Module 8 - Special Populations Flashcards

1
Q

Special populations include

A
  1. Pregnancy and lactation
  2. paediatrics
  3. geriatrics
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2
Q

drugs that are least likely to pass through fetal-placental barrier

A
  • water soluble
  • ionized
  • bound to plasma proteins (molecules too large)
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3
Q

effects of increased levels of progestins?

A
  • delayed gastric emptying (give more time for absorption to occur)
  • increased volume of breath and causes pulmonary vasodilation (higher absorption of inhaled anesthetics only)
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4
Q

changes during pregnancy that affect Absorption

A
  • the blood supply to organs responsible for absorption may change
  • increased levels of progestins
  • Gastric acidity reduced (affecting ionization of drug)
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5
Q

Changes during pregnancy affecting distribution

A
  • Increased Blood volume can dilute drugs and decrease plasma protein concentrations
  • blood flow to uterus and kidneys is increased resulting in higher distribution
  • blood flow to skeletal muscle is decreased resulting in lower distribution
  • altered lipid levels alter transport and distribution of drugs.
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6
Q

Changes during pregnancy affecting metabolism

A

Drug metabolism can be increased (drugs become inactive faster) and decreased (drugs become inactive slower) depending on specific CYP450 enzymes.

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7
Q

Changes during pregnancy affecting elimination / excretion

A
  • blood Flow to kidneys increases significantly as pregnancy progresses
  • directly increases glomerular filtration rate (GFR) and therefore elimination of MOST drugs is increased (may not be clinically significant)
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8
Q

Considerations: pharmacotherapy during pregnancy

A
  1. what is the effect of the CONDITION on the pregnancy? - danger to baby?
  2. what is the effect of the PREGNANCY on the condition? - Danger to mother?
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9
Q

Def: Teratogens

A

A substance, organism, or physical agent to which an embryo or fetus is exposed that produces a permanent abnormality on structure or function, causes growth retardation, or results in death.

  • extent of significance is very dependent on timing during pregnancy
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10
Q

Examples of teratogens

A

ACE-I
Statins
Lithium
Some anticonvulsants, antibiotics, etc

  • NEVER rely on memory to determine teratogenicity of drug ALWAYS look it up!
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11
Q

FDA pregnancy categories

A

A - studied in pregnant women and proven to be safe
B - animal studies revealed no harm, BUT no human trial available. OR animal studies showed harm BUT human trials revealed no harm
C - Animal studies revealed har AND no human tails available OR No animal or human studies
D - Studies have revealed harm to fetus but benefits of therapy may outweigh risks in some women
X - studies have confirmed harm and product is contraindicated in pregnancy

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12
Q

Guidlines for pharmacotherapy During Lactation

A
  • administer drug immediately after last feeding to ensure lowest possible levels at next feeding
  • Administer drug before longest period between feedings (overnight)
  • preference of short half-life drugs with high-protein binding
  • consider whether drug is safe to use in infants
  • advise pt to check on safety of the drug every time
  • avoid natural health product due to lack of reliable information
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13
Q

Drugs that can decrease Milk Production

A
antihistamines 
sedating medications 
some decongestants 
weight loss medications 
diuretics 
high doses of Vitamin B6 
Estrogen 
Nicotine 
Ergot Alkaloids (for migraines)
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14
Q

MOA: Domperidone

A

a dopamine antagonist - also increases prolactin levels (indirectly) - off-level used to increase breast milk production

lactation feedback system uses positive feedback - the act of breastfeeding releases more prolactin, which causes more milk production

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15
Q

Adverse effects: Doperidone

A

Headache, cramping, diarrhea, dry mouth, irregular menstrual bleeding; very small amount passes into breast milk.

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16
Q

Nurse’s role: pregnancy and lactation

A

Provide objective and non-judgmental information to pt
Act as a resource for information
participate in conversations of benefits vs. risks of treatment
refer patients to appropriate resources
support patient regardless of her decision

17
Q

Developmental considerations - pediatrics

A

Organ function is still in development and is responsible for most pharmacokinetic changes
paediatrics (child) includes Newborns - 18 years of age
sites of administration for injections change as age increases and as muscles grow (vaccinations)
doses of drugs are often prescribed as mg/kg or body surface areas (BSA) regimens which require absolute precision in calculations - weight adjusting dose will differ significantly based on age.

18
Q

Pharmacokinetic Changes in children affecting absorption

A

GI absorption generally slow in newborn and improves with age
r/t many factors: surface area, degrees of Gi tract profusion, gastric pH, gastric and intestinal motility, biliary function, Gi bacterial flora and dietary contents, first-pass effect - ALL effecting absorption
- generally decrease absorption

19
Q

Pharmacokinetic Changes in children affecting Distribution

A

Premature infants have higher membrane permeability
Body composition (more water and less fat) alters distribution - depending on solubility of drug
Lower plasma proteins leads to higher bioavailability of active drug - protein levels increase with age
as heart becomes stronger, cardiac output increases and tissue perfusion is enhanced, increasing distribution

20
Q

Pharmacokinetic Changes in children affecting metabolism

A
  • CYP450 system does not fully develop until 15-18 years of age
  • very low % of adult enzyme activity at birth and increases slowly over time
  • each individual enzyme develops at a different rate
  • lower liver perfusion also decreases rates of metabolism
  • Cumulative effect is generally slower metabolism
21
Q

Pharmacokinetic Changes in children affecting elimination / excretion

A
  • nephrogenesis complete at 36 wks gestation
  • glomerular filtration rate approaches adult levels at 6 months of age
  • tubule development (reabsorption and secretion) takes a bit longer
  • cumulative effect is generally SLOWER elimination / excretion of drugs than adults
22
Q

Medication administration in children

A
Younger children (3-5yrs): brief description followed by QUICK administration
older children (5+): can understand longer explanations before administration to ease anxiety
23
Q

monitoring Adverse effects in children

A
  • can be difficult to monitor due to inability to communicate or describe
  • specific drugs that cause specific adverse effects in children (ASA –> eye’s syndrome)
  • important to use resources
24
Q

Nurse’s role: pharmacotherapy in children

A
  • provide comfort - for children and parents
  • encourage dafe medication practices at home
  • individualize medication administration techniques to each child
  • carful monitoring for adverse effects
  • encourage adherence at home
  • Educate parents.
25
Q

Def: polypharmacy

A

a high number of medications (5-10+) which increases the chances of:

  • drug-drug and drug-disease interactions
  • drug-induced problems
  • prescribing cascades
26
Q

pharmacotherapy consideration in Geriatric patients

A

In general - physiological processes slow down as age advances

27
Q

Pharmacokinetic Changes in Geriatrics affecting Absorption

A
  • Gi motility slows, gastric pH increased, decreased blood flow to and from GI tract
  • Cumulatively, alterations in absorption are usually clinically insignificant
  • important to note that GI tract is the most common site of distress in elderly, likely due to changes in eating habits, nutrition, and elimination.
28
Q

Pharmacokinetic Changes in Geriatrics affecting distribution

A
  • Lower total body water results in less distribution BUT higher serum concentrations of water soluble drugs
  • lipid soluble drugs can accumulate in the higher fat content
  • lower plasma protein production leads to higher concentrations of unbound drug
  • inefficient BBB leads to higher incidences of cognitive effects
29
Q

Pharmacokinetic Changes in Geriatrics affecting metabolism

A
  • CYP450 enzymes still active and it is highly controversial whether activity is significantly reduced
  • Lower levels of metabolism likely due to reduced hepatic blood flow, therefore any drug metabolized by liver (regardless of specific enzyme) will potentially have longer half-life
30
Q

Pharmacokinetic Changes in Geriatrics affecting elimination / excretion

A
  • Renal blood flow, GFR, and tubular functions (reabsorption and secretion) all gradually decline with age
  • Serum Creatinune remains to be best marker of GFR, can calculate creatinine clearance to predict drug elimination
31
Q

Some reasons adherence may be difficult in Geriatric patients?

A
may be r/t:
finances 
physical limitations 
visual impairment 
cognitive decline 
polypharmacy 
unpleasant adverse effect
32
Q

ways to improve adherence in geriatric patients?

A
  • ensure patient understanding
  • contacting supportive financial services
  • easy-open containers or pill boxes
  • simplify regimens
  • engage family members or other supports
  • schedule adequate follow-up
33
Q

what medications should NOT be crushed to altered?

A
  • enteric-coated
  • Extended release (ER, XR, XL), sustained release (SR) modified release (MR) controlled delivery (CD) long-acting (LA)
  • drugs knows to directly irritate esophagus or stomach
  • drugs meant for sublingual or buccal administration
  • capsule contents should not be crushed
34
Q

some reasons older adults are at an increased risk for adverse effects?

A
  • polypharmacy
  • physiological changes that affect pharmacokinetics and pharmacodynamic of medications
  • difficulty to differentiate between an adverse effect and normal aging process
35
Q

complications around adverse effects in geriatric patients

A
  • Advere effect and disease / condition can present differently in a geriatric patient - atypical symptoms, also may not be able to communicate symptoms
36
Q

what awesome symptoms that medications should be considered the underlying cause of in Geriatric patients?

A
- rapid weight loss 
sudden change in mental status 
dehydration 
restlessness 
falls 
urinary or fluid retention 
change in bowel habits 
anorexia 
Major change in functional status of organ
37
Q

Potentially inappropriate medications in Geriatrics

A
Antihistamines 
Bensodiazapines 
Digoxin - reduce renal clearance and can cause serious toxicity 
Muscle relaxants 
NSAIDs 
Phenytoin 
Antipsychotics (both classes) 
TCAs
* exception to every rule - these are just generally inappropriate, not always.
38
Q

nurse’s role: geriatric patients

A
  • briefly review med list
  • follow suggestions that can improve adherence
  • assess and monitor for adverse effects
  • if possible discard all unused, and expired medications
  • periodically question patent about NHP and OTC use
  • Suggesting environmental modifications to decrease fall risk