Patient Education & Patient Focused Considerations Flashcards
INSULIN INTERACTIONS:
that increases glucose, antagonize insulin
corticosteroids
diuretics
thyroid drugs
sympathomimetic drugs
niacin
INSULIN INTERACTIONS:
increase hypoglycemic, decrease blood glucose
alcohol
sulfa antibiotics
anabolic streoids
MAOIs
Salicylates
INSULIN INTERACTIONS:
masks triglycerides, risk of not noticing HYPOGLYCEMIA
Non selective beta blockers
Age related changes have a dramatic effect on_______
Increased risk of adverse effects and toxicity at ?
Age related changes have a dramatic effect on pharmacokinetics (ADME)
Increased risk of adverse effects and toxicity at both ends of spectrum of life (newborn and OA)
Drugs cross the placenta primarily by _______.
diffusion
Placenta- access fetus by diffusion (high con to lower cont)
Factors Affecting Pregnancy Safety? (3)
Drug properties
Fetal gestational age
Maternal factors
frequency, doses
fetal gestational age (40 weeks): the greatest risk is in 1st trimester- due to rapid proliferation
maternal factor- kidney/live/ genetic
US Food and Drug Administration (FDA) has implemented?
REVISED pregnancy safety categories.
Drug levels in breast milk are usually ___ than in maternal circulation
Exposure depends on ___ of consumed milk
lower
volume
Drug Therapy During Breastfeeding
Breastfed infants are at risk for exposure to drugs consumed by the mother
Breast milk is not the primary route for maternal drug excretion
Consider risk–benefit ratio
Drug transfer to a fetus is most likely to occur in ____ semester- blood flow to fetus is highest, and are more likely to absorb it
LAST trimester
premature/ preterm infant
younger than 38 weeks gestation
neonate/ newborn infant
younger than 1 month
infant
1 month to younger than 1 yr
child
1 yr to younger than 12 yr
adolescent
13 to 19 yr
Neonatal and Pediatric Considerations: Pharmacokinetics
Absorption
- Gastric pH until 1 to 2 years
- Gastric emptying
- First pass elimination
- Bile salt formation,
- Bioavailability
- Intramuscular absorption
Gastric pH LESS acidic (MORE BASIC) until 1 to 2 years of age
Gastric emptying SLOWED- drug stays longer
First-pass elimination REDUCED- immature liver, more free drug is more available and can lead to toxicity
REDUCED bile salt formation
REDUCED bioavailability
***Intramuscular absorption FASTER and irregular
Neonatal and Pediatric Considerations:
Dose of drug and why?
IMMATURE vital organs absorption is affected
DECREASE the amount of drug they get
They get LOWER DOSE due to risk for toxicity
Neonatal and Pediatric Considerations:
Distribution
- total body water differences result in
- total body water, means?
- protein binding
- blood-brain barrier
Total body water differences result in INCREASED distribution and dilution of water-soluble drugs.
GREATER total body water means lower fat content.
DECREASED level of protein binding (low albumin)
IMMATURE blood–brain barrier means more drugs enter the brain
Neonatal and Pediatric Considerations:
Metabolism
- Liver function, production of enzymes
- Older children’s differences from younger ones, and dosage and frequent requirement
- Other factors to consider
Liver IMMATURE; does not produce enough microsomal enzymes
Older children may have increased metabolism, requiring higher doses or more frequent administration than infants.
Other factors: liver enzyme production, genetic differences, and substances to which the mother may have been exposed during pregnancy
Dosage consideration for younger individuals
Decrease the dose= first pass effect affects ORAL meds, in the liver (has detoxify effects)
Neonatal and Pediatric Considerations: Pharmacokinetics
Excretion
- Kidney function, what does it affect
- Perfusion rate of kidneys
Kidney IMMATURITY affects GLOMERULAR FILTRATION RATE and tubular secretion.
DECREASED perfusion rate of the kidneys may reduce the excretion of drugs.
Factors Affecting Pediatric Drug Dosages
- Skin is
- Stomach lacks
- Lungs have
- Body temperature (what can occur)
- Liver and kidneys
Skin is thin and permeable.
Stomach lacks acid to kill bacteria.
Lungs have weaker mucus barriers.
Body temperatures are less well regulated, and dehydration occurs easily.
Liver and kidneys are immature, impairing drug metabolism and excretion.
Methods of Dosage Calculation for Pediatric Patients?
ALWAYS USE… 2
Body surface area method
~~~Uses the West nomogram
Always use weight in kilograms, not pounds.
Always use height in centimeters, not inches.
Body weight dosage calculations
Uses mg/kg
Weigh and measure child!!
General Considerations
Prepare all equipment and supplies first.
Have caregivers stay as appropriate.
Assess for comfort methods before, during, and after drug administration.
Infants
Toddlers
Preschoolers
School-age children
Adolescents
Older Adult Patients
5 NURSING CONSIDERATIONS
High use of medications
Polypharmacy
Nonadherence
Increased incidence of chronic illnesses
Sensory and motor deficits
Older adults age
older than age 65 years
Older adults
- Cardiovascular
CO
Blood flow
DECREASE OUTPUT= DECREASE ABSORPTION + DISTRIBUTION
DECREASE BLOOD FLOW= DECREASE ABSORPTION + DISTRIBUTION
OLDER ADULTS
- GI Tract
pH
Peristalsis
INCREASE PH (ALKALIME GASTRIC SECRETIONS) = ALTERED ABSORPTION
DECREASE PERISTALSIS = DELAYED GASTRIC EMPTYING
OLDER ADULTS
- Liver
Enzyme Production
DECREASE ENZYME PRODUCTION = DECREASE METABOLISM
OLDER ADULTS
- KIDNEY
BLOOD FLOW
KIDNEY FUNCTION
GFR
DECREASED BLOOD FLOW= DECREASED METABOLISM + DECREASED EXCRETION
DECREASE FUNCTION = DECREASE EXCRETION
DECREASE GFR = DECREASE EXCRETION
Older Adults: Pharmacokinetics
ABSORPTION
- pH
- gastric emptying
- GI tract movement
- BLOOD FLOW
- absorptive surface of GI TRACT
Gastric pH less acidic (like little babies)
Gastric emptying slowed
Movement through gastrointestinal (GI) tract slowed because of decreased muscle tone and activity
Blood flow to GI tract reduced
Decrease CO = decrease blood flow to major organs = decrease absorption (ABSORPTION FROM THE GI TRACT, CIRCULATION, LIVER, SYSTEMIC CIRCULATION)
Absorptive surface of GI tract reduced
Decreased ability of stomach to produce HCL
DECREASE muscle tone and activity in GI tract
OLDER ADULTS dosage
Decreased absorption of drugs- increase the dose for therapeutic response
start low, go slow
Older Adults: Pharmacokinetics
DISTRIBUTION
- TOTAL BODY WATER %
- FAT CONTENT
- PROTEIN PRODUCTION and relationship to binding of drugs
Lower total body water percentages (unlike infants)
Increased fat content (less lean muscle)
Decreased production of proteins by the liver, resulting in decreased protein binding of drugs (and increased circulation of free drugs)
Older Adults: Pharmacokinetics
Metabolism
- Production of enzymes in the liver
- Blood flow to the liver
- leads to a prolonged ____ of many drugs
- potential for _______ if not monitored
Aging liver produces fewer microsomal enzymes, affecting drug metabolism.
Blood flow to the liver is reduced- accumulation and toxicity
Leads to a prolonged half-life of many drugs
~~~Potential for accumulation if not monitored
Older Adults: Pharmacokinetics
Excretion
- GFR, why?
- Number of intact neurons
Decreased glomerular filtration rate due to decreased BF, and CO
Decreased number of intact nephrons
(Decreased GFR, CO, kidney perfusion and intact nephrons > delayed drug excretion and drug accumulation)
Liver function test
AST, ALT-assess ability to metabolize and eliminate meds > risk for toxicity and accumulation
Kidney test
Creatinine, BUN, urea, nitrogen, GFR
Opioid effects in OA
confusion, constipation, urinary retention, nausea, vomitoing, respiratory depression, falls
NSAIDs in OA
edema, nausea, gastric ulceration, bleeding, kidney toxicity
Antichollinergics and antihistamine in OA
blurred vision, dry mouth, constipation, and sedation, urinary retention, tachycardia
Anticoagulants in OA
major/ minor bleeding episodes, many drug interactions, dietary interactions
Antihypertensives
nausea, hypotension, diarrhea, bradycardia, heart failure, impotence
Antidepressants
sedation, strong cholinergic adverse effects
Cardiac glycosides
visual disorders, nausea, diarrhea, dysrhythmia, hallucinations, decreased apetite, weight loss
Older Adults: Beers Criteria for Prevention of Adverse Drug Events
A listing of drug and drug classes to be avoided in older adults
Identified disease states considered to be contraindications for some drugs
Three categories:
Potentially Inappropriate Drugs and classes in Older Adults
Potentially inappropriate medications to avoid with certain diseases
Medications to be used with caution in older adults
ISNP-SAFE MEDICATIONS FOR OAs
Ethnocultural Considerations
Canada is a multiculturally diverse nation.
Aboriginal populations are growing faster than the rest of the Canadian population.
The 2016 census reported 21.9% of Canadians identify as landed or permanent immigrants
Three in ten Canadians who are visible minorities are Canadian born.
Ethnopharmacology
Provides an expanding body of knowledge for understanding specific impact of cultural factors on patient drug response
Hampered by lack of clarity in terms such as race, ethnicity (phenotype versus genotype?)
Ethnocultural assessment needs to be part of the assessment phase of the nursing process.
Not every patient from the same country shares the same culture.
Phenotype
observable characteristic
Genotype
genes, DNA
Ethnocultural Influences and Genetics on Drug Response
Polymorphism
Medication response depends on the level of patient adherence (adherence is complex).
Use of natural heath remedies that may alter a drug response
Environmental and economic factors
Awareness of ethnocultural
Polymorphism
age, size, body composition, gender > effects of drug therapy
critical in understanding how drugs may result in different responses in different individuals
Ethnocultural Assessment
Languages
Health practices and beliefs
Past uses of medicine
Use of herbal treatment, folk or home remedies, natural health products
Use of over-the-counter drugs
Usual response to illness
Responsiveness to medical treatment
Religious practices and beliefs
Support for patient’s ethnocultural community
Dietary habits
Ethnocultural Nursing Considerations and Drug Therapy
Important to be knowledgeable about drugs that may elicit varied responses in culturally diverse patients
Recognition that patterns of communication may differ
A thorough ethnocultural assessment is needed.
~~Maintaining, protecting, and restoring health
Nursing Process
Assessment
~~Pediatric considerations
~~Older adult considerations
~~Ethnocultural considerations
Planning
Nursing Diagnosis
Planning
Implementation
Evaluation
Should you give aspirin to anyone under the age of 18?
Do not give aspirin to anyone less than 18- can cause seizure, coma, death, and Reyes’s syndrome
period of greatest danger of drug induced developmental defects
1st trimester
3 factors that contribute to safety/ harm of drugs
drug’s properties
dosage and duration of therapy
concurrently administered drug
fetal gestational age
1st trimester- rapid cell proliferation, organs are developing (NO SELF TREATMENT)
Last TRIMESTER- drug transfer TO occur
maternal
mother’s physiology
(kidney and liver function > increase drug levels)
genotypes
precense of enzymes
4 conditions require medications during pregannacy
HTN, epilepsy, diabetes, infection
3 labels for pregnancy
pregnancy, lactation, F & M reproductive potential
Breast feeding
circulation > breastmilk > infant
fat solubility, low molecular weight, non ionization, increase concentration
drug level in milk is lower (depends on volume of drug taken)
eGFR
assess deterioration of kidney function and stage kidney disease
Albuminuria
urine albumin to creatinine greater than 2.0 mg/mmol/L for men/ greater than 2.8 mg/ mmol/L for women
serum creatinine levels
creatinine- by product of muscle metabolism
medication response depends on
adherence, use of alternative natural health products
European and African decent
slow acetylators- increase drug concentrations, decrease dose
Japan + inuit
rapid acetylators; increase metabolism; increase dose
Asian
poor metabolizers of antipsychotic/ antidepressants
lower dose
white
rapid metabolizers
increase drug dose
african RESPONDS BETTER TO WHICH PILLS
respond better to diuretics and calcium channel blockers
chinese
decrease dose of antidepressant
pediatrics
mg/kg
BSA- organ maturity is considered
OA MAIN CONCERN
polypharmacy
water composition of
infants
premature newborn
children
adult
infants- 75%
premature newborn- 85%
children- 64%
adult (40 to 60 years) F- 55% M- 47%
adult (60 above) F- 46% M- 52%
decrease blood flow to liver LEADS TO
altered metabolism
School age
WHAT TO INCLUDE IN TEACHING
brief, concrete explanation
magical thinking
comfort measures after injection
polymorphism
age
cultural beliefs
nutrition
Neonates
immature renal system
admitted from home
ask wife to bring meds in their original container
antihypertensives
dizzy, fainted, decrease BP
pregnancy
consult with HCP about taking medications during pregnancy
Japanese had strong reactions unlike others
decrease dose
3 domains of learning
cognitive
affective
psychomotor
Cognitive domain
level at which basic knowledge is learned and stored
thinking process
incorportates a persons previour experiences
Affective domain
conduct that expresses feelings, needs, beliefs, values, and opinions
Psychomotor domain
learning of a new procedure or skill; often called the doing domain
demonstration, step by step approach
Patient Education:Assessment
Adaptation to any illness
Age
Barriers to learning
Cognitive abilities
Coping mechanisms
Cultural background
Developmental status
Education, including literacy level
Emotional status
Environment at home and work
Folk medicine, home remedies, and alternative or complementary therapies
Family relationships
Financial status
Health literacy
Psychosocial growth and development
Health beliefs
Information patient understands about past and present medical conditions
Language(s) spoken
Level of knowledge about current medications
Misinformation about drug therapy
Mobility and motor skills
Current medications, including over-the-counter and herbal medications
Motivation
Nutritional status
Past and present health behaviours
Past and present experience with drug regimens and other therapies
Race and ethnicity
Religion or religious beliefs
Readiness to learn
Self-care ability
Sensory status
Social support
Erikson’s Stages of Development
Infant- years and name of stage
Infant (birth to 1 year)
Trust versus mistrust
toddler
ERIKSON
Toddler (1 to 3 years)
Autonomy versus shame and doubt
preschool
ERIKSON
Preschooler (3 to 6 years)
Initiative versus guilt
school aged
School-aged child (6 to 12 years)
Industry versus inferiority
adolescent
Adolescent (12 to 18 years)
Identity versus role confusion
young adult
Young adult (18 to 45 years)
Intimacy versus isolation
middle aged adult
Middle-aged adult (45 to 65 years)
Generativity versus stagnation
older adult
Older adult (older than 65 years)
Integrity versus despair
Patient Education:Nursing Diagnoses
Deficient knowledge
Readiness for enhanced knowledge
Falls, risk for
Ineffective self-health management
Readiness for enhanced health management
Impaired memory
Injury, risk for
Nonadherence
Readiness for enhanced communication
Readiness for enhanced power
Readiness for enhanced decision-making
Sleep deprivation
Patient Education:Planning
Goals and outcome criteria
Specific
Measurable
Realistic
Based on patient needs
Stated in patient terms
Time frame
Patient Education:Implementation
Teaching–learning sessions
Consideration of age-related changes
Consideration of language differences
Safe administration of medications at home
Return demonstration with equipment.
For adults, it is recommended that materials be written at a Grade 8 level.
Patient Education:Teaching–Learning Sessions
Individualize the teaching session
Use positive rewards or reinforcement for accurate return demonstration of procedures or techniques
Complete a medication calendar
Use audiovisual aids
Involve family members or significant others
Teach on a level that is meaningful to that patient
Resources for non-English-speaking patients
Provide education in patient’s native language
Provide detailed written instructions in native language
Patient Education:Evaluation
Verify whether learning has occurred.
Ask questions.
Have the patient provide a return demonstration.
Behaviour, such as adherence to a schedule
Occurrence of few or no complications
Develop and implement new plan of teaching as needed for: Nonadherence & Inadequate levels of learning
Patient Education:Documentation
Learner assessment
Outcomes
Content provided
Strategies used
Patient response to the teaching session
Overall evaluation of learning
hard of hearing
do not shout, speak normal but low pitch sound
vision
clean glasses
large print
non glare
avoid contrast
short term memory
small info at a time
written instruction
repeat info frequently
teaching begins at
begins at time of diagnosis/ admission
individualized
discharge plan
individualized
based on patients level of cognitive development
MILD anxiety
results in learning by increasing the pts motivation to learn
assess learning needs
validation of pt’s present level of knowledge
Does not understand english
interpreter who can speak pts native language for sessions
psychomotor domain
teach how to administer eyedrops
how to measure a pulse before taking beta blockers
how to give injection
