Clinical Management

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Clinical Management
2013-05-26 11:06:02
Clinical Management

Clinical Management
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  1. Discuss pharmacotherapeutics and the cost of drugs
    The cost of drugs is one of the most expensive aspects of medical care for patients. Even those with insurance drug coverage or Medicare D may have considerable costs, especially with non generic drugs. There is much pressure from drug representatives to prescribe new drugs, and patients are often influenced by direct-to-to consumer advertising, but the FNP must ensure that drugs are prescribed on evidence. Additionally, the cost versus benefit of drugs must always be considered. It is the responsibility of the FNP to act in the best interests of the patient and to educate the patient about drugs. The FNP should evaluate the costs of drugs when determining which drug to prescribe, if a less expensive drug is as effective as a more expensive or newer drug then the less expensive drug should be prescribed. The FNP should educate people about the use of generic drugs as a cost saving measure, as in most cases-these are as effective as non-generic.
  2. Discuss principles of pharmacokinetics
    Usually the equivalent of 5 half-lives is needed to completely eliminate a drug. Five half-lives are also needed to achieve steady-state plasma concentrations if giving doses intermittingly. Context-sensitive half-life, in contrast, is the time needed to reach a specific amount of decrease (50-60%) after stopping administration of a drug. Recovery time is the length of time it takes for plasma levels to decrease to the point that the person awakens. This is affected by plasma concentration. Effect-site equilibrium is the time between administration of a drug and clinical effect (the point at which the drug reaches the appropriate receptors) and must be considered when determining dose, time, and frequency, of anesthetic agents. The bioavailability of drugs may vary, depending upon the degree of metabolism that takes place before the drug reaches its site of action.
  3. Discuss principles of pharmacokinetics and pharmocodynamics
    Pharmacokinetics relates to the effects that the body has on a drug and pharmacodynamics relates to the effects that a drug has on the body. Both must be considered to ensure adequate dosing to achieve the optimal response from medications. With all drugs there is an intake (dose) and response. Pharmacokinetics relates to the  route of administration, the absorption, the doseage, the frequency of administration, the distribution, and the serum levels achieved over time. The drug's rate of clearance (elimination) and doses needed to ensure therapeutic benefit must be considered. Most drugs are cleared through the kidneys, with water-soluble compounds excreted more readily than protein-soluble compounds. Volume of distribution (intravenous drug dose divided by plasma concentration) determines the rate of which the drug passes into tissue. Drug distribution depends on the degree of protein binding and ion trapping that takes place. Elimination halftime is the timeneeded to reduce plasma concentrations to 50 % during elimination.
  4. Discuss pharmocotherapeutics: Placental transfer of drugs.
    The placenta acts as a barrier to protect the fetus, but its main function is to provide oxygen and nutrients for the fetus by linking the maternal and fetal circulation. Virtually all drugs cross the barrier to some degree, some by active transport. Some drugs are readily diffused across the placental barrier and can affect the fetus. Drugs that are non-ionized, fat-soluble and have low molecular weight diffuse easily as does glucose. Once a substance crosses the barrier, the lower pH of the fetal blood allows weakly basic drugs, such as local anesthetics and opiods, to cross into fetal circulation where they became ionized and accumulate because cannot pass back into maternal circulation (ion trapping). Giving an intravenous injection during a contraction, when uterine blood flow decreases, reduces the amount of the drug that crosses the placental barrier. A few drugs with large molecules (heparin, insulin) have minimal transfer, and lipid-soluble drugs transfer more readily than water-soluble.
  5. Discuss the use and toxicity of digitalis.
    • Digitalis drugs, most commonly administered in the form of digoxin(Lanoxin), are derived from the the foxglove plant and are used to increase myocardial contractility, left ventricular output, and slow conduction through the atrioventricular node, decreasing rapid heart rates and promoting diuresis. Digoxin does not affect mortality, but increases tolerance to activity and reduces hospitalizations for heart failure. Therapeutic levels (0.5-2.0 ng/ml) should be maintained to avoid digitalis toxicity, which can occur even if digoxin levels are within therapeutic range, so observation of symptoms is critical. Potassium imbalance may cause toxicity. Evidence of toxicity include:
    • *Early signs: Increasing fatigue, lethargy, depression, nausea and vomiting.
    • *Sudden change in heart rhythm.
    • *Sinoatrial (SA) or AV block, new ventricular dysrhythmias, and tachycardia (atrial, junctional, and/or ventricular).
    • Treatment of digitalis toxicity involves discontinuing medication and monitoring serum levels and symptoms. Digoxin-immune Fab (Digiband) may be used to bind to digoxin and inactivate it if necessary.
  6. Discuss principles of pharmacodynamics
    Pharmacodynamics relates to biological effects (therapeutic or adverse) of drug administration over time. Drug transport, absorption, means of elimination, and half-life must all be considered when determining effects. Responses may include continuous responses, such as blood pressure variations, or dichotomous responses, in which an event either occurs or does not (such as death). Information from pharmacodynamics provides feedback to modify medication dosage (pharmacokinetics). Drugs provide biological effects primarily by interacting with receptor sites (specific protein molecules) in the cell membrane. Receptors include voltage-sensitive ion channels (sodium chloride, potassium, and calcium channels) ligand-gated ion channels and trans membrane receptors. Agonist drugs exert effects after binding with a receptor while antagonist drugs bind with a receptor but have no effects, so they can block agonists from binding, The total number of receptors may vary, up regulating or downregulating in response to stimuli (such as drug administration). Dose-response curves show the relationship between the amount of drug given and the resultant plasma concentration and biological effects.
  7. Discuss pharmocotherapeutics: Cardiac pharmacology (angiotension-converting enzyme {ACE} inhibitors, angio-tension receptor blockers, b-blockers, and aldosterone agonist)
    • There are a number of different types of medications used for the treatment of heart failure and hypertension:
    • ACE inhibitors, such as captopril (Capoten), enalapril(vasotec), and lisinopril (prinvil), decrease afterload and preload and reverse ventricular remodeling but may cause hypotension initially and are contraindicated with renal insufficiency.
    • B-Blockers, such as metoprolol (Lopressor), carvedilol (Coreg), esmolol (Brevibloc), slow the heart rate, reduce  hypertension, prevent dysrhythmias, and reverse ventricular remodeling, but should be monitored carefully for those with airway disease, uncontrolled diabetes, slow irregular pulse, or heart block.
    • Aldosterone agonists, such as spironolactone (Aldactone), decreases preload and myocardial hypertrophy and reduces edema and sodium retention but may increase serum potassium.
  8. Discuss pharmocotherapeutics: Corticosteroids
    The adrenal cortex, triggered by the adrenocorticotropic hormone (ACTH) produced by the pituitary gland, produces 3 types of steroids from cholesterol: Glucocorticoids (such as cortisol and hydrocortisone), mineralocorticoids (aldosterone), and androgens (testosterone). Glucocorticoids, especially cortisol, have a powerful anti-inflammatory effect, inhibiting cell mediated immune response, and have been synthesized into a number of corticosteroids, which are steroids that resemble cortisol. Replacement therapy for Addison's disease, however is usually done with natural hydrocortisone and cortisone. Synthetic corticosteroids are used to treat many disorders, including arthritis, lupus erythematous, inflammatory Bowel Disease asthma and cancer, but they have severe side effects, such as increased fatty deposits and weight gain, osteoporosis, sodium retention, adrenal suppression, diabetes mellitus, depression, mood swings, gastric ulcers, acne, thinning of skin, and impaired healing, so use must be carefully monitored.
  9. Discuss clinical decision-making: Tennis elbow (Tennis elbow test)
    • Tennis elbow is the inflammation of the lateral epicondyle affecting the tendon of the extensor carpal brevis muscle. This injury occurs in sports and activities that involve repetitive wrist extension against resistance, such as badminton and squash, and often relates to poor techniques or incorrect grip size. It is more common in those over 30. Symptoms include lateral elbow pain, stiffness, and forearm pain. Tests include the Tennis elbow test:
    • *The person in a sitting position
    • *The elbow on the affected arm is  extended (with severe pain flexed at 90*), wrist flexed and hand in a fist.
    • *The examiner supports the elbow with 1 hand.
    • *The forearm is pronated, and the wrist is extended and deviated radially against resistance.
    • *A positive finding is pain at the lateral epicondyle on the outside of the elbow.
  10. Discuss clinical decision-making: Cranial Nerve assessment (Nerves I, II, and III)
    Cranial Nerve assessment:

    • I. Olfactory (smell): The person is asked to smell and identify a substance, such as coffee or soap, with one nostril held closed, and the other.
    • II. Optic (vision): Test visual acuity and the ability to recognize color. Test each separately. Red desaturation is tested by having the person look at a red object with the first 1 eye and then the next to determine if the color looks the same with both eyes or is dull with 1 eye.
    • III. Oculomotor (eye muscles and pupil response): Using a penlight, the examiner checks eyes are checked for size, shape, reaction to light, and accommodation. Eyes are checked for rotation and conjugate movements. The lids should be examined for ptosis.
  11. Discuss clinical decision-making: Cranial Nerve assessment (Nerves IV,  and V)
    • Cranial Nerve assessment:
    • IV: Trochkear (eye muscles-upward movement): Eye movement is checked by having the person follow a moving finger with the eyes on the vertical plane.
    • V: Trigeminal (chewing muscles, sensory): The person closes eyes for the sensory examination and is instructed to indicate when part of the face is stroked (light stroke with cotton). The forehead, cheek, and jaw are stroked. The same areas are then examined for sharp or dull. The eye should be observed for blinking and tearing, but touching the cornea with cotton or other items should be avoided as it can cause an abrasion. The jaw muscles are assessed by having the person hold the mouth open as well as palpating the muscles on each side to determine if they are equal in size and strength.
  12. Discuss clinical decision-making: Cranial Nerve assessment (Nerves XI, and XII)
    • Cranial Nerve assessment: Spinal accessory (muscle movement-sternocleidomsstoid, trapezious): These muscular movements are tested by the examiner placing the hands along the side of the face and asking the person to turn the face first 1 side  and then the other side and then the other against resistance to determine if strength is normal and equal. Then, the examiner places the hands on the person's shoulders and asks the person to shrug the shoulders, elevating them upward, against resistance to determine if the strength is normal and equal.
    • XII: Hypoglossal (tongue): The examiner asks the person to stick out the tongue to determine if it deviates to 1 side, indicating a lesion on that side of the brain. To determine if there is equal strength on both sides of the tongue, a tongue blade is held against the side of the tongue and the person asked to push against it with the tongue. Both sides are checked to determine if strength is normal and equal.
  13. Discuss clinical decision-making: Cranial Nerve assessment (Nerves VIII)
    • Cranial Nerve assessment: VIII: Vestibulocochlear (balance and hearing): Balance is checked with tandem gait and Romberg's test. Hearing is checked (with the person's eyes closed) by rubbing fingers together or holding ticking watch next to 1 ear and then the other. Weber's test may be done to evaluate lateralization and Rinne's test for bone and air conduction.
    • A. Weber's test: A vibrating tuning fork is touched to the top of the head or the forehead and person asked if sound is equal in both ears. Hearing deficit in 1 ear suggests sensorial hearing loss.
    • B. Rinne's test: A vibrating tuning fork is held on the mastoid bone and the time measured until sound ceases. Then the vibrating tuning fork is held at the external ear. Sound is normally heard twice as long through air as through bone. If there is conductive hearing loss, the sound is heard longer through the bone. If there is sensorineural hearing loss, the sound is heard longer through the air.