week 4: Ch. 8-10 [Lifespan pharm] Flashcards
Most medications can cross the ____________ and are secreted in breast milk
placenta
_____% of women take at least one medication during pregnancy
90%
[and 80% during first trimester]
Pharmacotherapy is _____________ if possible until after delivery & lactation
postponed
What kind of conditions must be managed during pregnancy?
preexisting conditions
pregnancy complications
conditions unrelated to pregnancy
Physiological changes during pregnancy can alter the normal pharmacokinetic response by:
speeding it or slowing it
increased levels of _______________ cause a decrease in gastric tone and intestinal motility, resulting in delayed gastric emptying > extended drug absorption time
progesterone
High __________ levels cause increased hydrochloric
acid production.
▪ May affect absorption of certain acid labile drugs
estrogen
______________ increases pulmonary blood flow,
respiratory tidal volume, and minute volume by 40%
Progesterone
▪ Respiratory agents may be absorbed in larger
quantities.
▪ Higher serum drug levels
Distribution is affected during pregnancy by changes in total body water, which may increase by:
over 50%
[ Leads to greater hemodilution of plasma proteins and drugs ]
Highly lipophilic drugs are distributed into lipid-rich _____________
breast milk.
Maternal heart rate may increase up to ____ beats a minute leading to greater drug distribution.
15
Metabolism is significantly altered by __________
– Some cytochrome enzymes increase & others are decrease
pregnancy
Excretion is _____________ during pregnancy
▪ Renal changes due to pregnancy results in
increased renal elimination of drugs
▪ Doses of medications must be adjusted
Enhanced
Placenta = Temporary organ
– Allows for ___________ and ________ exchange between mother and fetus
nutrition and gas
____ % of the mother’s cardiac output circulates
through placenta
▪ Maternal blood does not circulate through fetus
10%
The __________ offers degree of protective filtration of maternal blood
▪ Prevents certain harmful substances from reaching fetus
▪ Vitamins, fatty acids, glucose, and electrolytes freely pass from mother to fetus.
placenta
Most drugs cross placenta by :
simple diffusion.
Few drugs cross placenta by way of :
active transport.
Drugs do not have to cross the placenta or enter fetal blood to cause:
fetal abnormalities.
Drugs may cause constriction of placental blood vessels, impairing :
nutrient exchange
Factors impacting transfer of drugs across placenta
–____________ level in the mother
▪ The higher the dose taken by mother, the more
drug circulates through the placenta.
▪ Rationale for prescribing lowest effective dose
– _________ of the drug
▪ Highly lipid-soluble drugs cross placenta more
easily than water-soluble drugs
*Molecular __________
*Protein binding
*Drug ionization
*_________________ to the placenta
– Plasma drug level in the mother
▪ The higher the dose taken by mother, the more
drug circulates through the placenta.
▪ Rationale for prescribing lowest effective dose
– Solubility of the drug
▪ Highly lipid-soluble drugs cross placenta more
easily than water-soluble drugs
*Molecular size
*Protein binding
*Drug ionization
*Blood flow to the placenta
Teratogens
– Substance, organism, or physical agent that
interferes with growth or development of embryo or fetus and produces permanent abnormality or death.
– Potential fetal consequences
▪ Intrauterine fetal death
▪ Physical malformations
▪ Growth impairment
▪ Behavioral abnormalities
▪ Neonatal toxicity
Incidents of teratogenic events occur in approximately ____% of all pregnancies
3%
Well-known example of a __________ is thalidomide.
teratogen
thalidomide effects
– Causes fetal effects from 35 to 48 days after last menstrual period
▪ 35 to 37 days, no ears
▪ 39 to 41 days, no arms
▪ 41 to 43 days, no uterus
▪ 45 to 47 days, no tibia
▪ 47 to 49 days, triphalangeal thumbs
Describe the preimplantation period = Weeks 1 to 2 of first trimester
– Developing embryo has not established a _________________ with mother.
– “All-or-none” period [death or no effect from a ____________]
– Embryo’s ________ systems have not begun to form.
– Drugs are less likely to cause congenital malformations during this period.
– Drugs like ___________ can create a negative environment for the embryo, causing potential intrauterine growth retardation.
– Developing embryo has not established a blood supply with mother.
– “All-or-none” period [death or no effect from a teratogen]
– Embryo’s organ systems have not begun to form.
– Drugs are less likely to cause congenital malformations during this period.
– Drugs like nicotine can create a negative environment for the embryo, causing potential intrauterine growth retardation.
Describe the Embryonic period = 3 to 8 weeks postconception
– Period of maximum sensitivity to ______________
▪ Can lead to structural malformation and spontaneous abortion during this period.
– Specific abnormality is related to ________ formation at time of exposure.
– Period of maximum sensitivity to teratogens
▪ Can lead to structural malformation and spontaneous abortion during this period.
– Specific abnormality is related to organ formation at time of exposure.
Describe the Fetal period= 9 to 40 weeks or until birth
– Continued growth and maturation of organs
– Blood flow to placenta_____________ & placental membranes become ____________
▪ Increases transfer of substances between _________________________ circulation
▪ Nausea, vomiting, abdominal cramps, flushed skin, and diaphoresis are some normal symptoms of pregnancy or adverse drug reactions.
▪ Impairments of mother’s liver or kidneys have profound effect on maternal and fetal safety
– Continued growth and maturation of organs
– Blood flow to placenta increases & placental membranes become thinner
▪ Increases transfer of substances between maternal & fetal circulation
▪ Nausea, vomiting, abdominal cramps, flushed skin, and diaphoresis are some normal symptoms of pregnancy or adverse drug reactions.
▪ Impairments of mother’s liver or kidneys have profound effect on maternal and fetal safety
____% of mothers breastfeed their infants.
▪ ___% for at least 6 months
77%
49%
Breast-feeding benefits
Provides nutrition, emotional bonding, and immune protection to neonate
Drugs enter breast milk by :
passive diffusion.
Alveolar cells in breast have large gaps between them during first week.
▪ Allowing substances to :
penetrate milk
Nonspecific drug effects seen in breast-feeding infants may include:
▪ Diarrhea
▪ Constipation
▪ Sedation
▪ Irritability
Factors affecting absorption in children:
Gastric pH
gastric emptying
blood flow
skin
– Increased gastric pH = stabilizes by age 2 or 3
– Delayed gastric emptying
– Low blood flow to skeletal muscles in infants
– Skin of infants thin, highly permeable
Factors affecting distribution in children
– Proportion of water to fat
▪ Approximately ______ a newborn’s body weight is water > lower serum drug levels
– Immature _______ function > potential toxicity.
– Underdeveloped _________________ > potential toxicity
– Proportion of water to fat
▪ Approximately 80% of a newborn’s body weight is water > lower serum drug levels
– Immature liver function > potential toxicity.
– Underdeveloped blood‒brain barrier > potential toxicity
Factors affecting metabolism in children:
– Immaturity of ____________________ enzyme system
▪ Significantly slower
–Reduced clearance rates
–Extended half-lives for drugs extensively metabolized by the liver
– Enzyme alcohol _________________ markedly reduced at birth
▪ Gradually increases until 5 years old
– Immaturity of hepatic CYP450 enzyme system
▪ Significantly slower
–Reduced clearance rates
–Extended half-lives for drugs extensively metabolized by the liver
– Enzyme alcohol dehydrogenase markedly reduced at birth
▪ Gradually increases until 5 years old
Metabolic rate reaches adult levels at _____ years of age.
3 to 5
If newborns are exposed to benzyl alcohol, what could happen?
▪ “Grasping syndrome”
–Can lead to respiratory and cardiovascular failure
Factors affecting excretion in children:
– __________ renal systems with __________ renal clearance.
▪ Drugs primarily excreted by kidneys may accumulate and cause __________________
[Infant able to concentrate urine at about __________ months of age – Standard pediatric dosages may be administered at 3 to 5 months of age]
– immature renal systems with slower renal clearance.
▪ Drugs primarily excreted by kidneys may accumulate and cause nephrotoxicity.
[Infant able to concentrate urine at about 3 to 5 months of age – Standard pediatric dosages may be administered at 3 to 5 months of age]
How should meds be administered for an infant 0-12 months old?
-_____________ infant/ offer paci
-Administer via ___________ into ears, eyes, nose, mouth
–Oral medications directed into ________________
*Give child time to swallow drug to avoid aspiration
–After administering rectal suppositories, hold
buttocks for 5 - 10 minutes
▪IM or IV –Smallest appropriate needle used.
–________________ preferred site for IM injection
–Rotate injection sites from one leg to the other to avoid overuse
–Feet and scalp veins provide good sites for IVs.
-Hold/cuddle infant/ offer paci
-Administer via droppers into ears, eyes, nose, mouth
–Oral medications directed into inner cheek
*Give child time to swallow drug to avoid aspiration
–After administering rectal suppositories, hold
buttocks for 5 - 10 minutes
▪IM or IV –Smallest appropriate needle used.
–Vastus lateralis preferred site for IM injection
–Rotate injection sites from one leg to the other to avoid overuse
–Feet and scalp veins provide good sites for IVs.
For the infant and toddler, where should an IV be placed?
feet and scalp veins
Two-year-olds metabolize drugs at a very _______ rate
▪ Drug doses must be adjusted to maintain
therapeutic levels.
rapid
For infants and toddlers, where should intramuscular injections be given?
vastus lateralis [thigh]
For preschoolers (age 3-5), IM injections can be given in the vastus lateralis, or in the:
ventrogluteal site [hip area]
For preschoolers (age 3-5), IV can be given in the feet, scalp, or:
peripheral veins (hands, etc..)
For school age children (6-12), which site is preferred for IM injections?
ventrogluteal site
Common needs for pharmacotherapy for an adolescent:
▪ Skin problems
▪ Headaches
▪ Menstrual symptoms
▪ Sex-related concerns
▪ Eating disorders
▪ Alcohol and tobacco use
▪ Sports-related injuries
2 ways to determine pediatric drug dose
- Body weight method
– Calculation of # milligrams of drug based on child’s weight in kilograms
– Method is simple; Dose can be calculated quickly. - Body surface area (BSA) method
– Accounts for pharmacokinetic differences
– Estimates blood volume, metabolism, drug effects
– Calculators online to calculate BSA
Which age group takes the most meds and why?
older adults - comorbidities
Physiologic Changes Related to Aging
GI system:
– Motility ___________
– _____________ in blood flow
– Reduced _____________________________ synthesis by liver
– Decreased volume of total body ________
– Motility decreases
– Decrease in blood flow
– Reduced serum albumin synthesis by liver
– Decreased volume of total body water
Physiologic Changes Related to Aging
Cardiovascular system:
– Changes in cardiac __________
– Increased peripheral _____________ (hypertension)
– _____________ contractile force
– Changes in cardiac muscle
– Increased peripheral resistance (hypertension)
– Decreased contractile force
Physiologic Changes Related to Aging
Central nervous system:
- Decreased _________________________________________________________________________________________________
– Declining efficiency of ____________________ barrier
– Progressive loss of cognitive ability
– Decreased brain size, number of neurons, and
peripheral nerve function
– Declining efficiency of blood–brain barrier
– Progressive loss of cognitive ability
Physiologic Changes Related to Aging
Renal system:
– Blood flow _____________
– Fewer functional _____________
– Renal function___________
▪Results in prolonged exposure to certain medication
– Blood flow decreases
– Fewer functional nephrons
– Renal function declines
▪Results in prolonged exposure to certain medication
Drug absorption in older adults-
– Slower, yet absorption still complete
– Increased risk of GI adverse effects possible
Drug distribution in older adults-
– Fat-soluble drugs stored in ________________
– Water-soluble drugs
▪Higher concentrations due to decreased total-body
____________
– Liver function _________
▪Higher concentrations of active drug
– Decreased drug binding to _____________________
▪Increased free drug concentrations
▪Greater pharmacologic effect
– Increased permeability of ______________________
▪Enhanced CNS effects of certain drugs
– Fat-soluble drugs stored in fat tissue
– Water-soluble drugs
▪Higher concentrations due to decreased total-body
water
– Liver function declines
▪Higher concentrations of active drug
– Decreased drug binding to plasma proteins
▪Increased free drug concentrations
▪Greater pharmacologic effect
– Increased permeability of blood‒brain barrier
▪Enhanced CNS effects of certain drugs
Drug metabolism in older adults-
– Reduced ___________ function
– Decreased __________ mass
– Diminished ______________________
– Alteration in activity of ______________ enzymes
– Reduced hepatic function
– Decreased liver mass
– Diminished blood flow
– Alteration in activity of hepatic enzymes
Excretion in older adults-
– Diminished renal function consistent from patient to
patient
– Slower clearance of drugs from body
Pharmacodynamic changes in older adults-
– Decreased numbers of __________ and
– Changes in receptor ____________
▪Decreased response to beta-adrenergic agonists
and antagonists
▪Increased response to anticholinergics
– Decreased numbers of receptors and
– Changes in receptor sensitivity
▪Decreased response to beta-adrenergic agonists
and antagonists
▪Increased response to anticholinergics
Potential barriers to adherence to meds in older adults-
– Visual impairment
– Functional disabilities
– Cognitive dysfunction
– Hearing impairment
Describe drug misuse among older adults
-Overuse, underuse, or erratic use
– May be unintentional or deliberate
– Self-adjusting dose common
– Splitting doses to make expensive medication last
longer
– Patients rarely report these practices to provider.
Adverse Drug Reactions in Older
Adults may include:
– Sudden change in mental status
– Rapid weight loss
– Dehydration
– Restlessness
– Anorexia
– Urinary retention or fluid retention
– Changes in bowel habits
– Functional status change in any system
Beers criteria (aka Beers list)
– Potentially inappropriate medications (PIMs) for__________________
– Drugs that have a high risk of causing adverse drug
reactions
– Use of these drugs should be avoided or closely monitored.
– Nurses should be familiar with the list and potential adverse effects.
– Potentially inappropriate medications (PIMs) for older adults
– Drugs that have a high risk of causing adverse drug
reactions
– Use of these drugs should be avoided or closely monitored.
– Nurses should be familiar with the list and potential adverse effects.
For older adults, Nurse plays a key role in:
– Optimizing pharmacotherapy outcomes
– Addressing adverse effects, drug interactions, issues
of polypharmacy
– Makes a connection between patient, family, &
medication regimens
