Prescription review

Question 1

what is the PReSCRIBER mneumonic?

Answer 1

• Patient details
• Reaction (i.e. allergy + reaction to medication)
• Sign the front of the chart
• Contraindications
• Route of drug
• Intravenous fluids - assess if needed
• Blood clot prophylaxis - assess if needed, what to give
• Anti-Emetic - assess if needed
• Pain Relief - assess if needed

Question 2

What to check for patient details?

Answer 2

needs to have 3 e.g. name, DOB and hospital number

can use patient sticker with all of this on

Question 3

What are the main groups of contraindications to consider?

Answer 3

1. anti-platelets + anti-coagulants not to be given to patients who are actively bleeding, suspected of bleeding or at high risk of bleeding
2. SE of steroids (STEROIDS) - Stomach ulcer, Thin skin, oEdema, Right + L HF, Osteoporosis, Infection (incl. Candida), Diabetes, cushing’s Syndrome
3. safety of using NSAID - No urine, Systolic dysfunction (HF), Asthma, Indigestion, Dyscarsia (clotting abnormal)
4. broad SE of anti-HTN - hypotension, bradycardia (beta-blocker, CCB), electrolyte disturbance (ACEi, diuretics)

Question 4

What are the SE of steroids?

Answer 4

STEROIDS

• Stomach ulcers
• Thin skin
• oEdema
• Right and left heart failure
• Osteopororsis
• Infection incl. candid
• Diabetes (usually ↑ BM)
• Cushing’s Syndrome

Question 5

What factors to consider if NSAID is safe to prescribe?

Answer 5

NSAID

• No urine e.g. renal failure
• Systolic dysfunction e.g. HR
• Asthma
• Indigestion
• Dyscrasia (clotting abnormality)

Question 6

SE of anti-HTN

Answer 6

• Hypotension for all (earliest Sx, postural hypotension)
• Beta-blocker + CCB → bradycardia
• ACEi + diuretics → electrolyte disturbance
• ACEi → dry cough
• Beta-blockers → wheeze in asthmatics, worsening acute HF (useful in chronic)
• CCD → peripheral oedema, flushing
• Diuretics → renal failure
• Thiazide (bendroflumethiazide) → gout
• K+ sparing (spironolactone) → gynaecomastia

Question 7

what considerations for medication routes are there?

Answer 7

• vomiting - anti-emetic given SC/IM/IV, if only short period of vomiting don’t convert all other
• degree of clinical well/unwell - i.e. IV Abx for very unwell

Question 8

When should 0.9% NaCl not be used?

What should be given instead?

Answer 8

Hypernatraemia or hypoglycaemia → 5% dextrose instead

Ascites → human albumin solution instead

Shocked from bleeding → blood transfusion, crystalloid until blood available

Question 9

what indications for fluids?

Answer 9

• acutely unwell or volume depleted
• maintenance fluids in NBM patients or with very low oral intake

Question 10

what fluids for hypernatraemia or hypoglycaemia?

Answer 10

5% dextrose

Question 11

what fluids for ascites patients?

Answer 11

human albumin solution to maintain oncotic pressure

Question 12

what fluids in shocked pt secondary to haemorrhage?

Answer 12

blood transfusion

crystalloid (normal saline) until blood available

Question 13

what is the maximum amount of IV potassium?

Answer 13

do not give more than 10 mmol/hour

Question 14

considerations for maintenance fluids?

Answer 14

• General rule - 3L/24hrs for adults, 2L/24hrs for elderly
• Electrolytes - 1L 0.9% saline and 2L of 5% dextrose (1 salty, 2 sweet)
• Normal potassium require 40mmol KCl per day → put 20 mmol in 2 bags

Question 15

rough maintenance amounts for adults + elderly?

Answer 15

• adults = 3L
• elderly = 2 L

over 24 hours

Question 16

attaining maintenance electrolytes from IV fluids

Answer 16

• 1 salt + 2 sweet - 1L NaCl 0.9% with 2L 5% dextrose
• if normal K+ on bloods need 40 mmol per day - give as 20 mmol into 2 bags

Question 17

what to check everytime you are prescribing fluids?

Answer 17

• U&Es
• fluid status
• if giving for reduced urine output examine bladder for signs of retention

Question 18

what rate of maintenance fluids?

Answer 18

• 24 hours divided by number of L to be give
  
  • 3L in 24 hours - 8hrly
  • 2L in 24 hours - 12 hrly

Question 19

what is standard VTE prophylaxis?

Answer 19

LMW heparin e.g. 5000 units dalteparin SC OD

compression stockings

Question 20

who shouldn’t get compression stockings?

Answer 20

peripheral arterial disease pt e.g. absent pulses distally

Question 21

what anti-emetic for nauseated patients?

Answer 21

regular

• Cyclizine 50mg 8 hourly IM/IV/oral (SE fluid retention)
• Metoclopramide 10mg 8 hourly IM/IV if HF
• Ondansetron 4mg or 8mg 8 hourly IV/oral

Question 22

who should metoclopromide be used with caution/not used?

Answer 22

• parkinson’s
• young F - risk of dyskinesia

Question 23

what anti-emetic for patients who are not-nauseated at the current moment?

Answer 23

prescribe as needed (PRN)

• Cyclizine 50mg 8 hourly IM/IV/oral (SE fluid retention)
• Metoclopramide 10mg 8 hourly IM/IV if HF

Question 24

what pain releif for neuroleptic?

Answer 24

shooting, stabbing or burning

1st line

• amitriptyline 10mg oral at night
• pregabalin 75mg oral 12 hourly

Question 25

what analgesia for diabetic neuropathy?

Answer 25

duloxetine 60mg OD oral

Question 26

analgesia prescription for regular and PRN based on severity of pain

Answer 26

Question 27

what anti-emetic can be used in parkinson's and why?

Answer 27

cyclizine - anti-histamine MOA domperidone with anti-DA MOA (doesn't cross BBB unlike metoclopramide)

Question 28

what are the signs of anti-muscarinic toxicity?

Answer 28

* dilated pupils * loss of accommodation * dry mouth * tachycardia

Question 29

what do these signs suggest: * dilated pupils * loss of accommodation * dry mouth * tachycardia

Answer 29

anti-muscarinic toxicity elderly are more vulnerable to it, often start on lower doses e.g. oxybutinin