anticoagulant)
162
Factors Influencing Drug Effects on Breastfeeding Infant
-Some drugs destroyed in infant GI tract
-Some drugs cannot be absorbed through GI tract
-Such small amount in milk causes no harm
163
Breastfeeding and Pharmacotherapy
-Avoid pharmacotherapy if possible
-Admin drug immediately after feeding or while the baby is sleeping
-Use drugs with shorter half life
-Use drugs with high protein binding (will not be as easily secreted in breast milk)
-Have OTCs approved by doctor
164
Pharmacotherapy For Infants (birth-12mo)
-Use posterior half of inner cheek for oral drugs
-Use vastus lateralis for IM injections
(avoid butt bc of sciatic nerve damage risk)
-Use feet and scalp veins for IV site
165
Pharmacotherapy for Toddlers (1-3yr)
Give short explanations and immediate administration of drug
-Hug, touch, praise to comfort
-Use jam or syrup to mix meds in smallest amount possible
-Use vastus lateralis for IM injections
-Use scalp and feet veins for IV
-Use parents as a tool to help calm child
166
Pharmacotherapy for Preschool (3-5)
-Have them participate if safe
-Ventrogluteal site may be used for IM but can still use vastus lateralis
-Use peripheral sites for IV
-Brief explanation then immediate admin
-Child can use doll to act out what will happen or has happened to them to give them more sense of control
167
Pharmacotherapy of School-age (6-12)
-Respiratory and GI upset are most common ailment
-Usually quite cooperative
-Can let child choose to take one med before the other or choose drink
-Make them feel like they have choice
168
Pharmacotherapy Adolescents (13-16yr)
-Primary Concern: Sexual activity, STD/STI, pregnancy
-Alcohol and tobacco use
-Illicit drug experimentation
-Opioid use and overdose
-Give teen privacy and time to ask questions
-Give independence and education
169
Polypharmacy
-Taking multiple drugs concurrently
-Increases risk of drug interactions and side effects
-Nurse should encourage pt to report all prescriptions and OTC drugs to provider on each visit
-Educate pt on purpose of each drug
170
Absorption in Older Adults
-Slower Due To: decreased gastric motility and decreased blood flow to organs
-Increase gastric pH, orals take longer to dissolve
171
Distribution in Older Adults
-Increase fat leads to more storage for lipid soluble drugs and vitamins
-Plasma level decreased, lower therapeutic response
-Less body water, dehydration effects more severe
-Less lean body mass and water, higher concentration of water soluble drugs
-Lower plasma protein binding, more free drug in blood, more risk for drug-drug interaction
-Less cardiac output, slower drug distribution
172
Metabolism In Older Adults:
-Decreased enzyme production in liver, less hepatic drug metabolism
-Lead to increase half life, prolong and intensify drug response
-Decline in liver function, decline in first-pass effect
173
Excretion in Older Adults
-Decreased kidney function
-Decreased excretion of drugs by kidneys
-Higher potential of toxicity of drug
-May need to adjust dosage and timing to reduce risk of toxicity
