Pharm

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maxnimus
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201231
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Pharm
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2013-02-17 20:24:53
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Pharm
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Pharm
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  1. ◦Telephone (TO or PO) & Verbal Orders (VO)
    • RN must do Read back–
    • Mustbe cosigned by the licensed health care provider that gave order w/in 24 hrs
  2. How do Narcotic order differ from others?
    Cannot be refilled automatically. Must have new prescription if extended.
  3. Most important pharm fact when taking a medical history
    Allergies
  4. Traditional 5 rights:
    1.Right client

    2.Right drug

    3.Right dose

    4.Right time

    5.Right route
  5. Additional 5 Rights:
    Additional 5 “Rights”

    1.Right assessment

    2.Right documentation

    • 3.Client’s right to
    • education

    4.Right evaluation

    • 5.Client’s right to
    • refuse
  6. Requirements when giving meds:
    • 1) Wash Hands
    • 2) Double check allergies
    • 3) 2 pt ID ( check arm band)
    • 4) Assess Pt
    • 5) Check order
    • 6) Check Label 3 times
    • 7) Check Expiration Date
    • 8) Make sure pt takes med
  7. Behaviors to avoid when administering meds:
    —Do not be distracted, “safe/quiet zones”

    —Do not give drugs poured by others

    —Do not transfer drugs to another container

    —Do not give poorly labeled drugs

    —Do not leave drug with patient

    —Do not call name to identify patient

    —Do not give drug if allergic
  8. —U or IU – write instead:
    units or international units
  9. —QD or QOD – Write
    Every day/daily or every other day
  10. —MSO4 & MS – write:

    —MgSO4 – write:
    morphinesulfate

    magnesiumsulfate
  11. —Estimated that how many  of
    administered doses involve some type of error
    19%

    of that  more than 40% is due to administration errors
  12. Errors of Omission
    —Errors of Omission

    ◦Not prescribed

    ◦Not dispensed

    ◦Not administered

    ◦Not taken
  13. Errors of Commission
    —Errors of Commission

    ◦Wrong drug

    ◦Wrong dose

    ◦Wrong drug substitute

    ◦Wrong patient

    ◦Wrong route

    ◦Allergic reaction

    • ◦Drug-food-therapy
    • interaction

    ◦Communication failures

    • ◦Failure to follow
    • policy

    • ◦Failure to follow
    • drug specific instructions

    • ◦Drug overuse without
    • therapeutic benefit
  14. Call HCP and dont dispense if:
    • Order incomplete
    • Pt having adverse Rx
    • Dosage seems incorrect
  15. Stock Drugs
    —Advantages

    ◦Always available

    ◦Cost efficiency

    —Disadvantages

    ◦More errors

    ◦–Poured by many

    ◦Drug expiration may be missed
  16. Unit Doses
    —Advantages

    ◦Fewer errors

    ◦Saves time

    ◦Correct dose without calculation

    ◦Billed for specific # doses

    —Disadvantages

    ◦Time delay to get drug

    ◦Not readily replaceable if damaged
  17. Pharmaceutics
    The art and science of preparing and dispensing drgs and medicines
  18. Pharmacokinetic
    Quantitative study of how drugs are taken up, bilogically transformed, distributed, metabolized, and eliminated from thebody
  19. Pharmacodynamics
    Quantitative study of drug action

    • —Primary: Desired physiologic effect
    • Ex: Benedryl and decreased histamine response


    • —Secondary: Physiologic effect that may be desirable or undesirable.
    • Ex: Benedryl and Drowsiness
  20. Factors effecting drug absorption
    Route of administration

    Blood flow & supply

    Pain & Stress

    GI motility

    Exercise

    Food or other drugs

    pH
  21. Bioavailability
    Is the amount of the drug that reaches systemic circulation and also known as the fraction absorbed
  22. First Pass Effect
    The process where liver enzymes inactivate a fraction of the ingested drug; anydrug that exhibits signficiant first-passmetabolism must be administered in a quantity sufficient to ensure that an effective concentration ofactive drug exits the liver into the systemic circulation, from which it can reach the target organ
  23. PO Drugs First Pass Effect
    Always less than 100%
  24. IV Drugs first Pass
    100%
  25. Distribution of Drugs
    Process by which drug becomes available to body fluids & tissues. Influenced by blood flow, the drug’s affinity to the tissue, and the protein-binding effect.
  26. Protein Bound Drugs
    Bound drug portion is inactive. Beware of toxicity esp if two PB drugs are given together.
  27. Free (Unbound Drugs)
    Active Drugs. Hypoalbuminemia (lack of protein) can lead to drug toxicity.
  28. Factors effecting drug distribution
    Protein binding

    Plasma protein & albumin levels

    Abscesses, exudates, glands, & tumors decrease distribution

    Drugs that accumulate in fat, bone, liver, muscle, & eye tissue negatively effect drug distribution.
  29. Factors effective 1/2 life
    • Metabolism
    • Elimination
    • Kidney Liver D/O
  30. Elimination
    Done by kidneys.

    Protein bound drugs can not be excreted via the kidneys
  31. Creatinine Clearence
    ◦Most accurate renal function test

    • ◦Creatinine is the metabolic
    • byproduct of muscle tissue that is excreted by kidneys

    ◦Less muscle mass = lower values (women & elderly)

    ◦Normal is 85 to 135 ml/min
  32. Dose Response
    Relation between minimum vs max dose needed for desired effect.

    Plasma or serum level too low may lead to inadequate dose. Too High: Toxicity.
  33. Therapeutic Index
    Therapeuti index estimates the margin of safety of a drug through the use of a ratio that meassures the effective (therapeutic or concentration) dose (ED) in 50% of persons or animals  and the lethal dose in 50% animals
  34. What does a Low Therapeutic Index imply?
    Narrow Margin of Safety. Dose typically monitored via blood tests.
  35. Trough
    Lowest plasma drug concentration

    Shows rate of excretion.

    Typically blood work done just prior to next dose
  36. Peak
    Time of highest plasma drug concentration & shows rate of absorption
  37. Loading Dose
    Large initial dose. Helps saturate biologic system earlier.
  38. Side effects vs. Adverse Reactions
    Side effects can be desirable.

    Adverse reactions are never. They tend to be more severe.
  39. Kinase-linked receptor
    Ligand binding domain on cell surface. Drug activates enzyme inside cell.
  40. Ligand-gated ion channels
    Drug spans cell membrane, ion channels (Na and Ca) open initiating effect.
  41. G protein coupled receptor systems
    Drug activates receptor which activates G-protein which activates effect
  42. Nuclear receptors
    Achieved by entering nucleus of cell by means of a transcription (reading and coding)process.  Activation is prolonged.
  43. Class I in 1970's controlled substances act
    High abuse potential

    No medical use (heroin)
  44. Class II of 1970s Controlled Substances Act
    • High abuse potential
    • Accepted medical use (morphine)
  45. Class III 1970s Controlled Substances Act
    • Medically accepted
    • Less potential abuse
    • Possible dependence (codeine)
  46. Class IV 1970s Controlled Substances Act
    • Medically accepted
    • Possible dependence (phenobarbital)
  47. Class V of 1970s Controlled Substance Act
    • Medically accepted;
    • Limited potential dependence
    • (opioids for diarrhea & cough)
  48. Misfeasance:
    Negligence (wrong drug/dose) results in death
  49. Nonfeasance
    Error of omission results in death
  50. Malfeasance
    Correct drug by wrong route causes death
  51. Class A of FDA Pregnancy Categories
    Studies show no fetal risk
  52. Class B of FDA Pregnancy Categories
    • No fetal risk in animal studies; no risk
    • assumed in humans.
  53. Class C of FDA Pregnancy Categories
    • Fetal risk in animal studies; weigh risk
    • vs. benefit.
  54. Class D of FDA Pregnancy Categories
    D.  Established/Proven fetal risk; weigh risk vs. benefit if life-threatening
  55. Class X of FDA Pregancy Categories
    Established/Proven fetal risk; risk more tahn benefit; avoid in pregnancy
  56. —Phase I of Human Testing
    Determines human drug dosage in healthy subjects
  57. Phase II of Human Testing
    Demonstrate drug safety & efficacy subjects with disease
  58. Phase III & IV of Human testing
    Demonstrate drug safety & efficacy in wide client population & collect long term data
  59. Additive Effect
    • 1+1= 2
    • Beneficial/ Or Non

    • ◦Hydralazine + Nitroglycerin=
    • > Hypotension (requires caution and patient knowledge)

    ◦Beta blocker + diuretic = < BP (desired)
  60. Synergism (Potentiation)
    —Two drugs with different mechanisms of action that produce greater effects together

    —i.e., 1+1=3

    —Examples:

    • ◦Codeine + ASA = >
    • pain relief

    • ◦Ampicillin + Sulbactam =>therapeutic
    • effect
  61. Drug Interference
    —One drug increases or decreases the metabolism or excretion of another
  62. Displacement
    Two Drugs compete for binding sites

    Ex: antinflammatory and anticoagulants
  63. Antagonism
    • —Effects of two drugs that cancel each other
    • 1+1=0
  64. Narcan
    • ◦Naloxone (Narcan) prevents opiates
    • from binding to CNS receptor sites (caution not to push the Narcan all at once)
  65. Incompatability
    • —Interaction of 2 drugs interferes w/action of at least 1 drug
    • Ex: Mixing drugs in IV can cause crystalization
  66. Drug Food Interaction
    • —Food slows most drug absorption, but not
    • drug actions EXCEPT:

    • ◦Tyramine foods (beer, wine,
    • cheese, pickled herring, yogurt, liver and yeast extract) + MAO inhibitors =
    • severe HTN

    • ◦Vit K foods (green leafy
    • veggies, broccoli, bananas, fish) + warfarin (Coumadin) = < anticoagulation

    • ◦Dairy
    • products impair absorption of tetracycline

    • ◦Grapefruit
    • juice + calcium channel blockers = < BP & possible toxicity
  67. Drug Lab Interactions
    —Abnormal plasma or serum electrolytes can affect certain drug therapies

    Ex: Hypokalemia & Lasix
  68. EPS (Extrapyamidal Syndrome)
    • Psuedoparkinsonism (5-30 days After)
    • Acute Dystonia (May be within days)
    • Akathisia (May be early)
    • Tardive Dyskinesia (Usually after a year)
  69. Pseudoparkinsonism
    • Stooped Posture
    • Shuffling Gait
    • Rigidity
    • Bradykinesia
    • Termors At Rest
    • Rolling Motion of Hand
  70. Tardive Dyskinesia
    • Protrusion & Rolling of Tongue
    • Sucking and smacking movements of lips
    • Chewing Motion
    • Facial Dyskinesia
    • Involuntary Movements of Body and Extremities
  71. Akathisia
    • Restless
    • Trouble standing still
    • Paces the floor
    • Feet in constant motion
  72. Acute Dystonia
    • Facial grimacing
    • Involuntary upward eye movement
    • Muscle spasms of the tongue, face, neck, and back.
    • Laryngeal Spasms
  73. Sympathetic Response
    • Dilates Pupils
    • Dilates Bronchioles
    • Increases HR
    • Constricts Blood Vessels
    • Relaxes Smooth Muscle of GI
    • Relaxes Bladder
    • Relaxes Uterus
  74. Parasympathethic Response
    • Constricts Pupils
    • Constricts Bronchioles and Increases Secretions
    • Dilates Blood Vessels
    • Increases Peristalsis
    • Constricts Bladder
    • Increases Salivation
  75. Adverse Rx in Antipsychotics
    • Sudden Death
    • Prolonged QT time (time between contractions)
    • Diabetes, Hyperglycemia, Dyslipidemia, Hypertension
    • Neuroleptic Malignant Syndrome
  76. Neuroleptic Malignant Syndrome (NMS)
    Immediately withdraw anti-psychotics

    • Sudden high fever
    • BP Fluctuations
    • Muscle Rigidity
    • Altered Mental Status
    • Tachycardia
    • Dysrhythmias
    • Seizures
    • Rhab
  77. Client education on antipsychotics
    • Compliance issues
    • 6 weeks for full effect
    • No Alcohol or smoking
    • Lab work needed
    • Possible Photosensitivity
    • Eye Exams necessary
    • Orthostatic Hypotension possible.
  78. Antipsychotic Interventions
    • V/S
    • Compliance
    • Give w/ Food
    • Deep IM by Z Track
    • Monitor for EPS, NMS
    • Check Urine Output
    • Serum glucose
  79. Lorazepam/ Ativan
    • GABA effects
    • Decrease Anxiety
    • High PB
    • T 1/2= 10-20hrs
    • Excreted in urine

    Can cause Drowsiness, confusion restlessness, hallucinations

    Adverse: either hypo/hyper tension

    Do not D/C Abruptly: withdrawls
  80. MAOIs can form a hypertensive crisis with:
    • Tricyclics
    • Tyramine Foods
  81. Fluoxetine (Prozac)
    • SSRI
    • Do not block dopamine or NE, Cholinergic and Alpha 1 receptors
    • Used for Depression, Anxiety and Migraines.

    Common side effect: Insomnia/ Nervousness, Sexual Dysfunction

    Drug interference with St. Johns wart
  82. TCAs vs SSRIs vs MAOIS
    MAOI given when unresponsive to others

    SSRI more expensive, less side effects, more used

    TCAs block NE and Serotonin removal compared to SSRI which only block Serotonin

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