week 4: Ch. 8-10 [Lifespan pharm]

Question 1

Most medications can cross the ____________ and are secreted in breast milk

Answer 1

placenta

Question 2

_____% of women take at least one medication during pregnancy

Answer 2

90%

[and 80% during first trimester]

Question 3

Pharmacotherapy is _____________ if possible until after delivery & lactation

Answer 3

postponed

Question 4

What kind of conditions must be managed during pregnancy?

Answer 4

preexisting conditions
pregnancy complications
conditions unrelated to pregnancy

Question 5

Physiological changes during pregnancy can alter the normal pharmacokinetic response by:

Answer 5

speeding it or slowing it

Question 6

increased levels of _______________ cause a decrease in gastric tone and intestinal motility, resulting in delayed gastric emptying > extended drug absorption time

Answer 6

progesterone

Question 7

High __________ levels cause increased hydrochloric
acid production.
▪ May affect absorption of certain acid labile drugs

Answer 7

estrogen

Question 8

______________ increases pulmonary blood flow,
respiratory tidal volume, and minute volume by 40%

Answer 8

Progesterone

▪ Respiratory agents may be absorbed in larger
quantities.
▪ Higher serum drug levels

Question 9

Distribution is affected during pregnancy by changes in total body water, which may increase by:

Answer 9

over 50%

[ Leads to greater hemodilution of plasma proteins and drugs ]

Question 10

Highly lipophilic drugs are distributed into lipid-rich _____________

Answer 10

breast milk.

Question 11

Maternal heart rate may increase up to ____ beats a minute leading to greater drug distribution.

Answer 11

15

Question 12

Metabolism is significantly altered by __________

– Some cytochrome enzymes increase & others are decrease

Answer 12

pregnancy

Question 13

Excretion is _____________ during pregnancy

▪ Renal changes due to pregnancy results in
increased renal elimination of drugs
▪ Doses of medications must be adjusted

Answer 13

Enhanced

Question 14

Placenta = Temporary organ
– Allows for ___________ and ________ exchange between mother and fetus

Answer 14

nutrition and gas

Question 15

____ % of the mother’s cardiac output circulates
through placenta

▪ Maternal blood does not circulate through fetus

Answer 15

10%

Question 16

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.

Answer 16

placenta

Question 17

Most drugs cross placenta by :

Answer 17

simple diffusion.

Question 18

Few drugs cross placenta by way of :

Answer 18

active transport.

Question 19

Drugs do not have to cross the placenta or enter fetal blood to cause:

Answer 19

fetal abnormalities.

Question 20

Drugs may cause constriction of placental blood vessels, impairing :

Answer 20

nutrient exchange

Question 21

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

Answer 21

– 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

Question 22

Teratogens

Answer 22

– 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

Question 23

Incidents of teratogenic events occur in approximately ____% of all pregnancies

Answer 23

3%

Question 24

Well-known example of a __________ is thalidomide.

Answer 24

teratogen

Question 25

thalidomide effects

Answer 25

– 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

Question 26

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.

Answer 26

– 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.

Question 27

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.

Answer 27

– 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.

Question 28

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

Answer 28

– 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

Question 29

____% of mothers breastfeed their infants. ▪ ___% for at least 6 months

Answer 29

77% 49%

Question 30

Breast-feeding benefits

Answer 30

Provides nutrition, emotional bonding, and immune protection to neonate

Question 31

Drugs enter breast milk by :

Answer 31

passive diffusion.

Question 32

Alveolar cells in breast have large gaps between them during first week. ▪ Allowing substances to :

Answer 32

penetrate milk

Question 33

Nonspecific drug effects seen in breast-feeding infants may include:

Answer 33

▪ Diarrhea ▪ Constipation ▪ Sedation ▪ Irritability

Question 34

Factors affecting absorption in children: Gastric pH gastric emptying blood flow skin

Answer 34

– 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

Question 35

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

Answer 35

– 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

Question 36

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

Answer 36

– 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

Question 37

Metabolic rate reaches adult levels at _____ years of age.

Answer 37

3 to 5

Question 38

If newborns are exposed to benzyl alcohol, what could happen?

Answer 38

▪ “Grasping syndrome” –Can lead to respiratory and cardiovascular failure

Question 39

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]

Answer 39

– 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]

Question 40

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.

Answer 40

-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.

Question 41

For the infant and toddler, where should an IV be placed?

Answer 41

feet and scalp veins

Question 42

Two-year-olds metabolize drugs at a very _______ rate ▪ Drug doses must be adjusted to maintain therapeutic levels.

Answer 42

rapid

Question 43

For infants and toddlers, where should intramuscular injections be given?

Answer 43

vastus lateralis [thigh]

Question 44

For preschoolers (age 3-5), IM injections can be given in the vastus lateralis, or in the:

Answer 44

ventrogluteal site [hip area]

Question 45

For preschoolers (age 3-5), IV can be given in the feet, scalp, or:

Answer 45

peripheral veins (hands, etc..)

Question 46

For school age children (6-12), which site is preferred for IM injections?

Answer 46

ventrogluteal site

Question 47

Common needs for pharmacotherapy for an adolescent:

Answer 47

▪ Skin problems ▪ Headaches ▪ Menstrual symptoms ▪ Sex-related concerns ▪ Eating disorders ▪ Alcohol and tobacco use ▪ Sports-related injuries

Question 48

2 ways to determine pediatric drug dose

Answer 48

* 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

Question 49

Which age group takes the most meds and why?

Answer 49

older adults - comorbidities

Question 50

Physiologic Changes Related to Aging GI system: – Motility ___________ – _____________ in blood flow – Reduced _____________________________ synthesis by liver – Decreased volume of total body ________

Answer 50

– Motility decreases – Decrease in blood flow – Reduced serum albumin synthesis by liver – Decreased volume of total body water

Question 51

Physiologic Changes Related to Aging Cardiovascular system: – Changes in cardiac __________ – Increased peripheral _____________ (hypertension) – _____________ contractile force

Answer 51

– Changes in cardiac muscle – Increased peripheral resistance (hypertension) – Decreased contractile force

Question 52

Physiologic Changes Related to Aging Central nervous system: - Decreased _________________________________________________________________________________________________ – Declining efficiency of ____________________ barrier – Progressive loss of cognitive ability

Answer 52

– Decreased brain size, number of neurons, and peripheral nerve function – Declining efficiency of blood–brain barrier – Progressive loss of cognitive ability

Question 53

Physiologic Changes Related to Aging Renal system: – Blood flow _____________ – Fewer functional _____________ – Renal function___________ ▪Results in prolonged exposure to certain medication

Answer 53

– Blood flow decreases – Fewer functional nephrons – Renal function declines ▪Results in prolonged exposure to certain medication

Question 54

Drug absorption in older adults-

Answer 54

– Slower, yet absorption still complete – Increased risk of GI adverse effects possible

Question 55

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

Answer 55

– 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

Question 56

Drug metabolism in older adults- – Reduced ___________ function – Decreased __________ mass – Diminished ______________________ – Alteration in activity of ______________ enzymes

Answer 56

– Reduced hepatic function – Decreased liver mass – Diminished blood flow – Alteration in activity of hepatic enzymes

Question 57

Excretion in older adults-

Answer 57

– Diminished renal function consistent from patient to patient – Slower clearance of drugs from body

Question 58

Pharmacodynamic changes in older adults- – Decreased numbers of __________ and – Changes in receptor ____________ ▪Decreased response to beta-adrenergic agonists and antagonists ▪Increased response to anticholinergics

Answer 58

– Decreased numbers of receptors and – Changes in receptor sensitivity ▪Decreased response to beta-adrenergic agonists and antagonists ▪Increased response to anticholinergics

Question 59

Potential barriers to adherence to meds in older adults-

Answer 59

– Visual impairment – Functional disabilities – Cognitive dysfunction – Hearing impairment

Question 60

Describe drug misuse among older adults

Answer 60

-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.

Question 61

Adverse Drug Reactions in Older Adults may include:

Answer 61

– 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

Question 62

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.

Answer 62

– 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.

Question 63

For older adults, Nurse plays a key role in:

Answer 63

– Optimizing pharmacotherapy outcomes – Addressing adverse effects, drug interactions, issues of polypharmacy – Makes a connection between patient, family, & medication regimens