Which property of acetylsalicylic acid would a nurse recall when administering to a client

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1. 1. TOPIC 1: Nursing and Pharmmacology Pharmacology is the study of drugs and their actions on living organisms. Learning Objectives: Upon completion of this lesson the learner will be able to: • Describe the LPN role and legal responsibilities in the administration of medication • Explain how drug standards and the drug legislation affect drug regulation in Canada. • Explain the purpose of the Canadian Drug Acts and their application to nursing practice. • Define pharmacodynamics and pharmacokinetics • Define basic terminology used in pharmacology Define the following terms: o Pharmacology o Pharmacodynamics o Pharmacokinetics Drugs have a variety of names. Define the following terms: o Chemical name o Generic name o Trade (or brand) Explain the purpose of these two drug standards, and an example of a drug controlled by each Act. o Canadian Food & Drug Act o Controlled Substances Act Nursing and Pharmacology • Nurses must value their clients’ dignity and respect choices. • Nurse/client/family/multidisciplinary team work together for optimal health. • A Holistic view must be incorporated and include a view of cultural values/practices/medication use. Canadian Drug Legislation (Federal) There are a number of levels of legislation for drugs distributed in Canada: • "Canada Food and Drug Act" – differentiates drugs that can be sold only with a prescription (Rx.) from those that do not need a Rx.
2. 2. • "Controlled Drugs and Substances Act" – defines categories of controlled drugs, to prevent and treat drug dependence. Legislation states that: • Therapeutics drugs can be obtained by two methods only – prescription or over the counter (OTC) • Prescriptions are written ONLY by specified professionals. "Controlled Drugs and Substances Act" consists of: • Narcotic and Control Regulations • Benzodiazepine and Other Targeted Substances Regulation • Marijuana Medical Access Regulations • This act is for medications that are more frequently misused or abused. (Kozier & Erb p. 798) "Marijuana Medical Access Regulation" • This gives the authorization to possess or produce marijuana for medical reasons – HIV, cancer (nausea), MS, glaucoma • In 2001, Canada passed this act, being the first country in the world to do so. "Food and Drug Regulations" This act is responsible for regulation of all drugs in Canada and is categorized as: • Part A: administration of drugs • Part C: drugs • Part D: vitamins, minerals, amino acids • Part E: cyclamide, saccharin sweeteners • Schedule F: require a prescription • Part G: controlled drugs • Part J: restricted drugs Federal regulation of drugs divided into two categories: 1. Prescription (Categories with mandatory labelling “x”) 1. Prescription: “Pr” 2. Controlled: “C”
3. 3. 3. Narcotic: “N” 4. Targeted drugs: “TC” 2. Nonprescription Provincial Scheduling System This method of categorizing drugs is further to the above Federal legislation. • Schedule I: all prescription drugs, including narcotics, control drugs, target drugs • Schedule II: drugs do not require a prescription but can only be sold with the direct involvement of a pharmacist “ Over the Counter “ e.g.. Gravol in package of more than 30 tabs, Tylenol #1( 8 mg codeine) * Table 2.4 in Adams et al text • Schedule III: over the counter drugs “OTC”s that do not require a prescription but must be kept in an area not more than 6metres from the pharmacy. Eg. acetaminophen more than 650 mg/tab or in a container of more than 50 tabs • Schedule 4: Prescribed by pharmacists eg. “Morning after Pill” • Unscheduled Drugs: over the counter drugs do not require a prescription and can be sold in a non-pharmacy cough remedies, aspirin Narcotic Drugs • All products containing the symbol N on the drug label are Narcotics • Examples: morphine, methadone, opium, codeine, heroin, hydromorphone • Prescriptions must be written or faxed • Orders must be signed and dated by a physician, dentist, veterinarian or nurse practitioner Narcotic Preparations Exempt from Prescription • Products containing codeine plus 2 or more non-narcotic active ingredients are exempt from a prescription. • The amount of the codeine may not exceed 8 mg per solid dose form or 20mg/30 ml for liquid dosage forms. • In B.C. these products are kept behind the pharmacy counter Controlled Drugs • All products containing a controlled drug have the symbol ‘C’ on the drug label
4. 4. • All controlled drugs require a prescription • Examples: secobarbital, pentobarbital, anabolic steroids, Percocet, Dilaudid Targeted Drugs • Targeted Drugs identified with a ‘T/C’ on drug label , have same regulations as C and N drugs. • These drugs also have the potential for physical and psychological dependence. • The prescription requirements are the same as for the Controlled Part 1 drugs, but targeted drug substances do not need to be recorded in a register. • i.e. benzodiazepines (lorazepam, Ativan), their salts and derivatives. Considerations for Practice • Narcotic and Controlled drugs are kept in a locked cupboard • Nurses are responsible for administering these meds as prescribed, and for maintaining an accurate inventory of the drugs for each shift Prescription Drugs • Drugs not under regulation by Narcotics, Control or Target guidelines • Eg. antibiotics, antihypertensives, birth control Who Can Prescribe Medications? • Physicians • Dentists • Veterinarians • Podiatrist • Midwife – limited • Nurse • Practitioner • Pharmacists (restricted privileges) Role of the Nurse
5. 5. • RN’s and LPN’s are legally allowed to administer narcotics and controlled drugs. • Narcotics are kept in a locked cabinet • Strict record keeping is mandatory • Drugs are counted once per shift or according to agency policy For competency in medication administration, the nurse must: • Competently administer medication utilizing knowledge, skills, judgment and attitude to: o Assess the appropriateness of the medication for a particular client. That is, knowledge of the actions, interactions, usual dose, route and use of drug. The nurse must: • Prepare the medication correctly • Monitor the client while administering the medication including perform appropriate intervention as necessary • Evaluate the outcome of the medication on the client’s health status • Document the process Ethical, Responsible and Accountable • Ethical medication administration is to be upheld at all times. • LPNs are expected to involve clients in their own care by assessing their understanding of medications and by providing them with information about medications that is truthful, understandable and sensitive to their needs. LPNs are Responsible • Responsible medication administration is to be upheld at all times. • LPN’s must assume responsibility for their own knowledge, competence and limitations. LPNs are Accountable • Accountable medication administration is to be upheld at all times. • LPNs are accountable for ten rights of medication administration (CLPNBC 2010 Practice Directives) • LPNs are accountable for maintaining timely, accurate records of all medications they administer 10 Rights (CLPNBC 2010) • Right client
6. 6. • Right medication • Right dose • Right route • Right time • Right reason • Right documentation • Right for the client to be educated as deemed able to participate • Right of the client to refuse as deemed able to so • Right evaluation Basics of Nursing and Pharmacology Pharmacology Pharmacology: deals with the study of drugs and their actions on living organisms Pharmacology includes knowledge of how drugs are administered, how they are absorbed by the body and how the body responds. This will require a solid foundation in anatomy and physiology, chemistry, microbiology and pathophysiology. There are many different drugs for the many different diseases, and each one can be influenced by multiple factors such as age, sex, body mass... Therefore sound knowledge of pharmacology is pertinent to LPNs as they administer medications to patients. Pharmacokinetics Pharmacokinetics: the study of the absorption, distribution, biotransformation (metabolism) and excretion There are four phases of medication action in the body: 1. Absorption 2. Distribution 3. Metabolism 4. Excretion * These phases will be explored in more detail in the next class: Principles of Pharmacology.
7. 7. Pharmacodynamics Pharmacodynamics: the process by which a drug alters cell physiology. An understanding of pharmacodynamics will aid the LPN in predicting a client's response to a medication. The specifics of this will be further explored in the next module: Principles of Pharmacology. Drug Names Chemical Name • This provides the exact description of the medication's composition and molecular structure. • Chemical names rarely used in clinical practice: example N-acetyl-para-aminophenol is Tylenol Generic Names • Can be used in any country and by any manufacturer. The first letter of the generic name is NOT capitalized. • Pharmacists use the generic name • Example: acetaminophen Trade Names • Trademark or brand name and followed by the symbol ® and indicates that the name is registered and its use is restricted to the owner/manufacturer • Name is capitalized • Example : Tylenol Learning Activity Using your drug textbook (Davis’s Drug Guide), look up the following drugs: find generic and trade name • Valium • Tylenol
8. 8. • Gravol • Aspirin • Lasix TOPIC 2: Principles of Pharmacology Principles of Pharmacology All body functions and disease processes and most drug actions occur at the cellular level. Drugs are chemicals that alter basic processes in body cells. They can stimulate or inhibit normal cellular function and activities; they cannot add functions and activities. To act on body cells, drugs given for systemic effects must reach adequate concentrations in blood and other tissue fluids surrounding the cells. Thus, they must enter the body and be circulated to their sites of action (target cells). After they act on cells, they must be eliminated from the body (Kee, Hayes, & McCuistion, 2009).How do systemic drugs reach, interact with, and leave the body cells? How do people respond to drug actions? The answers to these questions are derived from cellular physiology, pathways, and mechanisms of drug transport, pharmacokinetics, pharmacodynamics, and other basic concepts and processes. These concepts and processes form the foundation of rational drug therapy. Learning Objectives: Upon completion of this class, the learner will be able to: • Describe the principles of pharmacology as related to common drug actions and interactions. • Describe the principles of pharmacology as related to food/ drug actions and interactions. • Describe the human factors that influence drug action Define the following terms: 1. Antagonists 2. Agonists 3. Partial agonists 4. Polypharmacy Pharmacokinetics: Once administered, all drugs go through four stages. Explain the action that takes place in each of these stages, and name the body organ/area where the action mainly occurs.
9. 9. 1. Absorption 2. Distribution 3. Metabolism 4. Excretion Define the following terms: 1. “half-life” 2. additive effect 3. synergistic effect 4. adverse effect 5. therapeutic effect 6. nephrotoxicity 7. allergic reaction 8. idiosyncratic effect Human factors affect drug action. State how each of the factors below affects medication. 1. Age 2. Body mass 3. Body weight 4. Sex 5. Metabolic rate 6. Presence of other conditions 7. Community and environment 8. Psychological/social/spiritual state 9. Culture and ethnicity Principles of Pharmacology Definitions: Pharmacodynamics
10. 10. Pharmacodynamics is the study of the actions and interactions between drugs and their receptors. A receptor is a specific site in the body with which the drug forms a chemical bond. Pharmacokinetics The term Pharmacokinetics refers to “Drug movement through the body”. *Stages involved are: 1. Absorption o Drug Admin Routes: Drugs are administered by many routes:  Oral  Percutaneous – inhalations, topical, sublingual  Parenteral – subcutaneous, intramuscular, intravenous  Intravenous - medications do not need to be absorbed as they are administered directly into the blood stream. o Rate of Absorption  The intravenous route of administration is the quickest for absorption as the medication directly enters the bloodstream.  The next fastest routes (in decending order) are:  Intramuscular  Subcutaneous  Percutaneous  Oral 2. Distribution o Distribution refers to the transportation of the drug from the site of absorption to the site of action in the circulatory system (blood) o A drug must have a certain blood level of the drug circulating for it to be effective. o Effectiveness depends on the amount of the drug and the vascularity of the tissues. Eg. Muscle tissue is far more vascular then adipose tissue 3. Metabolism o Metabolism is the process by which the body inactivates drugs.
11. 11. o This is mainly done in the liver and to a lesser degree by the lungs, GI tract, white blood cells 4. Excretion o Excretion refers to the elimination of the drugs from the body o Excretion is mainly done in the kidneys (urine) and bowels (feces) Other places Lungs (exhalation), skin (sweat/evaporation) and breast milk * You must know these stages and how they are involved in pharmacokinetics. Serum Half Life • The half life of a drug refers to the time required for the body to eliminate 50% of the drug. • Knowledge of the half life is important is determining the frequency of dosing. • Drugs with a shorter half life need to be administered frequently and drugs with a longer half life less frequent. Half Life Example • 20 mg of a drug that has a half life of two hours. • 10 mg (50%) remains after 2 hours How much drug remains after 4 hours? Answer 5 mg • After 6 hours = 2.5 mg • After 8 hours = 1.25 mg Effects of Drugs • Therapeutic Effect: relates to the reason the drug is prescribed. Also know as the desired effect/response • Adverse Effect: undesired response, can be severe or mild • Side Effect: secondary effect, unintended, mild adverse effect but still drug is producing a therapeutic effect • Nephrotoxicity: nephritis, renal insufficiency or failure occurs with several antimicrobial agents, NSAI. Drug excretion is impaired. Could lead to drug accumulation • Idiosyncratic Effect: an unexpected reaction • Allergic Reaction: immune response, mild to severe; rash to anaphylactic shock
12. 12. • Additive Effect:two drugs with same action are taken for double effect. o Example: Tylenol and Codeine • Synergistic Effect:Occurs when two drugs are given together and one drug enhances the effect of the other drug. This produces a greater effect than each drug given alone. o Example - Morphine and Gravol Adverse Reactions • Side effects • Toxic effects • Allergy • Accumulation • Drug Interaction • Tolerance • Dependence Factors Affecting Drug Action • Age • Body mass • Sex or gender • Environment • Route of administration • Time of administration * Refer to the resource under "Resources and Activities" More Definitions: Agonist versus Antagonist Agonists are drugs that interact with a receptor to stimulate a response ie the key fits. They can accelerate or slow normal cellular processes. Antagonists are drugs that attach to a receptor but do not stimulate a response, i.e. the key doesn’t fit. They inhibit cell function.
13. 13. Partial Agonist Partial Agonists are drugs that attach to a receptor creating a small response, but also block the responses of other drugs, i.e. the key partially fits and gets in the way of other drugs. Pharmacokinetics is an essential subject in pharmacology. It describes how the body handles drugs. Drug movement involves four processes: absorption, distribution, metabolism, and excretion. A thorough knowledge of pharmacokinetics enables the healthcare provider to understand the thearpeutic effects of a drug, as well as to predict potential adverse effects of drug therapy. TOPIC 3: Math Calculation Medication Calculations Calculating medication dosages for pills is a common math skill you will be using in your career. When a practitioner orders a medication, that specific dosage may not be available to you. While the pharmacy department will do their calculations, it is also your responsibility as the bedside nurse to make sure your patient get the correct dosage. Calculating how much medication your patient will need is easy. It's all about basic division. Formula for Calculating Dosages D x Q = X Desired x Quanity = Dose to give to patient H Have Let’s put this formula to work: Example # 1 The medication label reads : 0.25 mg per tablet. The dose ordered is 0.5 mg How many tablets do you give? Solve this using the formula D x Q = X H
14. 14. Medication Calculation Cont’d Values Equation Desired D = 0.5 mg Have H = 0.25 mg Quantity Q = 1 tablet X = Dose to give patient (make sure desired and have are in same units) Step1: Fill in the numbers (D) 0.5 mg x (Q) 1 tab = X (H) 0.25 mg Step2: Divide (D) by (H) (D) 0.5 '/. (H) 0.25 = 2 Step3: Multiply answer x (Q) 2 x (Q) 1 = 2 (X) Step 4 X = 2 Give the patient 2 tablets. What happens to the units of measure in this equation? • (D) and (H) must be in the same unit of measure. • Cancel all units eg. mg, that you see on both the top (D) and bottom (H). • Note that if the unit measure is only present once on the top, you can only mark it out once on the bottom, and vice versa. • Eg. 1 mg x 1 tablet = X 1 mg The mg cancel each other out - you are now solving for how many tablets to give. Why do units of measure matter? • The units of measure in drugs indicate the actual concentration of the medication. • For example the concentration of Tylenol is 325mg / tablet. However the concentration of “Extra Strength” Tylenol is 500mg / tablet. A single tablet of each contains a very different amount of medication! • This is very important to consider when calculating how much of a medication to give. Important points to remember:
15. 15. • round decimals to two places when necessary • always put a 0 before a decimal i.e. 0.25 ml (without the 0, the decimal might get missed and 25 ml administered instead of 0.250 • never put a decimal and 0 after a whole number i.e. do not write 2.0 ml (the decimal might get missed and 20 ml administered instead of 2) • when the unit is tablets, write the answer in a fraction i.e. 1 1/2 tablets. • when the unit is ml, write the answer as a decimal i.d. 1.5 ml. Example #2 The physician has ordered 1.0 g of Ampicillin. The Ampicillin bottle label reads that one capsule contains 0.5 g. (0.5g / capsule) How many capsules would you give? D = 1.0 g (Dose ordered) H = 0.5 g (Dose on hand) Q = 1 capsule (Quantity) X = How many capsules you will give (Scroll down for the solution...) Example #2 Solution Step 1: (D) 1.0g x (Q)1 capsule = X (H) 0.5g Step 2: 1.0 x 1 capsule = X 0.5 Step 3: 2 x 1 capsule = X Step 4: 2 capsules = X Therefore, give 2 capsules to the patient. Simple right?. Example # 3
16. 16. The doctor orders 0.25mg of digoxin PO daily. Your pharmacy has 0.5mg tablets. How many tablets do you give? Remember: D x Q = X H (Scroll down for the solution...) Example #3 Solution (D) 0.25mg x (Q) 1 tablet = X (amount to give) (H) 0.5 mg 0.25 x 1 tablet = X 0.5 0.5 x 1 tablet = X 0.5 tablets = X Therefore give 0.5 or ½ of a tablet. Splitting Pills On Example # 3, the dose required 0.5 of a pill. HOWEVER: • Not all pills can be split. • Make sure you check with the pharmacy if you are unsure if it is safe to split a pill or not. • As a general rule, most pills that are scored (indented line in the middle) can be split safely, but NOT ALL. Example # 4 – Liquid Medication The doctor orders 5mg of Robitussin PO daily. Your medication bottle from the pharmacy states 1mg / 2ml of Robitussin. There are 30ml in the bottle. How many mls do you give the patient? Solution for Example # 4
17. 17. (D) 5mg x (Q) 2ml = X (H) 1mg 5 x 2 ml = X 1 5 x 2 ml = X 10 ml = X Therefore, give the patient 10 ml of Robitussin Liquid. Example # 5 The physician has ordered 250 mg of acetaminophen at dinner. How many tablets will you give? Watch Out! There is something missing from Example # 5 (D) = 250 mg (H) = this is not provided (Q) = this is not provided Tell me, what more do you need to know? Example # 6 A drug is labelled 100 mg/ 2ml. Give 80 mg. (D) = ? (H) = ? (Q) = ? X = ? Example # 6 Solution (D) 80mg x (Q) 2 ml = X (H)100mg
18. 18. 0.8 x 2 ml = X 1.6 ml = X Therefore, give the patient 1.6 ml. Example #7 Medication is labelled 500mg/tablet Give 2 g. Think about this: What do you need to do with your units of measure before you calculate the dosage? You MUST convert all units to the unit of measure of the medication you have on hand. Example #7 Solution Convert the D & H to the same units (D) 2g = 2000mg (D) 2000mg x (Q) 1 tablet = X (H) 500mg 2000 x 1 tablet = X 500 4 x 1 tablet = X 4 tablets = X Therefore, give the patient 4 tablets. Math for Meds – Rule Summary • Always use the formula: D x Q = X H • Put the “like” units on the left of the equation. • (D) and (H) must be in the same unit of measure. • Cancel all units e.g. mg, that you see on both the top (D) and bottom (H). TOPIC 4: Drug Classifications
19. 19. Learning Objectives: Upon completion of the class, the learner will be able to:  Describe the drug classifications according to body systems.  Discuss drug research and explore various methods and sources for obtaining credible information.  Begin to develop a method of organizing pharmacological data that is individually suited, and allows for quick and accurate reference Class Preparation:  Refer to Reading List for required reading  Complete the following activity: oDrugs are classified in many different ways, such as how they affect a particular body system (i.e. those that affect the respiratory system). o Other classifications focus on the general effect of certain drugs on specific disease conditions or disorders, such as hypertension. Explain the purpose of these headings: 1. Action 2. Uses 3. Drug names 4. Dosages and routes 5. Contraindications 6. Precautions 7. Interactions 8. Nursing responsibilities Classifications Think back to the introduction concept in this course: Where can you find information on drugs?
20. 20. Have a look through your Davis Drug Guide: Do you see a pattern to how the drugs are categorized? There is a section in your Davis’s Drug Guide titled “Classifications”. Have a look at it, what information can you find here? As you learned in class # 1, the CPS is THE most reliable and complete source of information on medications. It is a compilation of drug monographs from all drug manufacturers.You also have access to eCPS. This is an online version of the Compendium of Pharmaceuticals and Specialties. Understanding the Reason for Medications • Classifications provide important information as to why the patient might be receiving the medication. • Take care to understand the individual reason for taking a medication based on history. • The same medication may be given for entirely different reasons to two different people. • Be aware of 'Pregnancy' Category as some medications are teratogenic to the fetus. Drug Classifications Classifications are based on how they affect body systems i.e. digestive system or respiratory system. They are also based on the effect of certain drugs on specific disease conditions (i.e. hypertension, Parkinson's). Getting to know classifications • This presentation will briefly discuss a number of drug classifications. • Please refer to your textbook if you want further detail or understanding. • You are also provided in this concept with a “table of classifications” which summarizes a number of classifications and gives examples of drugs for each. Anti-inflammatory Nonsteroidal anti-inflammatory drugs (NSAID): • Indication: Control mild to moderate pain, fever and various inflammatory conditions. • Action: inhibits production of prostaglandins Eg. acetylsalicylic Acid (Aspirin), ibuprofen, indomethacin.
21. 21. Topical Corticosteroid Anti-inflammatory Corticosteroid anti-inflammatory: • Action: Suppression of inflammatory response Eg. hydrocortisone topical ointment (local effects), dexamethasone (systemic effects). Corticosteroids hydrocortisone - (systemic effect) taken in oral tablets or IV. • Anti-inflammatory. • Used to treat adrenal insufficiency. • Immunosuppression in transplant surgery. Analgesics 1. Non-opioid Analgesics o Indications: Mild to moderate pain and fever o Actions: Inhibits prostaglandin synthesis Eg.  acetylsalicylic acid (Aspirin)  ibuprofen (Advil)  acetaminophen (Tylenol) o Note the following specific sub classifications:  indomethacin (Antirheumatic).  pyridium (Specifically for urinary tract). 2. Opioid Analgesics o Indications: Moderate to severe pain o Actions: Opiates bind to opiate receptors in the CNS, acting as agonists of endogenous opiods Eg.:  codeine (30 mg in Tylenol #3).  morphine.
22. 22.  Demerol (meperidine).  Dilaudid (hydromorphone). Antipyretic • Indication: used to lower fever of many causes • Action: affects thermoregulation of the CNS and inhibit effect of prostaglandins peripherally. Eg: o acetylsalicylic acid (Aspirin), ibuprofen (Advil).  adverse effects: both of these meds can cause GI bleeding. o acetaminophen (Tylenol).  inhibits synthesis of prostaglandins but does not have the GI side effects. Antiplatelet • Indications: Antiplatelet agents are used to treat and prevent thromboembolic events such as stroke and MI. • Action: inhibits platelet aggregation, prolongs bleeding time • Eg. acetylsalicylic acid (Aspirin) Anticoagulant • Indication: prevention and treatment of thromboembolic disorders. • Action: prevent clot extension and formation • Eg.: heparin (may be given IV for acute thromboemboli), Coumarin or Coumadin(warfarin). o This medication is given orally to patients who have pacemakers, heart valve replacement surgery, venous thrombus, pulmonary emboli or have atrial fibrillation. o Is also used as rat poisoning in large doses. * Adverse reaction and side effect is Hemorrhage. Nurses must monitor for bleeding and teach patient how to protect self from injuries etc.
23. 23. Anticonvulsant • Indications: Used to decrease incidence and severity of seizures. • Actions: Depress abnormal neuronal discharge in the CNS that results in seizures • Eg.: o phenytoin (Dilantin) most commonly used anticonvulsant o phenobarbital (a controlled drug) o valproic acid o diazepam (Valium) o carbamazepine (Tegretol) Digitalis Glycosides • Indications: Treatment of tachyarrhythmia (rapid irregular heart rate) and congestive heart failure • Action: slows and strengthens heart contractions. • Eg.: digoxin (Lanoxin) • Nursing considerations: o * adverse effect bradycardia, digitoxicity o monitor apical heart rate for one minute prior to administration, hold if HR < 60bpm o blood levels drawn to monitor for therapeutic level. Antacid • Indications: Used for indigestion, GERD, heartburn, hyperacidity (GI complaints) • Action: Neutralize gastric acid • Eg.: o Diovol - magnesium hydroxide/aluminum hydroxide. o Maalox -magnesium hydroxide/aluminum hydroxide.
24. 24. Laxatives • Indications: used to treat or prevent constipation. • Actions: Induce one or more bowel movements per day • Types: stimulants, stool softeners, bulk forming agents, osmotic cathartics • Covered in detail in next concept - see course resources. Antidepressant • Indications : used in the treatment of endogenous depression • Action: Generally, prevents the reuptake of dopamine, norepinephrine and serotonin by presynaptic neurons in the CNS. • Two major types: o 1. Tricyclic antidepressants – amitriptyline (Elavil) o 2. SSRIs – Prozac,Paxil, Zoloft, Luvox. Skeletal Muscle Relaxant • Indications: spasticity associated with CNS disorders, or therapy for acute musculo- skeletal conditions • Action: Act centrally or directly to relieve muscle tension and spasticity • Eg.: Baclofen, Zanaflex,Valium. Anti-infective / Antibiotics • Indication: treatment and prevention of bacterial infection • Action: Kill or inhibit the growth of susceptible pathogenic bacteria. Culture and sensitivity of infection site determines right medication. • Eg.: o Penicillins (Bind to cell wall resulting in cellular death).  Ampicillin.
25. 25.  Amoxicillin. * check for allergy to penicillin. o Sulfonimides (Stop bacterial synthesis of folic acid = cell death).  Sulfisoxasole  Sulfamethoxazole Cough Suppressant / Allergy, Cold, Cough Remedies • Indications: symptomatic relief of coughs by minor upper resp. tract infections • Actions: Suppresses the cough reflex by a direct effect on the cough centre in the CNS • Eg.: Benylin, Robitussin Cough Expectorant • Indications: coughs associated with viral upper respiratory infections • Actions: reduces viscosity of tenacious secretions • Eg.:guaifenesin o added to Benylin cough syrup (Benylin E) Note: Elixirs may be mixed with alcohol and may contain sugar. Antipsychotic • Indications: treatment of chronic psychoses • Actions: block dopamine receptors in the brain, also alters dopamine release and turnover. • Eg.:lithium carbonate (antimanic), haloperidol, chlorpromazine. Antianxiety • Indications: used in the treatment of anxiety disorders • Actions: Generalized CNS depression
26. 26. • Eg.: Lorazepam o usually sublingual if acute anxiety (acts within 15 min) o diazepam. An important nursing responsibility is to monitor respirations as an *adverse side effect of benzodiazepines is suppression of respirations. Bronchodilator • Indications: used in the treatment of airway obstruction (asthma or COPD) • Actions: bronchodilation • Eg.: o Theo-dur- (theophylline)  Relaxes bronchioles, dilates bronchioles o Aminophylline  converts to theophylline  blood levels drawn to monitor therapy * Side effect is tachycardia, anxiety. Monitor: breath sounds and vital signs for side effects. Artificial Tears / Ocular Lubricant • Indications: management of dry eyes due to lack of tears • Action: provide lubrication and protection to dry or artificial eyes • Eg.:Isopto tears. Spasmolytic / Urinary Tract Antispasmodic / Anticholinergic • Indications: treatment of urinary symptoms of neurogenic bladder – frequency, urgency, overactive bladder. Relief of bladder spasms • Action: inhibits the action of acetylcholine, reduces smooth muscle spasm. Delays desire to void. • Eg.: oxybutynin - Ditropan
27. 27. * Monitor voiding pattern. Antiparkinson • Indications: used in the treatment of parkinsonism of various causes. Therapeutic relief of tremor and rigidity. • Action: aimed at restoring the natural balance of acetylcholine and dopamine in the CNS • Eg.: Sinemet - levodopa. o levodopa is converted to dopamine in CNS. Hypnotic / Sedative • Indications: to provide sedation • Actions: Generalized CNS depression • Eg.: o phenobarbital. (hypnotic) o diazepam o lorazepam * Respiratory depression is a life threatening adverse effect. Resp. rate must be monitored. Antiulcer • Indications: treatment and prevention of peptic ulcer • Action: neutralizing or decreasing gastric acid, • Eg.: o cimetidine • * Side effect is confusion, particularly in the elderly. o Maalox o Diovol
28. 28. * Note that Ampicillin is used to treat h.pylori, a bacteria involved in the disease process of peptic ulcer disease. Therefore is listed under antiulcers in the Davis drug book. Antihypertensive • Indications: Treatment of hypertension of many causes • Action: Used to lower blood pressure to a normal level by a variety of mechanisms • Eg.: o Ace Inhibitors. Vasotec (enalapril, captopril) o Beta Blockers o Calcium Channel Blockers o Diuretics * Nursing responsibility: monitor blood pressure. Routes of Medication Administration • Po (by mouth) - swallowed, absorbed in gut, (enteric coated must not be crushed). • SL (Sublingual) - under the tongue, dissolves. • IM (Intramuscular) - absorbed by muscle. • SC (Subcutaneous) - delivered into the subcutaneous fatty tissue. • Intradermal - under the epidermal layer to the dermis. • IV (Intravenous) - directly into the bloodstream. This is the fastest route. • Topical - for local affect, ung.(Ointment) absorbed by skin. • Transdermal - controlled slow release; topical patch. • Rectal Right Time • Medications must be given at the right time to assure therapeutic levels. 1/2 hour before or 1/2 hour after the scheduled time is allowed.
29. 29. o Use the 2400 hour clock, i.e. 0100 is 1:00a.m and 1900 is 7:00 p.m. Use appropriate abbreviations. • Antibiotics are usually started after a culture has been obtained • Certain medications have a sustained release to assure a prolonged action for the medication - do not crush/chew or dilute. TOPIC 5: Quiz 1 and Math Calculations Quiz 1st Attempt Read first- Info re Quiz and Review Review the following: • Quiz # 1 Theory Exam 15% of grade • Look at the Learning Objectives for each topic. • Exam questions will be based on the course material and required readings covered in Topic 1-4 • Here is a bit of a study guide to help you focus on what’s important. Please make sure you review the following concepts. Pharmacodynamics Pharmacokinetic Absorption, distribution, metabolism, excretion Generic, trade, chemical names Canada Food and Drug Act – what is it? What is the purpose of it? Agonists, antagonists, partial agonists, receptors Half life - what is it and how do you calculate it? Side effects, idiosyncratic reactions/unexpected reactions Tolerance, dependence, accumulation Reliable vs unreliable sources of drug information Classifications – know the classification, use/action and common drug examples TOPIC 6: Principles and Routes of Medication Administration There are many ways that drugs may be delivered to body tissues. Drugs may be swallowed, inhaled, injected, inserted, or rubbed onto the body's surface. The method of drug delivery
30. 30. depends upon the nature of the drug itself and how it is used. The different routes affect important aspects of pharmacology including how quickly the drug acts and how long the effects will last. In general, all categories of drug delivery are associated with one of three major routes. The first major route is the digestive tract, or the enteral route. Drugs gaining access by this route enter the body either by the mouth, under the tongue, or into the rectum. The second major route is the parenteral method. By this method, drugs enter the body by a way other than the digestive tract, usually by injection directly into the cardiovascular circulation, the skin, or body cavities. If injected into the general circulation, drugs may be administered into veins or arteries. If injected through the skin, drugs may be administered into the dermis, beneath the dermis, or into muscles. If injected into a body cavity, drugs may be administered into spaces surrounding the spinal cord, abdominal organs, or into joints. The third major route of drug delivery is the topical route. Here drugs are placed directly onto the skin or associated membranes, such as nasal and respiratory passages, the ears, the eyes, or the vagina. Learning Objectives: Upon completion of the class, the learner will be able to:  Explain the principles of medication administration.  Identify the ten (10) Rights of Drug Administration  Identify the three (3) checks related to the administration of medications.  Describe the routes of medication administration.  Identify commonly used drug distribution systems in Canada.  Identify types of drug orders Complete the following questions: • As a practical nurse, observing the Ten Rights of drug administration is an ethical and legal responsibility. Using your pharmacology text and your CLPNBC Practice Guidelines, expand on the “reason” for these Rights: 1. Right reason 2. Right patient 3. Right drug 4. Right dose 5. Right route 6. Right time 7. Right to refuse 8. Right to education 9. Right documentation
31. 31. 10. Right evaluation • What is meant by “three (3) checks”? • Explain how these legal and ethical responsibilities as a practical nurse might affect your nursing practice? • What is your role as a Practical Nurse in administering medications? • How do you find out the care facility's policies on administration of medication? • How do you identifying and report a medication error made by you or a colleague? • Although no two drug distribution systems function exactly alike, some basicsystems currently in use are: 1. Floor or Ward Stock System 2. Individual Prescription Order System 3. Unit Dose System 4. Long-term (bubble pack) System • Identify the guidelines related to the Narcotic Control System. • Describe the 4 types of Drug Orders: 1. Stat 2. Standing 3. Renewal 4. PRN • State the nursing responsibilities related to physician’s Verbal Orders. Medical Distribution Systems, Orders of Drugs What are Distribution Systems? • Medications are supplied and administered to patients using organized and specific systems and methods in order to reduce risk of medication errors. • There are a number of distribution systems set up by the pharmacists or facilities.
32. 32. Medical Distribution Systems 1. Unit Dose System: o Uses portable carts containing a drawer with medications for each client o The unit dose is the ordered dose of medication that the client receives at one time. o Pharmacy/pharmacist refills daily or prn 2. Bubble Pack System: o Medications are packaged with one tablet or one dose per bubble o 2 wk/1 month supply on a card 3. Floor or Ward Stock System o Medications are available in large quantities, in multidose containers o Kept on ward or unit. 4. Individual Prescription o Supply of 3 – 5 days from pharmacy for individual client 5. Automated Dispensing System o Computerized access system automates the distribution, management and control of meds. o Protected by password Drug Orders • Physicians write drug orders • Must contain – patient’s name, drug name, dose, route, time and duration that order is in effect • Must be dated and signed • Agency policy usually determines when the order is outdated Types of Drug Orders 1. Telephone Order: o RNs and LPNs may take a drug order by telephone communication with the physician (check facility policy)
33. 33. o The physician must come into the facility to sign the telephone order within 24 hours 2. Stat Drug Orders: o Must be administered to the patient immediately & only once o Are usually indicated in an emergency o Are given on one occasion only and then discontinued o “Give diazepam 10 mg IV stat” o “Give diphenhydramine 50 mg IM stat” 3. Standing Orders: o An agency or physician specific order approved for administration for a specific reason o Usually for a specified number of doses and then automatically outdated and discontinued by pharmacy o Most common type of order o “Give cephazolin 1 G IV q6h x 4 doses” o “Give Sinemet 25/100 PO TID” 4. Renewal or Re-Order: o Physician must write a renewal or re-order for a medication to be continued after it is outdated by pharmacy o Usually applies to standing orders o “Re-order Sinemet 25/100 PO TID” 5. PRN (pro re nata = as necessary ) o A written order to be administered “as necessary” o Is intended to be given at the nurse’s discretion after assessing it is appropriate o “Give Tylenol 650 mg PO q 4-6 h for oral T >38° C” – can be given by the nurse upon assessing the patient’s temp to be > 38° C o Requires assessment before and after Drug Dose Forms Drugs come in many forms:
34. 34. • Tablets – compressed dry drug that may be scored; may be enteric coated to pass through the acid of the stomach in order to dissolve in the alkaline pH of the intestine • Capsules – cylindrical gelatin containers for dry or liquid drug • Lozenges/torches – flat disk of drug (usually flavoured) which is held in the mouth until dissolved • Elixirs – drug is dissolved in a clear, alcohol or water-based liquid that may be flavoured • Emulsions – dispersions of small droplets of water in oil, or oil in water • Suspensions – dry drug particles are dispersed in a liquid and must be shaken before administration • Syrups – drug is dissolved in a concentrated solution of sugar Professional Drug Safety • Administer meds immediately after pouring • Observe the medication being taken • DO NOT use outdated medications • DO NOT use a medication whose label is illegible • DO NOT alter a drug label • DO NOT return any drug to a drug container • REPORT MEDICATION ERRORS IMMEDIATELY to the charge nurse • NEVER give a medication that another nurse has poured. Medication Administration • In order to ensure that you SAFELY administer all medications, you must follow very specific protocols and routines. o 10 rights o 3 checks o General rules of medication administration 10 RIGHTS of Medication Administration Right Patient
35. 35. • Watch for name alerts (similar names between two or more patients) • Check name - MAR, ID band, photo, verify by staff, have pt. state name. • Take MAR to bedside • Check MAR against resident’s name band (or picture, or have another staff person confirm that you have identified the “right patient”) • Ask the resident their name Right Medication • Right drug, correct spelling • Right concentration of med. o Eg. 50 mg/1 mL or 50 mg/2 mL Right Dose • A “dose” is the amount of drug prescribed by a physician in mg (usually) or units, u (insulin) • You may need to assess the concentration of medication in a liquid or tablet and then calculate the dose • Is the dose on the MAR the usual or an acceptable dose for this drug? Question any dosage outside of usual dosage range • Double-check all calculations. Right Route • The route must be as per the physician’s order • Make sure the medication supplied is. for the prescribed route Right Time • Know abbreviations (specific time may not be indicated) o Eg. Order may say "30 minutes ac meals" • Must be given within 30 minutes of scheduled time. Right Reason Does this medication make sense for this patient?
36. 36. • If giving insulin, does this patient have diabetes? • If giving hydrochlorothiazide, does this patient have hypertension? • The right reason is checked during the “preliminary check” and the right documentation is done after the medication is taken. Right Documentation • Chart on the MAR immediately after giving the medication • For a PRN medication, document pre- and post-med findings • Document in the correct date and time line on the MAR • Assess agency policy regarding documentation of a “refused” medication and provide the patient’s stated reason • Promptly assess and document any adverse effects in progress notes Documenting Narcotic Use In a facility, the nurse must: • Record name and quantity of all narcotics received from pharmacy • Record name of patient receiving and physician ordering narcotics • Record patient, narcotic name, dose, time given • Two nurses must sign for a wasted amount of narcotic • Report missing narcotic immediately • All narcotic records must be safely stored Right to Education • Explain information to the patient about the medication • What they can expect, why they are receiving it, any precautions. Right of Refusal • Adult patients have the right to refuse any medication. • The nurse must ensure that the patient is fully informed of the effects of the medications and communicate any refusal to the appropriate Health Care Professional Right Evaluation
37. 37. • “The nurse should always assesses the patient’s health status ...medication history….before administering any medication to obtain baseline data by which to evaluate the effectiveness of the medication. • The extent of the assessment depends on the patient’s illness or current condition. It is essential that the effect/response of the client to the medication be documented” (Kozier et. al. 2010, pp. 812-813). 3 CHECKS * 5 rights - patient, medication, dose, route, time are done 3 times: 1. When removing medication from cart or shelf 2. Before pouring 3. After pouring General Rules of Drug Administration • NEVER give a med you did not pour • NEVER give a medication that isn’t labeled • NEVER chart for someone else • NEVER leave medications unattended • Chart immediately after giving the medication on the MAR • Give medications within 30 minutes of “time” • Report a medication error immediately • Lock medication cart if unattended • Return to assess medication response especially for PRN medications Routes of Administration • Enteral- via the Gastrointestinal tract (swallowed or via a feeding tube) o PO (tablets, capsules, liquids) • Percutaneous- across the skin or mucous membranes o SL, buccal, rectal, vaginal, transdermal, topical, inhalations, gtts (eye or ear) • Parenteral- bypasses the GIT o SC, IM, IV
38. 38. Medication ERRORS - Why do they happen? • Inadequate knowledge, skill and judgment - about patient, diagnosis, medication name/reason, proper administration. • Failure to comply with policies - poor attention to safety policies for medication administration. • Incorrect writing/transcribing of orders, verbal orders, illegible writing, misunderstood abbreviations, failure to document properly medications given or not given, unclear MARs (medication administration record) • Individual or system problems – nurse inexperienced, overtime worked, rotating shifts, use of casual or float nurses, interruptions, unclear labeling, drugs spelled or sound similar, packaging looks similar TOPIC 7: The Nursing Process and Medications for Specific Disorders The Nursing Process and Pharmacology The Nursing Process is a problem solving technique that uses 5 stages: • Assessment • Diagnosis • Plan • Implementation • Evaluation Assessment Stage involves: • Collection of data from client, family, chart, doctor • Taking a Drug history to evaluate the patients need for the medication • Obtaining a history of past/present over the counter drug use, prescription use, herbal use, street use • Identifying problems related to drug therapy - side effects, known allergies Diagnosis Stage involves: • Identifying concerns/problems with drug side effects • Managing swallowing problems (dysphagia) – can’t take meds Noting Impaired
39. 39. • Cognition – If forgetful, may miss med times • Identify concerns that maybe a medication could resolve eg. headache – obtain a Tylenol order? • Knowledge deficit leads to non compliance or over medication Planning Stage involves: • Identifying what the medications are required for. • Reviewing side effects of medications, be prepared to teach the client/family • Identify recommended dosage – does it follow the guidelines? • Review med admin times with pt. and family Implementation Stage involves: • Collecting data related to patient condition and medications in use. • Collaborate with the pharmacists on medication information/side effects, interactions, use reference books • Design education plan as needed for the patient and family • Administer medication using the 9 RIGHTS of medication administration Evaluation Stage involves: • The nurse must evaluate/assess the effectiveness of the medication • Observe for side effects • Chart and record medications given and their effectiveness. Laxatives Constipation Normally waste travels through the large intestine, reabsorbing water as it passes along. This keeps the stool of a normal soft consistency. However, if the stool remains in the colon for too long, the water is reabsorbed and small hard stools form. This causes discomfort and distension in the abdomen. Constipation can be caused by a number of factors:
40. 40. • Lack of exercise • Insufficient food or fluid intake • Medication regimes Sometimes pharmacologic intervention is required to ease constipation. Laxatives are given: • To relieve constipation • To prevent straining during bowel movement • To empty the bowel in preparation for bowel surgery or diagnostics tests Laxatives are contraindicated when there is: • Undiagnosed abdominal pain • Intestinal obstruction * You must assess your client, including a physical abdominal assessment, prior to administration of a laxative There are different types of laxatives: • Bulk –forming: substances that are largely unabsorbed from intestine, adding bulk to fecal mass to stimulate peristalsis; they pull water into intestinal lumen • Saline and osmotic agents: increase osmotic pressure in intestinal lumen and cause water to be retained; distension of bowel promotes peristalsis • Stimulants: the strongest and most abused laxative; they irritate GI mucosa and pull water into bowel lumen. • Osmotic laxatives: not absorbed in the intestine. Pulls water into the fecal mass to create a more watery stool. • Miscellaneous: o Mineral oil – acts by lubricating the stool and the colon mucosa Classification: Bulk Forming • Metamucil (psyllium) • Not absorbed from the intestine • When water is added the substance swells and become gel like • The added size to fecal matter stimulates defecation
41. 41. • Similar results as fibre intake • Act within 12 –24 hours but may take up to 2 –3 days • Must take with 8 –10 oz. water Classification: Osmotic Laxatives • Magnesium Citrate (Citro-Mag), Milk of Magnesia • Lactulose – pulls water into the intestine, softening stool and irritating bowel by distension. • Not well absorbed from the intestine and cause water to be retained in the bowel and absorbed into the stool • Distention of the bowel leads to increased peristalsis, watery stool • Results 1/2 – 6 hours • Sodium phosphate retention enemas give results in 15 minutes Classification: Stool Softeners • Docusate sodium (Colace) • Decreases the surface tension of fecal mass and allow water and fat to be absorbed into the mass • Results in softer stool and easier passage.Acts within 1 –3 days Classification: Stimulant Cathartics • Act by irritating the gastric mucosa and pulling water into the bowel • Oral Dulcolax, castor oil, Senokot • Produce results in 6 – 12 hours • Rectal suppositories bisacodyl results 15 min. – 2 hours. Glycerine 30 minutes • Pt. may experience abdominal cramping Classification: Miscellaneous - Laxative (Lubricant) • Mineral oil • Lubricates fecal mass • Effective 6 –8 hours Classification: Miscellaneous - Laxatives • Pulls waters into the intestine • Can produce electrolyte imbalances – use with caution
42. 42. • sorbitol( Microlax) Nursing Responsibilities • Assessment: abdominal assessment, check bowel records, assess diet and fluid intake, activity level, medications, age related concerns • Document findings, document interventions, document/assess results • Incorporate patient teaching as needed Laxatives • See pages 513 –516 ( Normal Function of the Lower Digestive tract) in Pharmacology for Nurses (Adams et al, 2010) • Review Student Guide questions. • Make a drug card for each laxative: o Bisacodyl o Psyllium powder o Docusate Sodium (Include Action, Trade name, Route given, Nursing measures/assessment that accompany administration of this med.) You will need these drug cards for nursing arts! Otic and Topical Medications Otic Medications 1. How are medications labeled for use in the ear? 2. Research Auralgan eardrops.(Hint: look online). 3. What are the indications for this medication? 4. What are the nursing considerations? Topical Medications Research the following classifications of Topical medications: 1. Antimicrobials 2. Antipruritics
43. 43. 3. Anti-inflammatory 4. Antineoplastics What are your nursing considerations when applying topical medications? TOPIC 8: Complementary, Indigenous and Alternative Remedies Learning Objectives: Upon completion of the class, the learner will be able to: · Identify complementary, indigenous and alternative remedies · Identify the implications of the use of herbal, vitamin and indigenous remedies with other medications · Identify the main nursing considerations related to these groups of drugs. Reflect on the following quote from Cook (2005): A Royal Commission on Aboriginal Peoples widely consulted Aboriginals in Canada. The Commission's 1996 Report advocated 4 cornerstones of Aboriginal health reform, one of which was "the appropriate use of traditional medicine and healing techniques [that] will assist in improving outcomes . . ." It reported that many expressed the sentiment that ". . . the integration of traditional healing practices and spirituality into medical and social services is the missing ingredient needed to make those services work for Aboriginal people." Nutritional Supplements and Herbal Medications Terms and Concepts Herbal Medicines • Medicines of botanical origin Minerals • essential components of enzymes, hormones, bones & teeth • regulate cell membrane permeability, pH, osmotic pressure, muscle contractility, O2 transport etc Vitamins
44. 44. • essential chemicals that regulate metabolism • fat soluble are A, D, E & K • What is the significance of a vitamin being fat-soluble - as opposed to water soluble? Mineral – Calcium Salts • Actions – activates nerve impulses (blood coagulation, essential for cardiac, smooth and skeletal muscle function) • Uses – treatment & prevention of hypocalcemia, Osteoporosis • Adverse Effects – arrhythmia, constipation • NC – assess for hypocalcemia (paresthesias, arrhythmia, muscle twitching), monitor VS & labs • Supplements – calcium carbonate, calcium gluconate • Best absorbed if taken with magnesium Anemia & Iron Anemia - ↓ in RBC number or ↓ in quantity of hgb • Iron is required for hgb synthesis • Only 5% - 10% of dietary iron is absorbed • Vitamin C increases absorption Ca+ inhibits absorption Types of Anemia 1. Iron-deficiency Anemia (nutritional anemia) – low or absent iron stores due to diet 2. Pernicious Anemia – lack of intrinsic factor → ↓ B12 absorption & malformed RBCs 3. Megaloblastic Anemia – low folic acid Minerals – Ferrous Sulphate • Action – iron source for production of hgb • Uses – prevention & treatment of iron deficiency anemia (only) • Adverse Effects – dark stools, epigastric pain, diarrhea, constipation • NC – monitor hgb, hct, reticulocytes, monitor BMs • Supplements - ferrous gluconate, ferrous sulphate
45. 45. Vitamin B12 – Cyanocobalamin • Action – co-enzyme for RBC production • Uses – pernicious anemia, prevention of B12 deficiency • Adverse Effects – well tolerated • NC - IM route only in pernicious anemia because... Minerals – Zinc • Action – co-factor for many enzyme reactions, wound healing • Uses – replacement & supplemental for those with deficiency, impaired wound healing • Adverse Effects – well tolerated • NC – teach not to exceed RDA, dietary sources (wheat germ, seafood, organ meat) • Supplement – zinc sulphate Vitamin D • Action – converted to active form in liver/kidneys, promotes absorption of Ca+ and phosphorus, helps regulate Ca+ levels • Uses – treatment of hypocalcemia, some bone diseases, vitamin D deficiency • Adverse Effects – toxicity (muscle pain, ↓LOC arrhythmia, bradycardia) – why is toxicity possible with this vitamin? • Meds – calcifediol, calcitriol, cholecalciferol Herbal Medicines • ¼ of prescription drugs are from herbs • Pharmaceutical industry uses ~ 120 compounds derived from plants which it discovered by studying folk remedies • Quinine, from South American cinchona tree bark is used to treat malaria • Digitalis (digoxin), a widely prescribed heart medication, is from the foxglove plant • Salicylic acid, the source of aspirin, from willow bark Lack of Regulation
46. 46. • As yet, the (OTC) herbal medicine industry is unregulated • False claims are not uncommon (effectiveness, “organic”, safety) • Studies have found wide discrepancies between the labeled contents and the actual contents of many products • Some herbs, like pharmaceuticals, have potentially harmful side effects • Many herbal products lack scientific study and validation of claims • Nurses need to be aware of herbs potential for; o Toxicity o Potential interactions with other medications Your Role Regarding Use of Herbs Our role is NOT to discourage their use but to ensure the MD knows about them prior to ordering regular pharmaceuticals. Herbs and the Nursing Process Assessment • Plant and other allergies? • List of herbal/vitamin supplements used • Client’s understanding of the indications for their use • Is the physician aware? (check MD’s history/progress notes) Why is this essential? Planning • Ask client/family if herbs are being used • Locate resources for client teaching • Check facility policy/MD/facility pharmacist for administration & documentation policies – why? • Clients or their family members sometimes store herbs in the room & don’t think to alert the nurse/MD Implementation / Evaluation • Advise MD of use of products, allergies • Teach client importance of advising MD/nurse about use of herbal products
47. 47. • Teach client about the products being used – what source will you use? • Assess client’s complaints and therapeutic response to supplemental products • Consult with team for appropriate action Herb – Gingko Biloba • Action – relaxes smooth muscle (vasodilation with improved arterial & capillary perfusion), free radial combatant, inhibits platelet aggregation • Uses – ↑ cerebral blood flow in elders (Alzheimer’s, ST memory loss, HA, dizziness), ↑ walking distance in intermittent claudication, ↑ peripheral perfusion in diabetes, improved wound healing • Adverse Effects – diarrhea, nausea, vomiting, dizziness (in large doses) • Interactions – caution in clients on platelet inhibitors & anticoagulants • Nursing Considerations – monitor: Herb – Black Cohosh • Action – compounds bind to estrogen receptors, suppress luteinizing hormone • Uses – PMS symptoms, dysmenorrhea, menopause • Adverse Effects – well tolerated • Precautions – safety in breast cancer not established, do not use for > 6 mo, not in first 2 pregnancy trimesters • Nursing Considerations – do not confuse with BLUE cohosh Herb – Feverfew • Action – smooth muscle relaxant, ↓ prostaglandin & leukotrienes, ? antiplatelet • Uses – prevention of migraine HA (smooth muscle relaxant), RA (antiinflammatory properties) • Adverse Effects – mouth ulcers, “post feverfew syndrome” (insomnia, headache, myalgia, anxiety so DC use gradually) • Nursing Considerations – teach for migraine HA prevention only, avoid NSAIDs (↓s effectiveness of feverfew) Herb – St. John’s Wort
48. 48. • Action – inhibits reuptake of serotonin etc, effects vary with product manufacturer • Uses – mild depression, OCD, topical (antiinflammatory, wound healing) • Adverse Effects – “serotonin syndrome” (sudden onset of confusion, nausea, vomiting, muscle spasm, tremor, fever → coma), photosensitivity • Nursing Considerations – not to use other serotonin-active drugs together, teach about serotonin syndrome Food / Drug Interactions • The potency & effectiveness of many medications is altered by the presence or absence of food/other medications etc in the stomach – read drug labels/orders carefully • Eg. Grapefruit increases the potency of many conventional medications, such as calcium channel blockers & benzodiazepines TOPIC 9: Nervous System Part 1 Learning Objectives: Upon completion of the class, the learner will be able to: · Describe major classes of drugs used to treat diseases/illnesses of the nervous system (Autonomic nervous system, Parkinson’s Disease, seizures, and anxiety/mood disorders and psychoses). · Describe the main nursing considerations related to this group of drugs. · Explain drug interactions, polypharmacy, and food/drug effects to medication used across the lifespan, particularly the older adult. · Explain the potential interaction of complementary, Indigenous and herbal preparations with nervous system medications. · Organize research of drugs used to treat diseases/illnesses of the nervous system in a way that allows for easy and accurate reference. Medications Used to Treat Disorders in the Nervous System Drug Calculations Practice Read the questions carefully!
49. 49. 1. Acetaminophen elixir is stocked as 160 mg/5 mL. The physician has ordered 15 mL to be given q4-6h prn for pain. How many mg will you be administering per dose? 2. MD order reads - KCl 15 mEq PO once daily. On hand - KCl 10 mEq/15 mL. What volume of medication will you administer per dose? 3. Desired medication – 1.0 g ibuprofen total daily in two equally divided doses. Medication on hand is 200 mg tablets. How many tablets will you administer per dose? Equivalents & Conversions 1 tsp = _____ mL 45 mL = _____ oz 0.17 G = _____ mg 0.01 mg = _____ mcg 2500 mcg = _____ mg 125 mg = _____ G Nervous System Classifications (This content is relevant for both Part 1 and 2). • Adrenergic Agents (agonists) • Adrenergic / Beta Blockers (adrenergic antagonists) • Cholinergic Agents (agonists) • Anticholinergic Agents (cholinergic antagonists) • Sedatives / Hypnotics (benzodiazepines, other) • Anti-Parkinson Agents (dopamine agonists) • Anxiolytics • Antidepressants • Antipsychotics • Anticonvulsants • Analgesics (opioid, non-opioid, salicylates, NSAIDs)
50. 50. Nervous System A & P – the Directors & Actors Central Nervous System (CNS) “directors” • Brain & Spinal Cord Peripheral Nervous System (PNS) “actors” • Spinal/Peripheral nerves 1. Somatic System 2. Autonomic system • Cranial nerves Neurotransmitters (nt) • Are chemicals that are released by one neuron, diffuse across the synaptic cleft, and are taken up by receptor sites on the next neuron • Thereby, passing on the action potential • Each neuron releases only one kind of nt • Neurotransmitters either stimulate or inhibit a function of a neuron ANS - Autonomic Nervous System– Sympathetic Agonists & Antagonists • Term “adrenergic” comes from nt name adrenalin (aka epinephrine) • Adrenergic agonist medications are called adrenergic agents (sympathomimetics) • Adrenergic antagonist medications are called adrenergic blocking agents • What does sympathomimetic mean? Adrenergic Agents • Catecholamine drugs that stimulate adrenergic receptors (alpha, beta, dopaminergic) • Meds – albuterol (Salbutamol, Ventolin), dopamine, epinephrine • Mechanism of action by Receptor Type: o In blood vessels - vasoconstriction (alpha) o In heart - ↑ HR (beta 1)
51. 51. o In lungs - bronchodilation (beta 2) o Other - ↓s Parkinson’s symptoms & ↑ renal perfusion & urine output (dopamine) What drug class will antagonize the effects of the adrenergic agonists? • General Uses – asthma, bronchospasm, hypotension, shock, decongestant, digitalis toxicity, COPD, cardiac arrest • Adverse reactions – arrhythmia, angina, severe hypertension, n/v, palpitations, tachycardia, skin flushing, dizziness, tremors Eg. albuterol (adrenergic agonist, bronchodilator) • Use – bronchodilator in asthma, COPD • Action – binds to beta 2 receptors to relax bronchiolar smooth muscle • Adverse Effects – nervousness, tremor, chest pain, palpitations • NC – assess HR, BP, respiratory asmt, monitor for bronchospasm, hyperglycemia in DM, give with meals Beta Adrenergic Blockers • General Effects - block access to naturally occurring catecholamines (epinephrine, norepinephrine, dopamine) thereby reducing their effects • General Uses – hypertension, arrhythmia, angina, post MI, controlled CHF, migraine HA, tremor • Precautions – asthma, diabetes (masks s/s of hypoglycemia) – Actual hypoglycemia could be misread as therapeutic effects of β-blockers mask S/S of hypoglycemia BETA ADRENERGIC RECEPTORS Types / Action of Beta Receptors Regarding β-blockers – ‘olol’ • Some beta blockers are selective, only blocking either beta 1 or beta 2 receptors • Others are non-selective, blocking both beta 1 & beta 2 sites • Client history, medication selection & ongoing nursing asmt are extremely important in assessing & intervening in adverse effects especially with non-selective drugs
52. 52. Beta Adrenergic Blockers • Adverse Effects - bradycardia, peripheral skin mottling, hypotension, bronchoconstriction, wheezing, worsening of CHF • Interactions - Additive effect with antihypertensive effects of other classes (additive effect may be desired) Why? • Meds - metoprolol (Betaloc, Lopresor) atenolol, timolol, propanolol o Metoprolol(β-blocker, antianginal, antihypertensive)  Use – hypertension, angina, prevention of MI  Action – blocks beta 1 (cardiac) adrenergic receptors, fairly selective) →↓BP & ↓HR  Adverse Effects – fatigue, weakness, CHF, pulmonary edema, bradycardia, impotence Why do these adverse effects make sense?  NC – assess apical & BP pre/post dose, monitor for S&S of CHF ANS – Parasympathetic Agonists & Antagonists • Term “cholinergic” from neurotransmitter name acetylcholine • Cholinergic agonist medications - called cholinergics (parasympathomimetics) • Cholinergic antagonist medications - called anticholinergic agents • Parasympathomimetic means...? Cholinergic Agents • Action - enhances parasympathetic effects of Ach in PSNS → ↓ HR, ↑ GI motility & secretions, ↑ contraction strength of skeletal muscle, ↑s bladder contractions • Use – ↑ bladder muscle contraction in urinary retention • Meds – bethanechol, neostigmine, pilocarpine • It is thought that boxwood may interact with cholinergic agents.
53. 53. Anticholinergic Agents • Action - inhibits cholinergic effects of acetylcholine → ↓ in parasympathetic activity (↑HR , ↑IOP, ↓s oral & URT secretions, ↓s GIT secretions & motility) muscle, ↓s bladder contractions • Adverse Effects – constipation, urinary retention, blurred vision, insomnia, confusion, agitation, dry mouth • Meds – atropine What NIs are necessary for these adverse effects? • some herbs like aloe, senna, buckthorn and cascara sagrada may have atropine-like actions and may increase atropine's effect. • What is your nursing responsibility regarding the patient's use of herbal medications? Sedatives / Hypnotics • Many are controlled substances o Hypnotics induce sleep o Sedatives induce calm which can cause sleep (dose related) • Chronic insomnia – 20% of elders & often associated with mental illness • General Action – CNS depression • Uses – improve sleep patterns, anxiolytic (prn, not routinely), pre-op sedation Benzodiazepines • Adverse Effects - dependence, over sedation, drowsiness, lightheadedness, confusion, hypotension • NC - Assess cause of anxiety/insomnia (attempt non-med interventions first) Safety precautions for ↓ LOC & ↓BP Monitor VS What might you expect? • Monitor for dependency • Advise client not to drink alcohol – Why? • Assess for additive effects with other CNS depressants • Meds: o Lorazepam (Ativan), oxazepam (Serax), diazepam (Valium)
54. 54. o Non-benzo (miscellaneous) - eszopiclone (non-benzodiazepine) • Lorazepam – anxiolytic, S/H • Uses – (variable) anxiety, etoh withdrawal, sleep, anticonvulsant, pre-op sedation • General action – CNS depression, ↑s GABA • Adverse Effects – dependence, dizziness, ↓ LOC • NC – controlled substance, assess for falls risk (implement fall prevention protocol), CNS depression, ensure safety. • Some herbal supplements may have an additive effect when taken with lorazepam. For example, kava, valerian, chamomile and hops have a sedating effect of their own. Other drugs have a stimulating effect and may reduce the effectiveness of lorazepam. Examples include gotu kola and ma huang. Who is most at risk for the “hangover effect” & why? Eszopiclone (Lunesta)– S/H Non-benzodiazepine • Use – insomnia • Action – CNS depression (enhances GABA), rapid onset, peak 1 hr • Adverse Effects – additive with other CNS depressants, tolerance • NC – give immediately prior to bedtime, ensure safety due to rapid onset Antiparkinson Agents Parkinson’s disease: • Is a neurodegenerative disease caused by a lack of dopamine in the extrapyramidal motor system in the basal ganglia • Dopamine is inhibitory and is lacking in Parkinson's disease causing what S&S … ? • “parkinsonism” – Parkinson-like symptoms associated with medication side effects, head trauma, tumour, infections Extrapyramidal Symptoms Associated with Parkinsonism Characterized by involuntary movements: • Akinesia - ↓ in spontaneous movements
55. 55. • Dystonia – impairment in muscular tone • Tardive Dyskinesia – repetitive involuntary movements (thrusting of tongue, lip smacking, puckering, pill rolling) • Parkinsonism – resting tremors, rigidity, shuffling gait, cogwheel movements Meds Used for Parkinson’s Disease (PD) Principles of Medication Therapy in PD 1. There is no known cure 2. Pharmacologic Goals are to control symptoms & slow progression (selegiline) 3. With onset of functional impairment, dopamine agonists are added (amantadine, bromocriptine) 4. carbidopa/levodopa (Sinemet) is most effective in relieving symptoms but effectiveness is 3-5 years (dose-related) → “on-off effect” 5. entacapone maybe added to slow metabolism of levodopa, so the required dose of levodopa is smaller Carbidopa / Levodopa (Sinemet) Antiparkinson Agent • Action - carbidopa - enzyme inhibitor that reduces metabolism of levodopa → ↑ in half- life of levodopa & a 75% reduction in required dose of levodopa (which leads to longer therapeutic effect) • levodopa crosses blood/brain barrier, is metabolized to dopamine and replaces dopamine deficiency in the basal ganglia • 10/100, 25/100 – usual starting dose 25/100, 25/250 – as levodopa effect is diminished • Anticholinergics may also be used to control drooling & tremor – Explain this... • Adverse effects – nausea, vomiting, hypotension, extrapyramidal symptoms • NC: o Separate anticholinergics by 2 hours o Give on time (why?) with food o Obtain baseline asmt of PD symptoms (pill-rolling, tremors, rigidity, drooling)
56. 56. o Obtain ongoing asmt of symptoms & report to MD prn Exactly what are you assessing for? Why do you need to continually assess & report to MD? • Kava can potentially worsen the symptoms of Parkinson's disease. Anxiolytic Medications Anxiety disorders are common... • Symptoms of anxiety – tension, ↓ ability to concentrate & comprehend, tachycardia, palpitations, tremor, GI disturbance, panic attacks, OCD, (dyspnea, diaphoresis, dizziness), phobias • Benzodiazepines o Favoured because less drug interactions than barbiturates o Dependency is a risk (withdraw slowly) o Action – CNS depression (stimulate GABA) o Adverse Effects – hangover, sedation, excessive use/abuse, hepatotoxicity o NC – monitor for toxicity, dependence, safety o Meds – lorazepam (Ativan), diazepam (Valium), oxazepam (Serax), hydroxizine (Atarax) • Sedating herbs such as kava and chamomile may increase the effect of benzodiazepines. They should be taken with caution. Antidepressant Medications • For mood disorders (abnormal depression & euphoria) • Mood disorders are either unipolar (depression) or bipolar (manic depression) • Depression is the second leading cause of disability (next to ischemic heart disease) • Etiology – nt dysfunction (norepinephrine, serotonin, GABA, dopamine, ACh), ↑ cortisol, situational stressors, genetics • Choice is based on therapeutic effect & tolerance of adverse effects • Therapeutic response takes 2 – 4 weeks • Therapy enhances response significantly
57. 57. What are the nursing assessments for a client with a mood disorder? What finding are you legally & ethically obliged to report? Define “affect”... Subclasses of Antidepressants 1. MAO inhibitors – inhibits destruction of many nt (selegiline), ++++ drug interactions 2. Tricyclics – block reuptake of nt in synaptic cleft (amitriptyline, imipramine 3. Selective serotonin reuptake inhibitors - As effective as tricyclics without anticholinergic & cardiac adverse effects • Tricyclic antidepressants may interact with herbs such as evening primrose and ginko (they may lower the pts seizure threshold). When using tricyclic antidepressants with St. John's wort, the health care professional must remain alert to signs of serotonin syndrome. • What is serotonin syndrome? • MAOIs interact with a number of herbal preparations. Ginseng, when taken with Nardil for example, can cause visual hallucinations, irritability, insomnia, mania, tremors and headache. When taken with ephedra, St. John's wort, or ma huang, hypertensive crisis could occur. • What is hypertensive crisis? Citalopram (Celexa) - SSRI • Action – inhibits reuptake of serotonin in synaptic cleft → prolonged effect • Adverse effects – restlessness, agitation, insomnia, anxiety, GI disturbance, suicidal thoughts, sexual dysfunction • NC – monitor affect, suicidal thoughts • Other SSRIs – fluoxetine (Prozac), sertraline (Zoloft) • Taking SSRIs in conjunction with St. John's wort or L-tryptophan may also put the patient at risk of serotonin syndrome. Kava may increase the effect of the SSRI Antipsychotic Medications • Psychosis – a thought disorder with loss of reality, hallucinations, delusions, often severe functional impairment (disability & handicap) What was the major neurochemical cause of psychosis? • First generation phenothiazines: (chlorpromazine, perphenazine)
58. 58. • Second generation phenothiazines have fewer side effects (quetiapine, loxapine, olanzapine, risperidone) • Taking chlorpromazine along with herbs such as kava or St. John's wort can increase the risk of experiencing dystonia. Kava has also been known to increase the effect of haloperidol. Kava can also increase the risk of CNS depression when taken with clozapine. 2nd Generation Anti-psychotics Loxapine, Quetiapine • Adverse effects: o Seizures, parkinsonism, tardive dyskinesia Adverse effects can be very serious and requires knowledge and excellent asmt skills What accounts for the adverse effect of ‘parkinsonism’ associated with these medications? • Drug Interactions: o Meds that ↓ therapeutic effects: dopamine agonists (carbidopa/levodopa, bromocriptine, amantadine) Why? o Others: beta blockers What adverse effect may be exacerbated? Quetiapine (Seroquel) – 2nd generation phenothiazine • Uses – treatment of psychosis associated with schizophrenia, psychotic depression, agitation in dementia • Action – blocks dopamine and/or serotonin • Adverse Effects – extrapyramidal effects, fatigue, drowsiness, OH, anticholinergic s/s (dry mouth, blurred vision, constipation, urinary retention) • NC – monitor for extrapyramidal effects (dystonia, tardive dyskinesia, Parkinsonism), OH, anticholinergic effects Such as…? Describe the above signs... Cholinesterase Inhibitors • Use – myasthenia gravis, mild-moderate dementia • Action – inhibits destruction of cholinesterase → prolonged action of Ach → improved memory and motor function
59. 59. • Adverse Effects – excessive cholinergic/parasympathetic effects (hypersecretion, bradycardia, nausea, diarrhea, abdominal pain) • Meds – donepezil (Aricept), rivastigmine (Exelon) Anticonvulsant Medications Seizures • Brief periods of abnormal electrical activity in the brain • May be convulsive or non-convulsive with many subtypes • Associated with altered LOC, sensory & motor effects • Causes – epilepsy, head injury (traumatic, infectious, chemical), hypoglycemia • Ongoing medication use when underlying cause cannot be identified and/or resolved • May require trial of different meds until a therapeutic effect is seen • Goal is to reduce frequency of seizures • Med classes used – benzodiazepines (diazepam, clonazepam), hydantoins (phenytoin - Dilantin), miscellaneous (carbamazepine) o carbamazepine (Tegretol) o Uses – prevention of some types of seizures (also used as an analgesic & anti- manic) o Action – chiefly unknown, affects Na+ channels o Adverse effects – N&V, drowsiness, dizziness, REPORT – OH, hypertension, dyspnea, edema (in HF), nephrotoxicity, hepatotoxicity, pruritic rash, bone marrow depression … Causing what? o NC:  HOLD med & contact MD for reportable adverse effects  Implement seizure precautions  Monitor CBC  Assess/document seizure activity  Safety related to hypotension, dizziness, other adverse effects
60. 60. • When a client is taking Dilantin, they must use great caution when using herbs that may increase potassium loss. Such herbs include herbal laxatives (buckthorn, cascara sagrada, and senna). PART 2 Medications Used in the Management of Pain Analgesics • opiate agonists • NSAIDs • salicylates • miscellaneous Pain & Its Management All of the following are subjective & variable: • Pain perception – awareness of the sensation • Pain threshold – point at which the pain is perceived as “pain” • Pain tolerance – ability to endure pain Analgesics – relieve pain without loss of consciousness or reflexes Acute Pain – a symptom Acute pain... • Short term due to sudden injury • Is a warning of tissue injury • Is purposeful • Activates the sympathetic nervous system • Pain ↓s with healing Chronic Pain – a disease • Gradual onset lasting > 3 months • Not related to an injury
61. 61. • Is NOT PURPOSEFUL • Divided into malignant (cancer) & non-malignant • Can arise from organs, muscular/connective tissues (nociceptive pain) or nervous tissue (neuropathic pain) • When uncontrolled, affects every aspect of life • Can have very serious harmful affects • Is now viewed as a disease (whereas acute pain is viewed as a symptom) Properties of a ‘good analgesic’ • Maximum pain relief • Will not cause dependence • Minimal adverse effects (constipation, hallucinations, respiratory depression, N&V) • Rapid onset & long duration of action • Minimal sedation • Inexpensive Mechanisms of Pain • Injury to tissues → release of prostaglandins, bradykinins, leukotrienes, histamine, substance P which stimulate nociceptors → pain impulse transmission to spinal cord and up to brain • opiate receptors – receptors that block pain when stimulated by opioids (naturally occurring or in med form) Pain Med Classes 3 Mechanisms of Action Analgesic action works either by interfering with nociceptor stimulation, impulse transmission or reception of the impulse in the brain: 1. ↓s release of prostaglandins etc 2. Interferes with impulse at spinal cord level 3. Binds to opiate receptors in the brain
62. 62. Opioids & the Ceiling Effect Ceiling effect – point at which a larger dose does not produce a better analgesic effect but does cause more adverse effects How is this different than tolerance? Opiate Agonists • Use – moderate to severe pain (acute, chronic, cancer) • Action– relieve severe pain without LOC o Stimulate opiate receptors in brain o Longer term use can cause dependence & tolerance • Interactions – additive effect with other CNS depressants • Adverse effects – respiratory depression, urinary retention, excessive use/abuse, dizziness, sedation, N&V, diaphoresis, confusion, OH, constipation • confusion is a sign of opiod toxicity. • Meds – morphine, codeine, hydromorphone, fentanyl, meperidine, methodone, oxycodone • Naloxone (Narcan) - Opioid antagonist What is the indication? Morphine (M-Eslon, MS Contin) – opioid analgesic • Use – moderate to severe pain • Action – binds to opiate receptors to ↓ pain perception • Adverse Effects – CNS depression (→ respiratory depression, hypotension, ↓ RR & depth, ↓ LOC/sedation/confusion, hypotension, constipation, diaphoresis), tolerance, dependence • NC: o Pre/post dose PQRST o Monitor VS & compare with baseline values, hold for shallow respirations < 12/min (or facility policy) o Hold in undiagnosed abd pain o Ensure safety
63. 63. o Assess/intervene for constipation o Assess for dependence (? methadone) • Certain herbs may potentiate the effect of morphine. One of these is yohimbe. Also use extreme caution when combining herbs that cause CNS depression with morphine as the risk of respiratory depression increases. Salicylates (Aspirin - ASA) • Uses: o Relief of mild - mod pain but no longer the med of choice for analgesia – Why? o Antipyretic, antiinflammatory for RA/OA, analgesic without sedation • Actions: o inhibits prostaglandin synthesis → ↓ pain, ↓ inflammation & ↓ fever o inhibits platelet aggregation (↓s risk of TIA & CVA, MI in those with unstable angina) • Adverse effects – GI bleeding, GI irritation • Interactions – ↑ risk of bleeding with concurrent use of NSAIDs, warfarin, heparin • NC – PQRST, T, pain, s/s of CVA/TIA according to specific indication, s/s of GI or other bleeding (oral etc), s/s of toxicity (tinnitus, confusion, N & V), no antacids within 2 hrs of EC tabs, give with food • Feverfew is an herb known to have an action similar to ASA. When taken together, the risk of bleeding may increase. Avoid other herbs that may also increase bleeding when on ASA therapy. Non Steroidal Anti-Inflammatories (NSAIDs) • Uses- analgesic, antiinflammatory, antipyretic o Not as effective as salicylates but less risk of GI bleeding o For pain & inflammation associated with RA, OA, spondylitis, gout and pain of other nociceptive origins, fever • Action – inhibits prostaglandin synthesis • Adverse effects – GI bleeding/irritation, constipation, nephrotoxicity, hepatotoxicity • Interactions – ↑ risk of bleeding with concurrent use of other NSAIDs, aspirin, warfarin, heparin
64. 64. • Meds – ibuprofen, diclofenac, naproxen • Because NSAIDs increase the risk of bleeding, herbs that may have a similar action should be avoided. Some of these include cat's claw, dong guai, evening primrose, feverfew, ginko biloba and red clover. There are many other herbs that may have a similar effect. Ensure that you do research. Non-Opioid Analgesic - acetaminophen • Use – mild to moderate pain, fever (has become drug of choice for antipyretic & analgesic as adverse effects are minimal) • Action - is unknown • Adverse effects – GI irritation, OD, hepatotoxicity (anorexia, N&V, jaundice, hepatomegaly, altered LFTs) • Trade names – Tempra, Tylenol Pharmacology & the Older Adult THIS INFORMATION IS RELEVANT FOR ALL THE FOLLOWING UNITS!!!! ‘Start low, go slow’ Important Concepts • Define "Polypharmacy" • Explain "Start low & go slow" Pharmacokinetics & the Elder In what ways are the following affected by aging? • Drug absorption • Drug distribution • Drug metabolism • Drug excretion Factors Influencing Absorption • Feeling unwell, ↓ appetite
65. 65. • Dysphagia • Dentition • Delayed gastric emptying • More alkaline gastric pH • Slowed GI transit time • Constipation & diarrhea • Nausea & vomiting • ↓ circulation Absorption in the Elder • Dysphagia o Elders often have ↓ saliva production o Some tablets/capsules are very large o Many drugs cannot be crushed (ER, EC, SR) o Phone pharmacy or follow agency protocol o Crush and mix in applesauce o Give liquid form if available o Obtain order for alternate route • Dentition o May be incomplete or uncomfortable – How will you assess? • Delayed gastric emptying o Can lead to more absorption than same dose in a younger adult o NSAIDs & salicylates (ulcergenic drugs) may be more harmful to stomach lining – Why? • More Alkaline Gastric pH o ↑ absorption of meds destroyed by acid → higher serum levels than younger adult and possible toxicity (antibiotics) o ↓ absorption of meds that need acid for absorption → lower therapeutic effect than usual adult (acetaminophen, aspirin) o Carefully monitor TACT & report prn
66. 66. • Miscellaneous GIT Factors o Slowed transit time, ↓ intestinal circulation, constipation, diarrhea, vomiting o Think about the effects each of these have on absorption... • For IM Administration o Muscle atrophy & ↓ perfusion (from aging but also inactivity) slows absorption • For Transdermal Administration o Skin is thinner (↑ing absorption) but skin is drier and perfusion to the skin is impaired (↓ing absorption) Factors Influencing Drug Distribution in the Elder Factors affecting distribution: • Body water distribution • CO • Regional blood flow • pH • ↓ albumin level in blood oft Percentage of body water • Elders have a lower body water concentration so med is more concentrated in their blood Lower albumin levels • from liver/kidney disease and/or poor nutritional status → ↓ protein binding & more unbound drug available for receptor binding → more rapid onset of action & shorter duration Drug Metabolism • Occurs mainly in the __________________________________________ • ↓ function in this organ → ____________ (↑ or ↓) rate of drug metabolism which can cause ________________________________________ leading to _________________________ • Explain “START LOW, GO SLOW” • Explain why the nurse must monitor liver function tests & report results to the MD
67. 67. Drug Excretion • Metabolites of drugs are mainly excreted by the __________________________ & ________________________ tracts • Antibiotics are given on a relatively frequent schedule (Q 6-8 H) because they are excreted rapidly by the kidneys – what is the significance of giving antibiotics late? • Monitor kidney function – BUN, urine creatinine, GFR (glomerular filtration rate) • Serum drug levels o Can indicate problems in absorption, distribution, metabolism & excretion o Can be used to assess cumulation & toxicity o Some medications are potent and require monitoring – digoxin, T4, antibiotic levels o Also useful for making dose or schedule adjustments Risks for the Elder • Cumulation & toxicity from ? _______________________ & ___________________________ function • The ‘hang over effect’ • Drug interactions caused by concurrent use of many medications _______________________________ • Altered pharmacokinetics from chronic illnesses • Under treatment due to fear of polypharmacy Nursing Considerations • Assess drug Hx including herbal products, nutritional supplements, laxatives, antacids • Nutrition Hx which would include current & baseline __________________________? • Oral assessment • New symptom - Medication related? – how will you assess this? • Start low & go slow monitoring TACT • Teach use of calendars, daily containers • Review need for meds – call MD prn
68. 68. • If using a med that is cautioned for the elderly, there should be documentation supporting its use for a specific client • Use facility protocols for med administration with dysphagia, get order for alternate route if available • Monitor for adverse effects – including toxicity, altered LOC & potential for lack of safety TOPIC 10: Nervous System Part 2 Pain and Substances of Addiction Learning Objectives: ·Describe major classes of drugs used to treat diseases/illnesses of the nervous system (sedative/hypnotics, pain management, and substances of addiction). · Describe the main nursing considerations related to this group of drugs. · Explain drug interactions, polypharmacy, and food/drug effects to medication used across the lifespan, particularly the older adult. · Identify pharmaceuticals that support end-of-life care. · Explain the potential interaction of complementary, Indigenous and herbal preparations with nervous system medications. Organize research of drugs used to treat diseases/illnesses of the nervous system in a way that allows for easy and accurate reference. Medications Used to Treat Disorders in the Nervous System Nervous System Classifications (This content is relevant for both part 1 and 2). • Adrenergic Agents (agonists) • Adrenergic / Beta Blockers (adrenergic antagonists) • Cholinergic Agents (agonists) • Anticholinergic Agents (cholinergic antagonists) • Sedatives / Hypnotics (benzodiazepines, other) • Anti-Parkinson Agents (dopamine agonists) • Anxiolytics • Antidepressants
69. 69. • Antipsychotics • Anticonvulsants • Analgesics (opioid, non-opioid, salicylates, NSAIDs) Nervous System A & P – the Directors & Actors Central Nervous System (CNS) “directors” • Brain & Spinal Cord Peripheral Nervous System (PNS) “actors” • Spinal/Peripheral nerves 1. Somatic System 2. Autonomic system • Cranial nerves Neurotransmitters (nt) • Are chemicals that are released by one neuron, diffuse across the synaptic cleft, and are taken up by receptor sites on the next neuron • Thereby, passing on the action potential • Each neuron releases only one kind of nt • Neurotransmitters either stimulate or inhibit a function of a neuron ANS – Sympathetic Agonists & Antagonists • Term “adrenergic” comes from nt name adrenalin (aka epinephrine) • Adrenergic agonist medications are called adrenergic agents (sympathomimetics) • Adrenergic antagonist medications are called adrenergic blocking agents • What does sympathomimetic mean? Adrenergic Agents • Catecholamine drugs that stimulate adrenergic receptors (alpha, beta, dopaminergic) • Meds – albuterol (Salbutamol, Ventolin), dopamine, epinephrine • Mechanism of action by Receptor Type:
70. 70. o In blood vessels - vasoconstriction (alpha) o In heart - ↑ HR (beta 1) o In lungs - bronchodilation (beta 2) o Other - ↓s Parkinson’s symptoms & ↑ renal perfusion & urine output (dopamine) What drug class will antagonize the effects of the adrenergic agonists? • General Uses – asthma, bronchospasm, hypotension, shock, decongestant, digitalis toxicity, COPD, cardiac arrest • Adverse reactions – arrhythmia, angina, severe hypertension, n/v, palpitations, tachycardia, skin flushing, dizziness, tremors Eg. albuterol (adrenergic agonist, bronchodilator) • Use – bronchodilator in asthma, COPD • Action – binds to beta 2 receptors to relax bronchiolar smooth muscle • Adverse Effects – nervousness, tremor, chest pain, palpitations • NC – assess HR, BP, respiratory asmt, monitor for bronchospasm, hyperglycemia in DM, give with meals Beta Adrenergic Blockers • General Effects - block access to naturally occurring catecholamines (epinephrine, norepinephrine, dopamine) thereby reducing their effects • General Uses – hypertension, arrhythmia, angina, post MI, controlled CHF, migraine HA, tremor • Precautions – asthma, diabetes (masks s/s of hypoglycemia) – Actual hypoglycemia could be misread as therapeutic effects of β-blockers mask S/S of hypoglycemia BETA ADRENERGIC RECEPTORS Types / Action of Beta Receptors Regarding β-blockers – ‘olol’ • Some beta blockers are selective, only blocking either beta 1 or beta 2 receptors • Others are non-selective, blocking both beta 1 & beta 2 sites
71. 71. • Client history, medication selection & ongoing nursing asmt are extremely important in assessing & intervening in adverse effects especially with non-selective drugs Beta Adrenergic Blockers • Adverse Effects - bradycardia, peripheral skin mottling, hypotension, bronchoconstriction, wheezing, worsening of CHF • Interactions - Additive effect with antihypertensive effects of other classes (additive effect may be desired) Why? • Meds - metoprolol (Betaloc, Lopresor) atenolol, timolol, propanolol o Metoprolol(β-blocker, antianginal, antihypertensive)  Use – hypertension, angina, prevention of MI  Action – blocks beta 1 (cardiac) adrenergic receptors, fairly selective) →↓BP & ↓HR  Adverse Effects – fatigue, weakness, CHF, pulmonary edema, bradycardia, impotence Why do these adverse effects make sense?  NC – assess apical & BP pre/post dose, monitor for S&S of CHF ANS – Parasympathetic Agonists & Antagonists • Term “cholinergic” from neurotransmitter name acetylcholine • Cholinergic agonist medications - called cholinergics (parasympathomimetics) • Cholinergic antagonist medications - called anticholinergic agents • Parasympathomimetic means...? Cholinergic Agents • Action - enhances parasympathetic effects of Ach in PSNS → ↓ HR, ↑ GI motility & secretions, ↑ contraction strength of skeletal muscle, ↑s bladder contractions • Use – ↑ bladder muscle contraction in urinary retention • Meds – bethanechol, neostigmine, pilocarpine • It is thought that boxwood may interact with cholinergic agents.
72. 72. Anticholinergic Agents • Action - inhibits cholinergic effects of acetylcholine → ↓ in parasympathetic activity (↑HR , ↑IOP, ↓s oral & URT secretions, ↓s GIT secretions & motility) muscle, ↑s bladder contractions • Adverse Effects – constipation, urinary retention, blurred vision, insomnia, confusion, agitation, dry mouth • Meds – atropine What NIs are necessary for these adverse effects? • some herbs like aloe, senna, buckthorn and cascara sagrada may have atropine-like actions and may increase atropine's effect. • What is your nursing responsibility regarding the patient's use of herbal medications? Sedatives / Hypnotics • Many are controlled substances o Hypnotics induce sleep o Sedatives induce calm which can cause sleep (dose related) • Chronic insomnia – 20% of elders & often associated with mental illness • General Action – CNS depression • Uses – improve sleep patterns, anxiolytic (prn, not routinely), pre-op sedation Benzodiazepines • Adverse Effects - dependence, over sedation, drowsiness, lightheadedness, confusion, hypotension • NC - Assess cause of anxiety/insomnia (attempt non-med interventions first) Safety precautions for ↓ LOC & ↓BP Monitor VS What might you expect? • Monitor for dependency • Advise client not to drink alcohol – Why? • Assess for additive effects with other CNS depressants • Meds: o Lorazepam (Ativan), oxazepam (Serax), diazepam (Valium)
73. 73. o Non-benzo (miscellaneous) - eszopiclone (non-benzodiazepine) • Lorazepam – anxiolytic, S/H • Uses – (variable) anxiety, etoh withdrawal, sleep, anticonvulsant, pre-op sedation • General action – CNS depression, ↑s GABA • Adverse Effects – dependence, dizziness, ↓ LOC • NC – controlled substance, assess for falls risk (implement fall prevention protocol), CNS depression, ensure safety. • Some herbal supplements may have an additive effect when taken with lorazepam. For example, kava, valerian, chamomile and hops have a sedating effect of their own. Other drugs have a stimulating effect and may reduce the effectiveness of lorazepam. Examples include gotu kola and ma huang. Who is most at risk for the “hangover effect” & why? Eszopiclone (Lunesta)– S/H Non-benzodiazepine • Use – insomnia • Action – CNS depression (enhances GABA), rapid onset, peak 1 hr • Adverse Effects – additive with other CNS depressants, tolerance • NC – give immediately prior to bedtime, ensure safety due to rapid onset Antiparkinson Agents Parkinson’s disease: • Is a neurodegenerative disease caused by a lack of dopamine in the extrapyramidal motor system in the basal ganglia • Dopamine is inhibitory and is lacking in Parkinson's disease causing what S&S … ? • “parkinsonism” – Parkinson-like symptoms associated with medication side effects, head trauma, tumour, infections Extrapyramidal Symptoms Associated with Parkinsonism Characterized by involuntary movements: • Akinesia - ↓ in spontaneous movements • Dystonia – impairment in muscular tone
74. 74. • Tardive Dyskinesia – repetitive involuntary movements (thrusting of tongue, lip smacking, puckering, pill rolling) • Parkinsonism – resting tremors, rigidity, shuffling gait, cogwheel movements Meds Used for Parkinson’s Disease (PD) Principles of Medication Therapy in PD 1. There is no known cure 2. Pharmacologic Goals are to control symptoms & slow progression (selegiline) 3. With onset of functional impairment, dopamine agonists are added (amantadine, bromocriptine) 4. carbidopa/levodopa (Sinemet) is most effective in relieving symptoms but effectiveness is 3-5 years (dose-related) → “on-off effect” 5. entacapone maybe added to slow metabolism of levodopa, so the required dose of levodopa is smaller Carbidopa / Levodopa (Sinemet) Antiparkinson Agent • Action - carbidopa - enzyme inhibitor that reduces metabolism of levodopa → ↑ in half- life of levodopa & a 75% reduction in required dose of levodopa (which leads to longer therapeutic effect) • levodopa crosses blood/brain barrier, is metabolized to dopamine and replaces dopamine deficiency in the basal ganglia • 10/100, 25/100 – usual starting dose 25/100, 25/250 – as levodopa effect is diminished • Anticholinergics may also be used to control drooling & tremor – Explain this... • Adverse effects – nausea, vomiting, hypotension, extrapyramidal symptoms • NC: o Separate anticholinergics by 2 hours o Give on time (why?) with food o Obtain baseline asmt of PD symptoms (pill-rolling, tremors, rigidity, drooling) o Obtain ongoing asmt of symptoms & report to MD prn Exactly what are you assessing for? Why do you need to continually assess & report to MD?

Which medication action would the nurse identify as the purpose of azathioprine?

When would the nurse have the laboratory obtain a blood sample to determine the peak level?

When teaching a client about digoxin which symptom will the nurse include as a reason to withold the digoxin?

Which nursing action is important when a health care provider prescribes enalapril for a client?