Week 1 Flashcards
5 health care professionals that can write prescriptions
- Physicians MD or DO
- Advanced Practice Nurses
- PA
- Dentists DDS or DMD
- Podiatrist DPM
Can a LPN administer medications?
Yes, however there are certain restrictions to what kinds of medications she can administer
Protocol for telephone or verbal orders
- Follow the institutions policy and READ BACK.
- Health care provider that gave the order must sign it within 24 hours of giving it
- Usually only given during emergencies
8 components of a medication order
- Date and Time of order
- Drug name- preferred generic
- Drug dosage
- Route of administration
- Freq and duration ( twice daily X 7 days)
- Any special instructions for the medication
- HCP signature if it was TO or VO order
- RN signature taking the order
5 types of drug orders
- Standing orders- all have different exp. dates
- One time (single) orders
- PRN (Pro-re-nata)- as needed
- STAT (Statim)- NOW orders
- Opioid orders- not automatically refilled- when extension needed a new prescription is req.
6 Rights of Drug Administration + bonus right
RMR- even if all the rights are followed a deadly medication error can still occur!!!
- Right PT
- Right drug
- Right dose
- Right route
- Right time
- Right documentation
* Right reason for giving the drug- sometimes we give medications for their side effects ex. benedryl for drowsiness*
Addition Rights of Drug Administration 4
- Right Assessment
- Right Education
- Right to Refuse
- Right Evaluation
8 Drug Administration Guidelines
- Wash hands
- Check allergies
- Check label of drug 3 times (once when retriving from drawer, once when getting the correct dosage, once by the bedside right before giving)
- Use 2 PT identifiers
- Assess PT before giving them the meds (ex. HBP meds take BP before giving them)
- Check exp date
- Recheck any med calculations
- Make sure PT takes the drug before you leave the room and DOCUMENT!
DO NOT USE LIST- what should you write instead
- U or UI
- QD
- QOD
- MS04 & MS
- c.c
- ug
- should we use the less than or greater then signs
- units or international units
- every day or daily
- every other day
- morphine sulfate
- mL or millimeter
- microgram or mcg
- nope write it out!
Disposal of Medications
-should you flush medications down the toilet
- Follow information on the drug insert
- Remove all identifying information
- Consult a pharmacists
- Community Drug-Take-Back service
- Transfer the substance into an undesirable substance such as kitty litter
- Not unless it states on the leaflet
Crushing Medications
-Enteric coated medications cannot be crushed normally bc they have a protective covering which prevents them from dissolving in the stomach so they can dissolve in the small intestine instead
High Alter Medications
-Medications that can cause great danger or harm if not used correctly PINCH Potassium Insulin Narcotics Chemotherapy Heparin
Client Educations
- Most of the information we tell PT about their meds is either forgotten or misunderstood
- Many pt feel bad that they cant understand the pharm insert of medication information
- Health care environment makes it hard for pt to tell us they do not understand the pharm info
- Many insurance companies require client teaching to be documented and recorded for $ back ex. stroke education before discharge
Teach Back
Effective way to determine how well the information was understood by the pt, more of an indicator of how well you taught the information then anything to do with them. Ask them to repeat you tell you how their medication should be taken etc in a non demeaning manner
During which process of med admin do more then 40% of med errors occur?
Administration of medications
Types of medication errors
- Omission
2. Commission
4 Omission Errors
- Not prescribed
- Not dispensed
- Not administrated
- Not taken
Nurses must make sure when a PT is NPO if they should still be taking medications or not
- Commission Errors
- Wrong drug
- Wrong dose
- Wrong pt
- Allergic reaction
- Drug food therapy reaction
- Wrong drug substitute
- Wrong route
- Drug overuse
- Failure to follow drug specific instructions
- failure to follow policy
Errors of commission and communication
communication failures:
- Bad handwriting
- Incomplete order
- Vague instructions
- Prescription not recognized
- Unknown or illegible HCP
When should you never give a drug?
- If the order is unclear or incomplete
- Dosage appears incorrect
- Client is having an adverse reaction
In any of the above or any situation getting worse call and report to HCP
Stock vs Unit Dose
Advantages of Stock: 1. Always available 2. Cost effective Disadvantages of Stock: 1. More errors- many people pour from the bottle, more drugs to choose from 2. Exp date might be missed
Advantages of Unit: 1. Fewer errors 2. Saves time 3. Correct dose without calculation 4. Billed for specific doses Disadvantages of Unit; 1. Time delay when you need more 2. If contaminated or damaged hard to replace
Pharmaceutics
Packaging, pharmacies, oral vs. tablets vs. soln
Pharmacokinetics
‘Motion’ What the body does to the drug
Pharmacodynamics
‘Action’- What the drug does to the body
1938- The FDA
Food, Drug, Cosmetic Acts
- Monitors and regulates the manufacturing of drugs and marketing of drugs
- Testing, labels, packaging
Health Insurance Portability & Accountability Act HIPAA 2003
- Privacy of health information
- Pharmacy cant access all of the PT information
- Private consult with the pharmacist
- Clients sign statements they received copy of the privacy practice
Nurse Practice Acts
- Vary by states
- NY/NJ- prohibits nurse from giving medications without valid prescription for HCP
- Outlines criminal offenses
Civil Offenses as outlined by the Nurse Practice Acts
- Misfeasances - negligence (wrong drug/dose) results in death
- Nonfeasance- Omission results in death
- Malfeasance- Correct drug by wrong route causes death
FDA Pregnancy Categories
- Classifies risks to fetus
- A, B, C, D, X
Which categories are safe during pregnancy?
- A & B especially during the 1st trimester
Category A Fetal Risk
- Studies show NO RISK
Category B Fetal Risk
- No fetal risk in animals so no risk is assumed in humans
Category C Fetal Risk
- Fetal risk in animal studies; weigh risk vs. benefits
Category D Fetal Risk
- Proven risk to fetus; weigh risk vs. benefits if life threatening
Category X Fetal Risk
- Proven fetal risk is greater then benefit AVOID DURING PREGNANCY
Phases of Human Clinical Drug Experimentation: Phase I
- Determines human drug dosage in healthy subjects
Phases of Human Clinical Drug Experimentation: Phase II
- Demonstrates drug safety & efficacy in subjects with disease
Phases of Human Clinical Drug Experimentation: Phase III & IV
- Demonstrates drug safety & efficacy in wide client population & collect long term data
EthnoPharmacology - define and give an example
- Study of drug responses that are specific to a specific group belonging to a certain social, cultural or biological phenomena
- AA respond poorly to ACE inhibitors causing a really bad cough
Pharmacogenetics
- Variations in the predicated responses to medications due to genetic factors
Transcultural Nursing
- combination of traditional health care practices ( use of teas, herbs, spices, special food, homeopathic remedies– all of which can provide neutral, beneficial or bad effects)
& complementary health practices & alternative health practices & mainstream health practices
Giger and Davidhizar Transcultural Assessment Model
The nursing assessment includes: communication, space, social org, time, environmental control, biological variations (pharmacogenomics), culturally unique
Additive Effects
- Sum of the effects
- Two drugs with the similar actions sum their effects
- Could be desirable or undesirable
1 + 1 = 2 - ex. Hydralazine and Nitroglycerin
ex. beta blocker and diuretic both used to dec BP
Synergism or Potentiation
- Clinical effect is greater than simply the combined effect of the two so its a higher then the additive effects
- two drugs with different mechanisms of action produces greater effects
1 + 1 = 3 - ex. codine and ASA for pain relief
ex. amicillin and sulbactam- inc. the antibiotic’s potency (this is an enzyme inhibitor so drug enters cell of bacteria)
Drug Interference
- One drug creates a difference in the other
- One drug increases or decreases the metabolism or excretion of another
- ex. Probenicid slows renal excretion of penicillin
ex. Warfarin, barbiturates & cimetidine affect metabolism of many drugs
Displacement
- One takes the place of the other
- Two drugs compete for binding sites on plasma proteins ( usually on albumin so when you give two drugs that need to bind to albumin only one gets to bind and the other stays unbound which can be a toxicity issue)
Antagonism
- One drug cancels out the effects of another
- ex. Narcan( do not push all at once) cancels the effects of opioid overdose
- 1 + 1 = 0
- ## Basis for antidotes to toxic effects of another drug or chemical
How does malnourishment impact the potential of a drug overdose?
- Malnourished individuals have a higher chance of having an drug overdose because they have less albumin so more unbound meds
Incompatibility
- One cannot exist with the other
- Interaction of 2 drugs interferes with action of at least 1 drug
- Always check before mixing IV drugs or injections
- Basis for drugs that bind/inactivate another toxic drug in GI tract
- Ex. Mg in antacids and tetracycline may impair absorption of tetracycline
Mixing different types of IV meds in the same tubing can cause crystalized drug and line occlusion
ex. laxatives dec absorption of medications bc inc paraslytasis so less time for the drug to be absorbed
Drug Abuse
- Using a drug in a way that is inconsistent with medical or social norms
- Overindulgence
- Has negative impact on psychologic, physical or social functioning
EVERYONE IS AT RISK
What does food do to drug absorption
-Food slows most drug absorption but does not always impact drug action
Some food and what drugs they impact
- Grapefruit- Ca channel blockers; possible toxicity and inc BP
- Vitamin K rich foods like leafy greens, bananas, fish and Coumadin and Warfarin
- Dairy Products- impairs absorption of tetracycline
- Tyramine Foods like beer, wine, cheese, pickled, liver- MAO inhibitors so can cause serve HBP
Which lab values impact drug interactions
- Plasma or serum electrolytes can impact how drug works in the body
- ex. Digoxin & low K or low Mg or high Ca: may cause digitalis toxicity
low K can happen when a PT is on a diuretic
What impacts can OTC or herbal therapies have?
- They might delay professional diagnosis and treatment
- Symptoms may be masked
- PT should always read label and consult a health care professional before use
- Potential for overdose
- Risk for drug-drug interactions
- Inactive ingredients can end up causing adverse reactions
- Could end up helping
Potential Risks/ Hazards of Herbs
- Lack of standards and regulation
- Possible interactions with other drugs
When should herbs never be used?
- Pregnancy
- Infants or small kids
- Alongside Chemo
- In large quantities
3 Phases of drug action
- Pharmaceutics- drug getting into the body
- Pharmacokinetics- body acting on drug
- Pharmacodynamics - drug acting on body
Pharmaceutic Phase
Drug becomes a solution so that it can cross the biologic membrane of the cells
Mainly applies to orally consumed tablets, does not apply to IV, Sub Q or intramuscular shots bc they are absorbed via blood or tissues
Pharmacokinetic Phase
- Absorption
- Distribution- protein binding
- Metabolism
- Biotransformation
- Excretion or elimination
WHAT YOUR BODY DOES TO THE DRUG
Pharmacokinetic Phase-
Absorption of Oral Meds
- First Phase Effect
- Bio-availability
First Phase Effect
- Drug passes through the liver before entering systemic circulation- chemical and biological barriers in GI environment (pH of GI tract can alter the power of a drug sometimes)
- oral drugs are metabolized to a certain level before going into the blood so not all of the dosage is being used by the body hence oral tablet form dosage is usually higher then the dosage given IV
Bio-availability
- % of drug that reaches systemic circulation
- PO drugs less then 100
- IV drugs usually 100
Pharmacokinetics: Distribution
- Process by which the drug becomes available to body fluids and tissues. so some of the drug gets bound to proteins (inactive) some into the blood (active/free) some to blood tissue affinity. All of these things produce the pharmacologic effect.
- Different drugs bind to different things some to proteins, some to tissue, some remain free in the blood.
How to drugs get excreted?
Protein bound drugs need to become free floating to be excreted.
Distribution: Protein Binding
- Bound drug is inactive
- Drugs can be highly binding 89% or low binding 30%
- Taking 2 highly binding drugs can lead to toxicity bc 1 drug takes all the protein and the other remains free
- Free drugs are the only ones that are active
- Hypo-albuminemia can lead to excess free drug & cause toxicity
Distribution: Impact of blood flow and Body Tissue Affinity
- Abscesses and exudates, glands, and tumors decrease distribution
- Amiodarone can cause lung toxicities
- Some drugs accumulate in fat, bone, liver, muscle & eye tissue
- In overweight people anesthesia stays in fat cells and releases slowly
Metabolism
- Process by which the body in-activates or bio-transforms the drugs
What is the primary site of metabolism?
Liver- enzymes convert or transform drugs into inactive metabolites or water- soluble substances for excretion therefore liver diseases such as cirrhosis or hep can affect metabolism
What happens hen metabolism decreases?
- Excess drug accumulates and it can lead to toxicity
What implications does an increase in bilirum signify?
- The liver may be leaking these enzymes which means the liver has decreased functioning and it can lead to toxic level of drugs bc the bio-avialabilty of these drugs will be very high.
What is the importance of knowing a drugs half life?
Liver dysfunction does what to a medication’s half-life?
- Half life helps us estimate the time req for a drug to reach a biologically steady state (this can req. 3-5 dosages before we can determine that the amount of drug going into the system is the same as is being secreted)
- it prolongs half life meaning that it takes longer for a drug to reach half potency
What is the main source of drug excretion?
- Kidneys - they filter unbound drugs and water soluable drugs and unchanged drugs
- Other routes include bile, feces, salvia, sweat, breast milk
Urine pH and drug excretion
- Acid urine excretes weak base drugs
- Alkaline urine excretes weak acid drugs
- Sometimes pt are given serum Bicarb to help them excrete drugs via urine
What is a good measure of kidney function aka most accurate renal function test?
- Creatinine Clearance or Cr Cl
- Creatine is the metabolic byproduct of muscle tissue that is excreted by the kidneys therefore people who have low muscle mass have lower values such as women and old pple so might need to dec dose for these people
Normal levels for creatine clearance
85-135
What is the standard protocol for drawing Cr Cl labs?
- Usually done in the morning and it is a snap shot of that the renal function that time, it may change rapidly even throughout the day!
Pharmcodynamic Phase
- Way that drugs affect out body and has 2 phases
1. Primary physiologic phase
2. Secondary physiologic phase
Primary Physiologic Phase
Desirable result- the dug is doing what we want it to do!
Secondary Physiologic Phase
- Could either be desirable or undesirable
- ex. Benadryl- could be desirable for someone who has trouble sleeping
Pharmacodynamics- Therapeutic Index
- Low or High
- Low-narrow margin of safety so need a much more exact dose and must be cautious
- High- large area of acceptable dose so has more room for error
Peak Level
- Highest plasma drug conc. and shows the rate of absorption
- Drug blood work done at prescribed time
Trough Level
- Lowest plasma drug conc and shows us the rate of excretion
- Drawn right before the next due dosage
Loading Dose
- Large initial dose
Side Effects
- Could be desirable or undesirable
Adverse Effects
- More serve than side effects
- Always undesirable
- Can be mild or serve
- Ex. hives or anaphylaxis
Toxic Effects
- Likely to occur when drug levels exceed therapeutic range
Drug Tolerance
- Occurs due to freq and repeated drug administration
Placebo Effect
Your mind thinks your getting better even without an active drug, just the thought of taking medication sometimes makes you feel better
Receptor Theories
- There are receptors on every cell membrane
- Ligand binding domain is the site on the receptor where the drug binds
What are the 4 receptor binding sites
- Kinase linked
- Ligand gated ion channels
- G- protein coupled receptors systems
- Nuclear Receptors
Kinase linked receptors
Ligand binding domain on cell surface. Drug activates an enzyme inside cell which signals an effect to take place
Ligand gated ion channels
- Drug spans cell membrane
- Ion channels Na and Ca open and begins the effect
G - protein
- Coupled receptor systems - drug activates receptor which activates G- Protein which activates effect
Nuclear Receptors
- Effect is achieved through the functions of the cell nucleus via a transcription process
- Activation is prolonged in this receptor family
Agonists
Drugs that produce a response
Antagonists
Drugs that block a response
Nonspecific/ Nonselective
Drugs that affect multiple sites and receptors- do not attach
Potentially Inappropriate Drugs PIM
Beers Criteria
- Meds to avoid in older adults regardless of diseases or conditions
- Meds considered potentially inappropriate when used i older people
