Mid Term Exam Flashcards
(246 cards)
1
Q
When there is less water in your blood, the concentration of particles is greater. ________ increases when you are dehydrated and decreases when you have too much fluid in your blood. Your body has a unique way to control __________. When it increases, it triggers your body to make antidiuretic hormone (ADH).
A
Osmolality
2
Q
Osmosis is an important concept when administering intravenous solutions, as their ________ influences the potential benefits and risks.
A
osmolality
3
Q
Fluid intake is regulated primarily through the thirst mechanism. The thirst control centre is located within the brain’s ______________.
A
hypothalamus
4
Q
_________ continually monitor the serum osmotic pressure, and when osmolality increases, even slightly (2–3%), the thirst centre is stimulated (Marieb & Hoehn, 2019). An increase in plasma sodium increases the osmotic pressure and stimulates the thirst mechanism. Increased plasma osmolality can occur with any condition that interferes with the oral ingestion of fluids or with the intake of hypertonic fluids.
A
Osmoreceptors
5
Q
The thirst centre will also be stimulated if plasma volume decreases, and ________ occurs, as in excessive vomiting and hemorrhage. In addition, stimulation of the renin–angiotensin–aldosterone mechanism, potassium depletion, psychological factors, and oropharyngeal dryness initiate the sensation of thirst.
A
hypovolemia
6
Q
The average adult’s fluid intake is about _________ mL per day; oral intake accounts for 1100 to 1400 mL, solid foods for about 800 to 1000 mL, and oxidative metabolism for 300 mL daily. Patients must be in an alert state to maintain their fluid intake independently.
A
2200 to 2700
7
Q
Infants, patients with neurological or psychological problems, and some older persons who are unable to perceive or respond to the thirst mechanism are at risk for ______.
A
dehydration
8
Q
a measure of the concentration of solutes in the urine.
measures the ratio of urine density compared with water density and provides information on the kidney’s ability to concentrate urine.
a routine part of urinalysis.
A
Urinary specific gravity (SG)
9
Q
Diet changes
Medicine PO or IV
Supplements
A
Treatment for electrolyte imbalances
10
Q
These 3 cause cardiac arrest / cardiac arrest if severe
A
hypermagnesemia
Hypercalcemia
Hyperkalemia
11
Q
Hypo - + chvosteks sign, hyperactive deep tendon reflexes, muscle cramps/twitching, grimacing, dysphagia, seizures, insomnia, tachycardia, hypertension
A
Magnesium
12
Q
hyper - lethargy, hypo deep tendon reflexes, bradycardia, hypotension, flushing, sensation of warmth, decreased resps, dysrhythmias, cardiac arrest
A
Magnesium
13
Q
Hypo - numbness and tingling in fingers and toes, + chvosteks sign (contracation facial muscle), muscle twitching, cramping, seizures, dysrhythmias
A
Calcium
14
Q
Hyper- anorexia, nausea and vomiting, constipation, fatigue, lethargy, decreased LOC, confusion, personality change, cardiac arrest if severe.
A
Calcium
15
Q
(sodium loss) - irritability, apprehension, confusion, postural hypotension, tachycardia, rapid, thready pulse, nausea, vomiting, dry mucous membranes, weight loss, tremors, seizures, coma.
A
Hyponatremia (low sodium)
16
Q
(water deficit) - intense thirst; dry, swollen tongue, restlessness, agitation, twitching, weakness, weight loss, postural hypotension
A
Hypernatremia (high sodium)
17
Q
Hypo - fatigue, muscle weakness, leg cramps, nausea, vomiting, soft/flabby muscles, paresthesias/decreased reflexes, weak/irregular pulse, polyuria, hyperglycemia
A
Hypokalemia (potassium)
18
Q
Hyper - irritability, anxiety, abdominal cramping/diarrhea, weakness in lower extremities, paresthesias, irregular pulse, cardiac standstill if sudden or severe.
A
Hyperkalemia (potassium)
19
Q
136 - 145 mmol/L.
A
Sodium
20
Q
3.5 - 5.1 mmol/L
A
Potassium
21
Q
1.15-1.35mmol/L( serum ionized) 2.10-2.50 mmol/L (total)
A
Calcium
22
Q
0.65 - 1.05 mmol/L
A
Magnesium
23
Q
1.0 - 1.5 mmol/L
A
Phosphate
24
Q
Each day an obligatory water loss of approximately ___ mL is essential, regardless of intake.
A
500
25
includes water loss through urine and feces.
Sensible water loss
26
is continuous, gradual loss of water from the respiratory and skin epitheliums. This may increase in response to changes in respiratory rate and depth.
Insensible water loss
27
Water loss from the skin is regulated by the sympathetic nervous system, which activates sweat glands. Fever may increase ____________.
Insensible water loss
28
Body fluids are distributed in two distinct compartments, one containing _________ and the other containing ___________.
intracellular fluid; extracellular fluid.
29
or cytosol, includes all fluid within body cells, accounting for approximately 60% of the body’s fluids.
Intracellular fluid (ICF)
30
all the fluid outside cells, is divided into three compartments: interstitial fluid, intravascular fluid, and transcellular fluids.
Extracellular fluid (ECF)
31
including lymph, is the fluid between the cells and outside the blood vessels.
Interstitial fluid
32
is blood plasma.
Intravascular fluid
33
separated from other fluid by epithelium, includes cerebrospinal, pleural, peritoneal, and synovial fluids and the fluids in the gastrointestinal tract.
Transcellular fluid
34
higher concentration of solutes than reference; water will move towards hypertonic solution
Hypertonic solution
35
lower concentration that reference; water moves away
Hypotonic solution
36
solution with same concentration of solutes as reference; no net water movement
Isotonic
37
movement of water to an area of lesser solute concentration to greater. No energy required. Stop when concentration is equal.
Osmosis
38
pressure needed to STOP osmotic flow (the force of water molecules against the membrane as they permeate it) determined by the concentration of solutes in a solution. High solute concentration = high pressure, draws water into itself.
Osmotic pressure
39
movement of ions and molecules in a solution - move across a semipermeable membrane, from an area of higher concentrations to an area of lower concentrations.
Diffusion
40
does not require energy. Gasses like O2, nitrogen, CO2, can permeate cell membranes and diffuse around body compartments
Simple diffusion
41
does not require energy, uses protein to carrier to assist with movement.
Facilitated diffusion
42
* Assess the patient's swallowing abilities, including their ability to cough, the presence of a gag
reflex, and their level of alertness, which may fluctuate.
* Give medications at mealtimes or when the patient is most alert.
* Prepare oral medications in the form that is easiest for the patient to swallow.
* Allow the patient to hold and drink from a cup of water, if possible. Thicken liquids or offer
fruit nectar if thin fluids (i.e., water) are not tolerated.
* Avoid using straws, which can increase the risk of aspiration and swallowing of air.
* Position the patient in a side-lying or upright semi-Fowler or high-Fowler position.
* Allow the patient to self-administer medications, if possible.
* If the patient has unilateral weakness, place the medication in the stronger side of the mouth.
* Administer pills one at a time, ensuring that each pill is fully swallowed and not caught in the
patient's cheek before administering the next.
* Stop administering medications if the patient starts sputtering or coughing. Consult the
prescriber and administer medications through another route or form, if available (e.g., rectal).
* Advise or assist the patient to perform oral hygiene following medication administration.
Strategies to prevent aspiration
43
Designed to be controlled release.
Coated for protection or taste.
Dissolvable.
Liquid-filled gel capsules.
Hazardous or irritants.
Intended for a small therapeutic window.
Drugs that cannot be crushed
44
Controlled Release
Enteric Coated
Long Acting
Modified Release
Sustained Action
Sustained Release
Extended Release
Cannot be crushed / opened
45
Some tablets are crushed for patients experiencing _________
Mixed with applesauce/pudding
dysphagia
46
We also ___________ before administering via NG or GT
crush / dissolve
47
Attach syringe labeled with medication to tube port and slowly instill diluted medications into the ___ tube by slowly and steadily pushing on the plunger.
NG Tube
48
Pour the diluted medication into the syringe and release the tubing to administer it. If you're giving more than one drug, flush between each dose with 15 to 30 ml of water. When finished, flush with 30 ml of water, clamp the ___, and replace the plug.
GT Tube
49
Alternative routes of administration, such as insufflation, suppository, intravenous, intramuscular, inhalational aerosol, transdermal, or sublingual, avoid the ______ effect because they allow drugs to be absorbed directly into the systemic circulation.
first-pass
50
Capsules
Softgels
Sprinkle capsules
Traditional tablets
Oral disintegrating tablets
Sublingual tablets
Effervescent tablets
Buccal tablets
Liquid
Lozenges
Types of oral meds
51
Traps medication released from MDI; buys patient time to inhale
Especially corticosteroid containing meds
A _____ or a breath-activated MDI may be used to ensure correct delivery of medication to the lower airways.
Spacer (Aerochamber)
52
a process of adding medications or moisture to inspired air by mixing particles of various sizes with air.
Droplets in the mist are much finer than those created by MDIs or DPIs.
A face mask or a mouthpiece held between the teeth delivers mist.
machines that turn liquid medications into a fine mist, allowing for easy absorption into the lungs. They are used for a variety of health conditions, including COPD, asthma, and cystic fibrosis, and are sometimes used in conjunction with inhalers.
Nebulization
53
WHEN: _______ are often recommended for patients who have a hard time using inhalers because of health issues, or patients who are unable to inhale deeply enough for other devices.
Nebulizers
54
Rinse mouth after steroid inhaler; do last if multiple types
Considerations for Inhalers
55
Posterior Pharynx: tilt the head backward
Ethmoid or Sphenoid sinus: place head gently over edge of bed OR pillow under shoulders and tilt head back
Frontal or Maxillary: tilt head back and turn towards the side to be treated
Nasal landmarks
56
Conjunctival sac
Eye landmarks
57
Ear canal
Ear landmarks
58
Apply the patch to a dry, flat skin area on your upper arm, chest, or back. Choose a place where the skin is not very oily and is free of scars, cuts, burns, or irritation.
Transdermal patch
59
Wash your hands with soap and water before and after applying a patch. Do not try to trim or cut the adhesive patch to adjust the dosage.
Monitor for Adverse effects
Nitro considerations
60
_______ -> diversion
Diversion: a medical and legal concept. involving the transfer of any legally prescribed controlled substance from the individual for whom it was prescribed to another person for any illicit use.
Fentanyl
61
Ask if they wanna do it themselves
Draping the patient
Ensure they are in a comfortable position/body temperature
Walk them through the process
Patient dignity considerations (rectal and vaginal meds)
62
Dropper 1-2 cm above conjunctival sac
Ointment applied directly to conjunctival sac
Proper eye med admin
63
Lubricate sup & gloves
Insert past the anal-rectal ridge to ensure retention
Insert along colon wall, not into a piece of stool
Stay in position for 15-30 mins
Retention enema: held in place 30 mins to 1 hour before expulsion for max absorb.
Inserting Rectal Meds
64
Empty bladder first, perform peri-care prior to admin
Provide peri-pad
Bedtime administration
Dorsal recumbent; Non-dominant hand to open labia
Remain supine for 10 mins
Insert supp along posterior wall 8-10 cm with applicator (suppository)
Inserting Vaginal Meds
65
DPIs hold dry powdered medication and create an aerosol when the patient inhales through a reservoir containing medication.
DPIs require little manual dexterity.
More med in lungs than other inhaled meds
DPIs only have one method of administration – must cover mouthpiece with mouth
Inhalation of dry powder medication
66
An MDI is a small handheld device that disperses medication into the airways through an aerosol spray or mist by activation of a propellant.
Dosage is usually delivered in 1 to 2 puffs.
2 methods of administration
Place lips around mouthpiece
Place device 2-4 cm in front of mouth (best)
Inhale deeply and slowly for 3-5 seconds while depressing cannister
Hold breath 10 seconds
Inhalation of medicated aerosol spray (unique route considerations)
67
Clean exudate/secretions; inner to outer canthus
Maintain asepsis
Gloves
Hold 1-2 cm above conjunctival sac
Close eyes gently after
Eye drops (unique route considerations)
68
Thin, even strip along the border of conjunctival sac
Inner canthus to outer
Close eyes gently after
Eye ointment (unique route considerations)
69
Room temp/warm solution (prevent vertigo, dizziness)
medication, concentration, dose or strength, number of drops, site of application (left, right, or both ears)
Ear drops (unique route considerations)
70
Nasal spray, drop, tampon
Nasal assessment
Do not blow nose after
Gloves
Documentation: Medication name, concentration, number of drops/sprays, nares into which medication was instilled
Intraocular disc
Resembles contact lens
Place disc in conjunctival sac, usually between lower lid and eye
Can remain in place up to 1 week
Direct application to mucous membrane
(unique route considerations)
71
Skin cleansed, hairless
Skin assessment
Gloves worn
On patch: date, time & initials
Documentation: type of agent applied, strength, and site of application; describe the skin findings before each application
Direct application to skin or mucosa (unique route considerations)
72
easy, avoid first-pass
Cilia damage, mucosal irritation, absorption may be affected by mucous secretions
Intranasal Advantages/Disadvantages
73
Can be formulated and applied to achieve local or systemic effects
Application is directly to the site of intended action
Fewer adverse effects than enteral or parenteral routes
No first pass metabolism or digestion by liver enzymes
For some routes, patient does not have to be conscious
Can be irritating to site of administration
Local application can produce systemic adverse effects
General topic (adv/dis)
74
skin testing (often forearm/upper back)
Length & gauge of needle: “tuberculin” syringe, 3/8 to 5/8 inch, fine guage 25-27
Angle of insertion: very close to parallel (5-15 degrees, bevel up)
Bleb formation (TB bubble)
Intradermal (unique delivery info)
75
Injection into the dermis just under the epidermis
Intradermal (ID)
76
Palliative care
Cannot tolerate PO
Poor venous access
Are all situations when we would use a _____________
subcutaneous indwelling line
77
Dosage is weight-based for IV
Dosage in units comes in concentrations of 10-10,000 units/mL
special/unique about injecting heparin
78
Labs allow monitoring of ideal therapeutic use
Heparin
79
aPTT - activated partial thromboplastin time - how long your blood takes to form a clot
ACT - activated clotting time
Blood clotting related labs
80
aPTT - how long your blood takes to form a clot
activated partial thromboplastin time
81
ACT stands for
activated clotting time
82
High alert medication
Patient teaching: you may bleed more easily. Alcohol may affect medication
Regular labs
Safety w anticoagulant (Heparin)
83
Obtain glucose level
Clean injection site/PPE
Use aseptic techniques during administration
2 nurse check
Stored in refrigerator
Insulin delivery safety
84
cannot be mixed
Onset: 90 min
Peak: plateau/“peakless”
Duration: 24 hours; 16-24 hrs
Long acting (clear) - insulin
85
(clear) (rapid for IV use only; short = regular)
Onset: 10-15 min - Peak: ~1-2 hours
Duration: ~3-5 hours; upwards of 6.5
Rapid and short acting - insulin
86
(cloudy)
Onset: 1-3 hours - Peak: 5-8 hours
Duration: up to 18
Intermediate-acting - insulin
87
Normal sized pt. 16mm (⅝ inch) 25-27 gauge
Children - 12mm (½ inch)
Insulin - 3/16 inch (4-4mm)
Needles used Subcut
88
Bariatric patients need a longer needle to insert through fatty tissue at base of skin fold. Use 90 degree angle. If you can pinch 2in of skin use 90 degree angle.
Thin patients use upper abdomen. If you can only pinch 1 inch of skin, use 45 degree angle.
Body size considerations subcut
89
Hold the syringe as if you were holding a dart, palm down. Or hold the syringe across the tops of your fingertips.
Be as sterile as possible (aseptic technique)
General subcut admin techniques
90
an anticoagulant
Acute thromboembolic disorders including DVT, pulmonary embolism, unstable angina, evolving MI Prophylaxis for clotting Does not break down existing clots
Injections for someone on anticoagulants? Apply pressure to site longer
Cannot be taken orally
Can be IV or SC
Dosage in units
Create a skin fold, must grasp for the duration of injection; only release after needle withdrawn
Slow rate – 30 seconds – reduces bruising and pain
Heparin
91
High alert med, 2 nurse check
Rapid Acting, Short Acting (“regular”), Intermediate Acting, Long Acting (4 types)
Uses rapid- or short-acting (bolus) insulin before meals and intermediate- or long-acting (basal) background insulin once or twice a day; Rapid acting administered ~ 10-15 minutes before meal, up to 15 after (but the closer the better)
When mixing: Draw up the rapid or short acting first; “clear before cloudy”
Measured in “units”
U-100 insulin = U100-marked syringe There are 0.3 mL, 0.5 mL for smaller doses these are still U100 if marked
Now: choose one anatomical site and rotate within it; Sites in descending order of absorption: Abdomen, arm, thigh, buttock
Insulin
92
Choose one site and rotate within it.
Sites in descending order of absorption: abdomen, arm, thigh, buttock
Tricep area
Abdomen fatty tissue. Umbilicus area
Anterior thighs
Subscapular area
Upper ventrodorsal gluteal area
Choosing & landmarking injection sites
93
1 to 1.6cm needle for subcut injections
Vials, ampoules
Insulin syringe, tuberculin syringe
Insulin (needle or pump)
Subcut equipment
94
Injections are deposited into loose connective tissue
Tissue does not contain as many blood vessels as muscle = meds absorbed slower than IM.
hot/cold affect absorption
Blood flow effect absorption
tissue contains pain receptors, expect discomfort
Subcut pharmacokinetics
95
Advantages
Smaller needles, less pain
Risk of infection lower
Disadvantages
Injection sites must be changed frequently
Subcut
96
Needle length selection is influenced by injection site, patients weight, and amount of adipose tissue
Determine needle gauge by the medication to be administered. gauge=a number that represents the size of the hollow bore. Lrg numbers = smaller diameter. Sm numbers = larger diameter.
General rule = <1 inch for SC and ID. >1 inch for IM
Longer needles may be required for bariatric pts.
Needle length and guage for injection
97
5 to 7.5 cm below the iliac crest
Upper outer quadrant of buttocks
Dorsogluteal (emergency) not used
98
3-5 cm below acromion process
Palpate 3 fingers below AP with your index fingers laying on the process.
Deltoid - small volumes 2mL.
99
Used in adults. Preferred site for administration of biologics to infants, toddlers, and children
Anterior lateral aspect of thigh
Muscle extends from a handbreadth above the knee to a handbreadth below the greater trochanter of the femur
Use the middle third section for injection
Muscle width is midline of thigh to midline of outer side of thigh
Patient positioning to relax muscle:
Seated
Lie flat with knee slightly flexed and foot externally rotated
Vastus lateralis
100
preferred - safe for children. Volumes >2mL
Place heel of opposing hand hand over greater trochanter
Do NOT place on iliac crest
Point thumb towards groin and fingers towards patient’s head
Point index finger to the anterior superior iliac spine
Extend middle finger back along iliac crest towards buttocks
Injection site is in the middle of the triangle formed by your pointer and middle finger
– patient positioning: supine or on side. Flex knee to help relax muscle
Ventrogluteal
101
Be vigilant - avoid distractions while preparing
Verify med has not expired
Use 2 identifier, check MAR
Clarify unclear meds with prescriber
Follow all policies and do not use “workarounds”
Use strict aseptic technique
Do not delegate med admin
Use no interrupt zones
Insert needle at proper angle, smoothly and quickly, slowly
Hold syringe steady once needle is in tissue to prevent tissue damage
Withdraw needle smoothly at same angle of insertion
Apply antiseptic pad or gauze to site, apply gentle pressure
Rotate injection sites to prevent formation of indurations and abscesses.
Induration - thickening/hardening of soft tissues due to inflammatory response
Injection safety
102
Risk of infection
uncomfortable/anxiety provoking
Unpleasant adverse effects, eg. pain, tissue damage
Risk of needle-stick injuries for nurses
Irritation at site of injection
Once drug has been administered, it cannot be removed if an error has been made
Injection disadvantages
103
Absorption is often more rapid, depending on blood supply to site of injection
Intravenous is the standard for measuring bioavailability
Alternate route for administration for patients that can’t take drug orally
Effects can be local or systemic depending on preparation and route
Appropriate for long term therapy
Injection advantages
104
are a means to quicks achieve therapeutic drug concentrations or prompt an immediate clinical response.
Loading doses
105
Physiological state in which the amount of drug removed via elimination - the amount of drug absorbed with each dose
Consistent levels that correlate w maximum therapeutic benefits
Achieved in about 5 half-lives worth of time for the drug
Steady state
106
the time required for one half the atoms of a given amount of a radioactive substance to disintegrate.
Half-life
107
time required for a drug to elicit therapeutic response
Onset of action
108
time period during which drug is in therapeutic range
Duration of action
109
Corresponds physiologically to increasing drug concentration at site of action
Not to be confused with peak level
Peak EFFECT
110
= highest blood level; Trough
Peak Level
111
= lowest blood level
Level
112
Maintain drug at concentration that produces therapeutic response
Pharmacotherapy goals
113
A ________ is an initial higher dose of a drug that may be given at the beginning of a course of treatment before dropping down to a lower maintenance dose. A
most useful for drugs that are eliminated from the body relatively slowly, i.e. have a long systemic half-life.
loading dose
114
Time required for serum levels to be reduced by one half (50%)
Represents the rate of elimination
5 half lives to reduce by 97%
Clinically useful to determine steady-state, eliminates duration of action
Shorter half life - given more frequently (morphine half life 3 hours)
Half-life
115
What chemical/physical properties of drug molecules affect how the body interacts with them and how does this happen?
Molecular size and shape
116
are absorbed more readily.
Smaller molecules
117
Drug ______ affects affinity of the drug for carrier molecules or other binding sites such as plasma proteins or tissue. Drugs of similar structure may exhibit competition for such binding sites, which can affect their pharmacokinetics.
shape
118
People who don't respond to medications as expected may have genetic differences that change the amount of enzyme made or how well it works. If your body breaks down a medication too quickly, too slowly or not at all, then a typical dose of it won't work as intended.
Polymorphisms in genes responsible for drug transport can affect pharmacokinetic properties of an administered drug and ultimately its plasma concentration as well as concentrations in the target tissues.
How genetics effect ADME
119
Administration route
Cell membrane permeability
Drug formulation
Age
Genetics
Nutritional status
Hormone status
Circadian rhythm
Function of organs
Disease
Factors that affect absorption
120
The main factors are disease, genetics, and age. Nutritional status, sex, hormonal status (e.g., the effects of pregnancy), and circadian rhythm have important influences. Maternal toxicity will affect the fetus. The _______ and _______ of drugs are frequently reduced by diseases.
Factors influencing absorption & excretion
121
time required to reach maximal therapeutic response
Peak effect
122
the extent and rate to which the active drug ingredient from the drug product is absorbed and becomes available at the site of drug action
Bioavailability
123
two drugs that have the same bioavailability and same concentration of active ingredient
Bioequivalents
124
Physiology: gastric emptying (fatty foods delay), surface area, temperature, blood flow
Absorption
125
Blood flow to target tissue
Drug solubility (lipophilic/hydrophilic)
Drug protein binding
Special physiological barriers (blood brain, fetal circulation)
Distribution
126
Physiological factors that can influence drug ________ include age, individual variation (e.g., pharmacogenetics), enterohepatic circulation, nutrition, sex differences or gut microbiota.
metabolism
127
Changes in PH
Kidney damage = reduced renal excretion
Renal excretion
128
Gasses and volatile liquids
Most drug excreted unmetabolized
Excretion rate affected by respiratory rate and blood flow
Pulmonary excretion
129
Sweat, saliva, breast milk, seminal fluid
Water soluble molecules
Glandular excretion
130
Biliary excretion
Enterohepatic recirculation
Intestinal excretion
131
Factors affecting: administration route, cell membrane permeability, drug formulation, physiology: gastric emptying, surface area, temperature
Heart
Spleen
Pancreas
Small intestine
Colon
Stomach
Portal vein
Liver
Systemic circulation
Target tissue
Target cell
Absorption
132
Transport of a drug by the bloodstream to its site of action
Factors affecting:
Blood flow to target tissue, drug solubility, drug-protein binding, special physiological barriers (blood-brain barrier, fetal circulation)
Distribution
133
= more drug reaching target tissue
More blood flow
134
Drugs distribute first to areas w ++ _____
blood supply
135
Lipid soluble cross cell membranes more readily
Drugs in their active forms are usually lipophilic
Solubility
136
______ cross cell membranes more readily
Drugs in their active forms are usually lipophilic
Lipid soluble
137
Drugs will bind to proteins in the bloodstream (albumin)
Only unbound drug molecules can freely distribute - “active”
Low albumin levels = risk for toxicity
Drug protein binding
138
two medications that are highly protein-bound may “compete” for binding sites on the albumin.
Protein binding site competition
139
Creates more free, unbound drug = unpredictable drug response
This is called a
drug-drug interaction
140
when the presence of one drug decreases or increases the action of another drug administered concurrently
Drug to Drug Interaction
141
Liver, heart & kidney
Metabolism (aka biotransformation)
Liver is a big player
Hepatic enzymes: cytochrome P450 system
Distribution organs
142
cytochrome P450 system
Drugs that are metabolic targets of specific enzymes are said to be substrates of those enzymes
Lots of drugs inhibit CYP450 system
Hepatic enzymes
143
Lots of drugs that _______ the CYP450 system results in toxicity
inhibit
144
Some substances activate the CYP450 system
inducers
145
Elimination of drugs from the body
Kidney; pulmonary; glandular; intestinal/fecal
Rate affects blood concentration
Inverse -> more excretion = lower blood concentration
Excretion
146
Inverse -> more ______ = lower blood concentration
Excretion
147
don’t prescribe but are responsible for own actions
Role of nurses
148
Unclear/poorly written: clarify immediately
Have drug knowledge - make sure you understand WHY you are administering
Monitoring for therapeutic & adverse effects
Legally, morally, ethically responsible for this
Clarify anything that the patient questions; recheck dose and order
Role of nurses
149
Eliminating error and limiting adverse events
Carefully monitoring and management
Role of nurses
150
Details of the drug you are given
Why the drug has been prescribed for this particular client
How it is administered, how it comes from pharmacy, what are the safe dose ranges
Nursing responsibilities
151
Failure to ensure safety (lack of adequate monitoring, failure to identify patient allergies/risk factors, inappropriate drug administration technique, failure to implement proper nursing actions based on lack of proper assessment of patient condition)
Medication Errors (failure to clarify unclear order, failure to identify and react to adverse drug reactions, failure to be familiar with medication prior to administration, failure to maintain level of professional nursing skills for current practice, failure to identify patient identity prior to administration, failure to document medication administration)
Failure to assess/evaluate (failure to see significant changes in patient’s condition after med, failure to report changes in condition, failure to take a complete medication history and nursing assessment/history, failure to monitor patient after med admin)
Areas of potential liability for nurses
152
Requirements for the control and sale of narcotics, controlled drugs, and substances of misuse
Narcotics require the label “N”
Schedule I contains Opiates
Schedule IV contains benzodiazepines, barbiturates, anabolic steroids
Physical security and records
Drugs listed in the CSDA
Psychological dependence
Physical dependence
Penalties (possessions, trafficking)
Controlled Substances Act (1997)
153
Schedule I: By prescription only and provided by a pharmacist
All prescription drugs
Schedule F: “Pr”
Controlled drugs (Part G)
Narcotic drugs
Schedule II: Dispensed by pharmacist, no public access
Schedule III: available at the pharmacy, but OTC
Unscheduled: available at any store
Levels of the national drug schedules program (NAPRA)
154
a drug only has one _____
Chemical name
155
(International Nonproprietary Name) lower case and most commonly used by HCPs
Generic name
156
(proprietary or brand name) often the original patented name is best known (20 years of exclusive use)
Trade name
157
drugs with more than one active generic ingredient (new trade name)
Combination drugs
158
Differences between brand and generic can present in the _________ of a drug
Generic drugs are less expensive
formulation
159
The best measure is to compare __________: the amount of the drug that reaches systemic circulation and that can interact w target tissues
Formulation can affect
bioavailability
160
How do we classify drugs?
Therapeutic
Pharmacological
161
describes condition for which drug is being given
Therapeutic classification
162
describes the mechanisms by which the therapeutic effect is achieved
Pharmacological classification
163
Subject to the Food and Drug Act, but not the same regulatory processes as prescription drugs
NHP
Vitamin + mineral supplements
Herbal remedies
Homeopathic preparations
Traditional medicines (Chinese, ayurvedic, etc)
Probiotics
Amino, fatty acids
Consumer use is growing
Consumers perceive as safe – not always the case
Can cause side-effects and interact with medications
Health Care Provider must be on alert for announcements about safe and effective use of NHPs
Risk of natural health products
164
an evolving list defining the prescription drugs to be covered under your company's benefit program.
Formulary
165
Drugs that can be obtained by patients without consultation with a HCP
Benefits
Usually have a high margin of safety and few adverse effects
Patients can treat themselves for common conditions by following directions on packaging
convenience
If not taken for appropriate reason may be ineffective, allowing patient condition to become worse
After many years of safe use, Rx may convert to a non-prescription drug
No drug is without risk
OTC drugs
166
Require a dispensing order (_____) from a qualified health care professional prior to patient receiving drug
Benefits
HCP can examine patient prior to ordering; ensuring order is appropriate for patient and condition
Maximize therapy by ordering specific drug for condition
Dose and frequency of dispensed drug can be controlled
Opportunity to teach proper use and expected side-effects
Prescription
167
Manage and monitor proper use of drugs, educate patients, and incorporate new research about existing drugs and new drugs as they emerge
Effective use of drugs and medications by a health care team depends on being able to apply knowledge related to:
Anatomy & Physiology
Pathophysiology
Chemistry
Microbiology
Nursing process
Role of Nurses w Prescriptions/Controlled Meds
168
Maintains a drug product database (CPS, Formulary - province, hospital, insurance companies)
Health Canada Involvement
169
Part of the Health Products and Food Branch of Health Canada
Regulates human health products
Marketed Health Product Directorate
170
After phase ___, manufacturer applies to Health Canada for a New Drug Submission and the drug is assigned a DIN
III
171
unique number on the label of an OTC or Rx drug product that has been evaluated by the TPD and approved for sale in Canada
DIN: Drug Identification Number
172
Small numbers of healthy subjects (<100)
Determine potential adverse effects, optimal dosage range
Days to weeks
Phase I
173
100-300 volunteers
Diagnosed w disease the drug is designed to treat
Effectiveness and adverse effects monitored
Phase II
174
1,000-3,000 people
Placebo introduced
Placebo controlled study
Blinded investigational drug study
Double-blind investigational drug
Clinical effectiveness, safety, dosage range
New drug submission sent to TPD/BGTD
Patent Act of Canada
Phase III
175
Post marketing studies
Voluntarily conducted by pharmaceutical manufacturer but study could be mandated by Health Canada
Phase IV - voluntary
176
_______ studies are preformed on humans
Clinical
177
_______ studies are in vitro, animal studies
Pre clinical
178
Priority Review of Drugs has ____ levels of testing
four
179
Therapeutic Products Directive (TPD) of Health Canada
Can take years
Pharmaceutical research process
180
study of medications
Pharmacology
181
substance capable of producing a biologic response
Drug
182
a drug given for the purpose of producing a therapeutic response
Medication
183
desirable (desired effect, positive outcomes)
Therapeutic response
184
Side effects
Adverse effects/events
Toxic effects
Adverse response
185
undesirable
Adverse response
186
mild
Side-effects
187
more severe
Adverse effects/events
188
most harmful
Toxic effects
189
Have a buddy nurse check calculations
3 Checks
* Follow the rights of medication administration.
* Be sure to read labels at least three times (comparing medication administration record with label) before, during, and after administering the medication.
* Use at least two patient identifiers whenever administering a medication.
* Do not allow any other activity to interrupt administration of medication to a patient.
* Double-check all calculations and verify with another nurse.
* Do not interpret illegible handwriting; clarify with the prescriber.
* Question unusually large or small doses.
* Document all medications as soon as they are given.
* When you have made an error, reflect on what went wrong and ask how you could have prevented the error.
* Evaluate the context or situation in which a medication error occurred. This helps to determine whether you have the necessary resources for safe medication administration.
* When repeated medication errors occur within a work area, identify and analyze the factors that may have caused the errors and take corrective actions.
* Attend in-service programs that focus on the medications commonly administered.
Prevent med errors
190
Taking a medication at the right time at the correct dose is critical to the success of pharmacotherapy
Patient must see the personal benefit
Patient education and strategies for adherence should be part of the individualized care plan for the patient
Should include information about drug including name, route, schedule, possible adverse effects and interactions
Factors affecting:
Drug may be too expensive or not part of insurance coverage
Complicated dosing regimens, with or without polypharmacy issues
Patient does not understand dosing regimen
Adverse / side effects that impact lifestyle choices
Headaches and dizziness
GI effects
impotence
Things that affect pt adherence
191
non-invasive, good for repeated dosing, safety; subject to first pass metabolism, prodrugs
Oral route
192
intravenous: rapid
Parenteral route
193
slower; intramuscular: larger volumes, slow-release formulas
Subcutaneous
194
localized, mucous membranes - rapid uptakes
Topical
195
Sustained release, can be irritating
Transdermal
196
rapid, efficient; initial localization to pulmonary system
Inhaled
197
The basic units of measurement in the metric system are the metre (_______), the litre (_______), and the gram (_______). For medication calculations, use only the measurements for volume and weight.
length; volume; weight
198
Sublingual, buccal, feeding tubes
By mouth (liquid, solid crushed)
Enteral
199
Intradermal, subcutaneous, intramuscular, intravenous, epidermal
Intrathecal, intraosseous, intraperitoneal, intrapleural, intra-arterial
Parenteral (no first-pass effect)
200
Lotions, creams, transdermal patches, optic, oral, inhaled, vagina, rectum
Topical
201
Solutions of various ______ are used for injections, irrigations, and infusions
concentrations
202
A solution contains a mass of _______ substance dissolved in a known volume of fluid or a given volume of liquid dissolved in a known volume of another fluid.
solid
203
When a _______ is dissolved in a fluid, the concentration is expressed in units of mass per unit of volume (e.g., g/mL, g/L, mg/mL).
solid
204
Potential for significant harm should error happen
Concentrated Electrolyte Solutions (KCl)
Heparin
Insulin
Morphine
Neuromuscular medications (paralyzing agents)
Chemotherapy medications
High alert meds / why they are high alert
205
Check against the MAR
When removing/obtaining drug from storage site
When preparing drug for admin
Immediately before administering
Prevent medication errors
Three checks of administration
206
10 rights of meds?
Right medication
Right dose
Right patient
Right route
Right time/frequency
Right documentation
Right reasons
Right to refuse
Right patient education
Right evaluation
207
Verify new orders in the MAR
Check label 3 times
Ensure medication label is legible
Only administer medications you have prepared
Do not leave prepared meds unattended
If a patient questions the med, double check
Right Medication
208
Check dose 3 times
If doing a calculation, have another nurse check
Use standard measuring devices
Ensure break is splitting even (if splitting tablets)
If crushing, ensure crusher is clean
Right Dose
209
Patient: use 2 at least 2 identifiers
Route: if unclear or unstated; verify
Time/frequency: some medications are time dependent
Right patient, right route, right time
210
Documentation must be thorough
Nursing responsibility to understand rationale for med
Documentation, reason, to refuse
211
patient should have an understanding of why they are taking the med; special admin instructions; adverse effects
nursing responsibility to monitor effectiveness, monitor for reactions and adverse effects; appropriate follow up
Right Education, evaluation
212
1. Standardized processes for prescribing, storing, preparing, administering medications
2. Limiting access
3. Using automated alerts and additional bright-coloured labels
4. Improving access to medication information for health care providers
Strategies that enhance safe use of high-alert medications include the following
213
must meet accreditation standards for medication management, which includes stringent policies for the proper storage, dispensing, and administration of controlled substances like opioids
Health care institutions
214
Must be familiar with both the federal and provincial/territorial regulations for medication administration and management by registered nurses and licensed practical nurses in their practice areas.
Adhere to additional legal provisions when administering controlled substances or drugs (medications that affect the mind or behavior), such as opioids. Violations of the Controlled Drugs and Substances Act are punishable by fines, imprisonment, and loss of nursing license.
Nurses
215
Nurses' responsibility for medication administration includes ensuring that the right medication is properly drawn up in the correct dose, and administered at the right time through the right route to the right patient. To limit or reduce the risk of administration errors, many hospitals employ a single-dose system.
10 med rights
Nursing responsibilities in medication administration
216
* To prevent contamination of the solution, draw the medication from the ampoule or vial quickly. Do not allow it to stand open.
* To prevent needle contamination, avoid letting the needle intended for the injection touch a contaminated surface (e.g., the outer edges of the ampoule or vial, the outer surface of the needle cap, your hands, a countertop, a table surface).
* To prevent syringe contamination, avoid touching the length of the plunger or the inner part of the barrel. Keep the tip of the syringe covered with a cap or needle.
* To prepare the skin, wash skin soiled with dirt, drainage, or feces with soap and water and then dry. Use friction and a circular motion to clean the skin with an antiseptic swab for 30 seconds. Swab from centre of site and move outward in a 5-cm radius. Allow the skin to fully dry before administering the injection and do not blow air on the site to speed up the drying time; this contaminates the surface.
Infection prevention
217
* Use caution when selecting intramuscular (IM) injection sites for infants and small children. The deltoid muscle should not be used.
* Children are unpredictable. Ensure that someone (ideally another nurse) is available to help restrain a child if needed.
* Awake a sleeping child before giving an injection.
* Distract the child with conversation, a ringing bell, or a toy to reduce the perception of pain.
* Give the injection quickly and do not argue with the child.
* Apply a local anesthetic (EMLA) cream to the site before the injection if possible.
General principles of safety for injections
218
Ask the patient to describe and demonstrate:
* Signs of hypoglycemia and actions to take
* The schedule they will follow for testing their blood and administering insulin
* The reason they are taking insulin
* Where they will store their insulin and supplies
* Reading the label of the insulin vial and the numbers on the syringe aloud (to show visual acuity)
* Performing hand hygiene and testing their capillary blood glucose
* Preparing the required insulin dose (based on the results if on a sliding scale)
* Selecting an injection site, cleansing the skin, and self-administering the insulin injection
* Disposing of needles safety
* Recording information in the logbook
Evaluation
219
* The patient will correctly administer subcutaneous insulin.
Teaching Strategies
Use discussion, printed information, videos, websites, and demonstration to explain:
* Where the insulin needs to be stored (e.g., refrigerator)
* That the insulin needs to be kept in its original labeled container
* Why and how to rotate sites for injection
* How to check the expiry date on the insulin vial
* How to determine the amount of insulin required (if on a sliding scale) based on the results of capillary glucose monitoring
* How to perform hand hygiene
* How to prepare a syringe with insulin for injection or prepare a prefilled insulin syringe pen
* How to select a site, cleanse the skin, and administer the subcutaneous insulin injection
* How to dispose of needles and supplies in a safe sharps container
* Keeping a daily logbook to record blood glucose results, type and dose of insulin, and injection site
Objective
220
C = comfort care - excluding attempted resuscitation
M = medical care - excluding attempted resuscitation
R = medical care INCLUDING attempted resuscitation
ACP Status
221
1: independent, almost ready for discharge
5: requires intensive care, totally dependent in all aspects
Acuity rating systems
222
event that could have resulted in unwanted consequences, but did not either by chance or through timely intervention
Near miss
223
Do not use critical comments about pt or care provided by another healthcare provider
Do not enter personal opinions
Chart only factual/objective descriptions of pt behavior
Charting objective & professional
224
Factual
Accurate
Complete
Documentation needs to be
225
Identification
Situation
Background
Assessment
Recommendations
Repeat back
I-SBAR-R
226
VERY clearly state the patient’s name, room number, and diagnosis
Repeat back any prescribed order
Clarify ANYTHING you are not sure about
Document “Telephone order” (TO) or “Verbal order” (VO)
Physician should co-sign the order within certain time frame (usually 24h)
Usually at night or emergencies
Most institutions do not allow students to take a T/O or a V/O
In some situations, good idea to have a second nurse listen to the T/O you are receiving – esp. if it's for a high alert medication or an emergency intervention
Telephone reporting/Telephone orders for Meds
227
Team members from each discipline develop a plan or plan for each problem Nurses document the plan in a variety of formats; generally, all of these formats include nursing diagnoses, expected outcomes, and interventions.
Care plan
228
Identify problems and make a single problem list (patient’s physiological, psychological, social, cultural, spiritual, developmental, and environmental needs).
Problems listed in chronological order at front of pt record to organize
Add & date new problems
Problem resolved - text of problem highlighted/lined out & date recorded
Problem list
229
Contains all available assessment information pertaining to the patient (e.g., history and physical examination, nursing admission history and ongoing assessment, physiotherapist’s assessment, laboratory reports, and radiological test results).
Provides the foundation for identifying patient problems and planning care.
It accompanies patients through successive hospitalizations or clinic visits.
Database
230
Database
Problem list
Care plan
Progress notes
Problem-oriented record
231
Patient summary
Summary info about pt
Demographics
ID number
Physician's name
Medical diagnosis
Medical and surgical history
Current treatments
Nursing care plan
Scheduled test/procedures
ADLs & Safety precautions
ACP status
Allergies
Kardex
232
Do:
Provide only essential information (name, sex, gender identity, age, physician’s diagnosis, and medical history)
Identify nursing diagnoses / health care problems & causes
Objective measurements / observations about pt condition & responses to health problems & emphasize recent changes
Significant info about family as it relates to pt problems
Review ongoing discharge plan (e.g., need for resources, pt level of preparation to go home)
Relay to staff significant changes in way therapies are given (e.g., diff position for pain relief, new med)
Describe instructions given in teaching plan and pt response
Evaluate resolutes of nursing/medical care measures
Clear about priorities to which incoming staff must attend
Shift hand off report
233
Don’t:
Review all routine care, procedures, tasks
Don’t review all biographical info already available
Critical comments about pt behavior
Assumptions about family relationships
Wait till discharge to discuss plan
Describe basic steps of procedure
Detailed content unless staff members ask for clarification
Results are “good” or “poor”
Force incoming staff to guess what to do first
Shift hand off report
234
Accurate
Comprehensive
Reflective of nursing practice standards
Timely
Factual & Objective
25% of time should be used for this
Proof that quality care was provided
Quality documentation
235
Molecule size (smaller drugs are absorbed faster)
Lipophilicity (= increased absorption)
Drug ionization - wants drugs to be neutral when absorbed not ionized; basic drug in acidic environment will not absorb well; acidic drug in basic environment will not absorb well
Membrane permeability
236
(smaller drugs are absorbed faster)
Molecule size
237
(= increased absorption)
Lipophilicity
238
wants drugs to be neutral when absorbed not ionized; basic drug in acidic environment will not absorb well; acidic drug in basic environment will not absorb well
Drug ionization
239
The deliberate and systematic collection of data from a primary source and secondary sources (sometimes called “collateral”)
Purpose:
Determine current & past health status & functional status
Current and past coping patterns
Assessment
240
pieces of very large cells in the bone marrow called megakaryocytes
Thrombocytes
241
occurs when blood clots block veins or arteries
Thrombosis
242
A blood clot that forms inside one of your veins or arteries
Thrombus
243
“clot-busting” drugs that break up and dissolve blood clots that get in the way of your blood flow
Thrombolytic
244
an unique molecule that functions both as a procoagulant and anticoagulant
Thrombin
245
a protein made by the liver. It is one of several substances known as clotting (coagulation) factors.
Prothrombin
246
a condition in which the platelets (also called thrombocytes) are low in number, which can result in bleeding problems
Thrombocytopenia
