pharmacology

Must- Knows About Pharmacology Basics By: Dave Manriquez RN.

Basic concepts and Drug Categories

Pharmacy:

Pharmacotherapeutics:

Pharmacology:

Vital facts:

DEFINITION OF TERMS

Study of drug effects on living organisms

Use of drugs to tx,dx or prevent disease

Art of preparing and dispensing drugs

Vital facts:

DEFINITION OF TERMS

Person licensed to prepare and dispense drugs

Pharmacist:

Book containing list of products used in medicine

Pharmacopoeia:

Study of dosage/amount of drugs given in the treatment of diseases

Posology:

Chemical name:

Official name:

Generic name:

Vital facts:

Name given before it becomes official

Name listed in official publications

Precise constituents of the drug

Trademark/brand name:

Name given by drug manufacturer

DEFINITION OF TERMS

Brand/ Trade name

Generic name

Chemical name

DEFINITION OF TERMS

OTC drugs:

Orphan drugs:

Vital facts:

DEFINITION OF TERMS

Discovered drugs but aren’t financially viable. Hence, left by drug companies.

Drugs for self- medication

http://images.google.com.ph/imgres?imgurl=http://www.herbtrader.com/images/categories/wellnessaccessories.jpg&imgrefurl=http://www.herbtrader.com/wellness/wellnessaccessories.html&h=340&w=326&sz=23&hl=tl&start=3&tbnid=qdulpAg63njbPM:&tbnh=119&tbnw=114&prev=/images?q=capsules&gbv=2&svnum=10&hl=tl

http://images.google.com.ph/imgres?imgurl=http://www.herbtrader.com/images/categories/wellnessaccessories.jpg&imgrefurl=http://www.herbtrader.com/wellness/wellnessaccessories.html&h=340&w=326&sz=23&hl=tl&start=3&tbnid=qdulpAg63njbPM:&tbnh=119&tbnw=114&prev=/images?q=capsules&gbv=2&svnum=10&hl=tl

PHARMACOLOGY BASICS

A patient tells you “Nurse, can I take acetaminophen for my abdominal pain. It’s been aching since last night.” What is your best response and why?

Nursing teachings for OTCs: SAMPLE CASE

PHARMACOLOGY BASICS

A patient asks you “Nurse, if I don’t get any relief from my first dose of Aspirin, is it safe to take a second dose?” What is your best response?


PHARMACOLOGY BASICS

A hypertensive patient is wondering why the other nurse asked him about what OTC drugs he was taking. He said “I never thought OTCs could cause hypertension.” Is there any truth to the patient’s statement?


PHARMACOLOGY BASICS

A patient taking antibiotics gets upset and tells the nurse “Are you sure I should stop taking my Maalox just because I’m taking antibiotics?” Is there something wrong with the nurse’s instructions?


od,bid,tid,qid

ad lib

ac, pc

Vital facts:

COMMON ABBREVIATIONS

OD, OS, OU

Rx take

elix

Tr

ss , ss

Vital facts:

COMMON ABBREVIATIONS

dil

One half

tincture

Dilute or dissolve

Category A

According to the Food and Drug Administration:

DRUG CATEGORIES (in r/t PREGNANCY)

Safe for human fetus

Category B



Risk to animal fetus

Safe to animal fetus

Safe for human fetus

Inadequate studies on H.F.



Category C

Adverse effects on animal fetus

Inadequate studies on H.F.



Category D

Risk to human fetus

Given if benefits outweigh the risk

Category X



Adverse effects on animal & human fetuses

Risks clearly outweigh the benefits

Universal Pharmacologic Nursing rule during pregnancy:

Never give any drug unless it is clearly needed

Tetracycline? Streptomycin?

Penicillin? Ampicillin? Cephalosporins? Erythromycin?

Can RIP be given to a TB gravida client?

Safe/ Unsafe drugs:


Safe/ Unsafe drugs:

Antihistamines, Decongestants, Acetaminophen?

Quinine antimalarials? Non-quinine only

General anesthetics? Metronidazole?


Isotretinoin:

Streptomycin:

Anticonvulsants (Phenytoin)

Unsafe drugs:

CHD, Cleft lip/ palate (steroids)

Nerve deafness

CNS defects


Unsafe drugs:

Iodides:

Goiter and mental retardation

Lithium:

Congenital heart defects

Barbiturate, Aspirin:

Bleeding problems


Pharmacodynamics

Peak plasma level:

Onset of action:

Definition of terms:

DRUG ACTIONS

Time when body initially responds to drug

Highest plasma level, Elimination rate=Absorption rate

Drug half-life: One half the previous dose

Plateau: Maintained concentration of drug in plasma thru series of scheduled doses

2 mechanisms:

Def’n:

Vital facts:

Process by which drug alters cell physiology

Being an agonist or an antagonist

PHARMACODYNAMICS

Receptor sites:

PHARMACODYNAMICS

Areas on the cell membranes where drugs act

Antagonist:

Agonists:

Receptor sites

PHARMACODYNAMICS

Example: Insulin

Curare antagonizes Ach @ Ach Receptor sites

Other concepts:

PHARMACODYNAMICS

Selective toxicity: Drug attacks only those foreign cell systems

Example:

Penicillin vs.

Bacterial infections

Chemothera-peutic drugs vs.

Rapidly multiplying cells

Pharmacokinetics

Purpose of a loading dose:

Critical concentration:

Study of:

Basic concepts:

PHARMACOKINETICS

Absorption, distribution, metabolism, excretion of drugs

A.K.A. Therapeutic serum level

To reach critical concentration early

Examples: Digoxin, Aminophylline

PHARMACOKINETICS: ABSORPTION

Def’n.:

Vital facts:

Process by which drug passes into the bloodstream


Stress:

Pain:

Blood flow: The richer the BS, the faster

Slows down gastric emptying rate– slow absorption

May cause vasoconstriction– slow absorption

Food: May interfere with drug absorption

Factors that affect Drug Absorption:


Solubility:

pH:

Exercise: More blood flow to muscles, less to GIT– Slow absorption

Acidic drugs are best absorbed in acidic environment

Liquids absorbed faster than solids

Factors that affect Drug Absorption:


Ideal time for giving oral drugs:

Safest way to deliver drugs:

Oral route

1 hour ac/ 2 hours pc

Vital facts:


IM & gender differences:

Males more muscles reaches peak levels faster

IM & heat to injection site:

Increased absorption

Vital facts:


PHARMACOKINETICS: DISTRIBUTION

Eg:

1st organs to receive drug:

Definition:

Vital facts:

Movement of a drug from its site of absorption to its site of action

Highly vascular organs

Liver,kidneys, brain


Drug is broken down into metabolites by liver enzymes

Deactivated metabolites

Activated metabolites

Directly into the portal venous system

Absorbed via the small intestines

Drug taken orally

The First- Pass Effect

excreted from the body

exerts effect on tissues


Obesity:

Blood volume:

Plasma- protein binding:

Plasma CHONs bring meds to their binding sites/ excretion

Lesser drug dose needed if FVD (+)

Blood flows through fat slowly

Receptor combination

Factors that affect drug distribution:


Placenta:

Most antibiotics:

Blood brain barrier:

Drug must be lipid-soluble and loosely attached to proteins

Not lipid soluble

Most drugs can pass thru the placenta

Barriers to drug distribution:


Trivia Time

What anti-inflammatory drug is ideal for meningitis?


Trivia Time: ANSWER

Dexamethasone


Critical thinking question:

Would you consider a person who has malnutrition at a higher risk for Aspirin toxicity? Why?


PHARMACOKINETICS: BIOTANSFORMATION

By-products:

Major site:

Definition:

Vital facts:Process by which a drug is converted to a less active form

Liver

Metabolites

Types of metabolites: Active and inactive

Impaired metabolism in… Older age, liver disease

PHARMACOKINETICS: METABOLISM

Drugs that increase metabolism:

Alcohol, nicotine, glucocorticoids

Drugs that may decrease metabolism:

Ketoconazole, Quinidine

PHARMACOKINETICS: METABOLISM

AKA: Detoxification

Vital facts:

PHARMACOKINETICS: EXCRETION

Other routes:

Common route of excretion:

Definition:

Vital facts:

Process by which metabolites and drugs are eliminated from the body

Urine

Feces, saliva,sweat,breast milk

Effect of old age: Decreased renal function


Half- life:

Useful concepts:

Half-life x 8= removal from body


Peak level:

Trough level:

15-30 minutes after giving the dose

15-30 minutes before giving the next dose

Question on half-life:

a.) Drug “x” has a half-life of 1 hour. How many hours will it take for drug “x” to be excreted away from the body?

b.) If it takes 16 hours for drug “y” to be excreted away from the body, what is its half-life?


Drug effects and Misuse

Age:

Weight:

Factors influencing drug effects:

DRUG EFFECTS

The heavier, the more tissues to perfuse

Elderly doses are usually 1/3 – ½ usual dose

Psychological fx: Placebo effect (if you think it will, it will)

Tolerance: Example: Morphine

Nursing implications:

Combine with other drugs to potentiate effects (eg: NSAIDS plus Morphine)

Environment:

Drug polymorphism:

Variation in response to a drug due to factors such as age, gender,size and body composition

Warm/cold, Noisy/Silent

Illness: Liver, kidney disease

Time of administration: Empty vs. Full stomach

Factors influencing drug effects:

DRUG EFFECTS

Adverse effect:

Side effect:

Therapeutic effect: Desired effect

Unintended effect

More severe side effect – may justify drug discontinuation

Drug toxicity: Drug overdosage

Drug allergy: Immunologic reaction to a drug

Different types:

DRUG EFFECTS

Cross- allergies:

Drug allergy:

Succeeding allergic reactions are usually much worse than the 1st

Sulfa drugs

Allergic Reactions

DRUG EFFECTS

The Normal Distribution:

DRUG EFFECTS

Key action:

Epinephrine SQ q15-20 mins as prescribed

Usual time of occurrence:

Anaphylactic reaction:

Severe allergic reaction

W/in mins to 2 weeks

DRUG EFFECTS

Allergic Reactions

Dermatological rxns:

Mild: skin care. Severe: Stop & call doc

Blood dyscrasias:

Ensure periodic CBCs

DRUG EFFECTS

Allergic Reactions

Lacrimal tearing

Pruritus:

Angioedema: Due to increased capillary permeability

Itching with or without a rash

Respi:

GIT:

DRUG EFFECTS

Allergic Reactions: Manifestations

Wheezing and dyspnea

Diarrhea, nausea and vomiting

Drug tolerance Unusually low physiologic response to a drug

Cumulative effect:

Increasing response to repeated drug doses (Rate of administration exceeds Metabolism)

Different types:

DRUG EFFECTS

Drug interaction

Example:

Idiosyncratic effect:Unexpected and unique drug effect on an individual

Unusual underresponse to a drug

Potentiating/ Synergistic effect

Inhibiting effect

Different types:

DRUG EFFECTS

Higher blood dose of Penicillin for a longer time

Probenecid blocks excretion of Penicillin

Probenecid is added

Penicillin for bacterial infection

Potentiating effect: An example

Lesser dose of Codeine needed

More pain relief

Aspirin is added

Codeine for pain relief

Additive effect: An example

Example:

Iatrogenic disease:Disease unintentionally caused by medical therapy

Hepatotoxicity, Fetal malformations

Different types:

DRUG EFFECTS

Physiologic dependence

Drug dependence

Drug abuse

Different types:

DRUG MISUSE

Psychologic dependence

Drug habituation

Physiologic d.:

Drug dependence:

Drug abuse:

DRUG MISUSE

Inappropriate intake of a substance

Person’s need to take a drug

Need for the drug by body cells

Usual cells affected: CNS cells

Effect upon discontinuation: Withdrawal effects

Different types:

Drug habituation:

Pyschological d.:

DRUG MISUSE

Emotional dependence on a drug

Mild psychological dependence

Different types:

Drug Computations

Formula:

DRUG COMPUTATIONS

Dose on hand Dose Desired

=

Quantity on hand Quantity desired(x)

Formula:

DRUG COMPUTATIONS

Erythromycin 500 mg is ordered. It is supplied in a liquid form containing 250 mg in 5 ml.

Formula:

DRUG COMPUTATIONS

Dose on hand Dose Desired

=

Quantity on hand Quantity desired(x)

250 mg

5 mL

500 mg

1 Liter=__ quarts

Vital conversion values:

DRUG COMPUTATIONS

1 quart

1 Liter=__ pints 2 pints

1cup=___ mL


DRUG COMPUTATIONS

240 mL

1 mL=__ drops/minims


DRUG COMPUTATIONS

15 drops= 15 minims

1 mL=__grams 1 gram

1 ounce=___ mL 30 mL

Minims= basic unit of liquid measurement in Apothecary system

1 ounce=__ drams 8 drams


DRUG COMPUTATIONS

1 tablespoon=___mL or ___teaspoons

15 mL= 3 teaspoons

1 gram(g)=___ grains


DRUG COMPUTATIONS

60 grains (gr)= 1 mL

Grains= basic unit of solid measurement in Apothecary system

1 kg=__ lbs


DRUG COMPUTATIONS

2.2 lbs


DRUG COMPUTATIONS

1 gallon=___Liters/ quarts 4 Liters= 4 quarts


DRUG COMPUTATIONS

1 mg =___ mcg 1,000 mcg

Convert 8 ounces to minims

Convert 2 pt to grains

Convert 30 pounds to ounces

Vital conversion values: Short exercise

DRUG COMPUTATIONS

It’s now time for actual problems!!!

Following mitral valve replacement surgery a client develops PVC’s. The health care provider orders a bolus of Lidocaine followed by a continuous Lidocaine infusion at a rate of 2 mg/minute. The IV solution contains 2 grams of Lidocaine in 500 cc of D5W. The infusion pump delivers 60 microdrops/cc. What rate would deliver 4 mg of Lidocaine/minute?

A) 60 microdrops/minuteB) 20 microdrops/minuteC) 30 microdrops/minuteD) 40 microdrops/minute

DRUG COMPUTATIONS

A client is receiving a standard concentration Heparin IV of 25,000 u Heparin in 250 ml D5W. The infusion is placed on an IV pump. The infusion rate is increased from 9 - 12 ml/hour. The Heparin dose is now ____ u/hr.

DRUG COMPUTATIONS

The health care provider orders an IV aminophylline infusion at 30 mg/hr. The pharmacy sends a 1,000 ml bag of D5W containing 500 mg of aminophylline. In order to administer 30 mg per hour, the RN will set the infusion rate at:A) 20 ml per hourB) 30 ml per hourC) 50 ml per hourD) 60 ml per hour

DRUG COMPUTATIONS

The following order is written for a clientwith deep vein thrombosis: Heparin 20,000units in 1000ml D5W to infuse at 1000 unitsof heparin per hour. How many ml of D5Wsolution should be administered per hour?A. 20B. 42C. 50D. 66

DRUG COMPUTATIONS

An infant who weighs 11 lb (5 kg) is toreceive 750 mg of antibiotic in a 24-hourperiod. The liquid antibiotic comes in a concentrationof 125 mg per 5 ml. If theantibiotic is to be given three times eachday, how many milliliters would the nurseadminister with each dose?A. 2B. 5C. 6.25D. 10

DRUG COMPUTATIONS

A physician orders 3000 mL of D5W to infuse over a 24-hour period. The drop factor is 10 drops per mL. A nurse sets the flow rate at how many drops per minute?

DRUG COMPUTATIONS

A patient who weighs 14 kg has a left lowerleg cellulitis. The drug ordered is ceftriaxonesodium (Rocephin), 75 mg/ kg/day IV piggy-backin two divided doses. Which of thefollowing amounts is correct for each dose?A. 105 mgB. 250 mgC. 525 mgD. 1050 mg

DRUG COMPUTATIONS

A patient with a deep vein thrombosis isreceiving 1200 units of heparin per hour,intravenously by infusion pump. The solutionavailable is heparin 25,000 units/500 ml.Which of the following is the correct pumpsetting?A. 20 ml/hrB. 58 ml/hrC. 24 ml/hrD. 13 ml/hr

DRUG COMPUTATIONS

A client has an order to receive 1000 ml ofintravenous fluids in 8 hours. The intravenousset delivers 60 microdrops per ml.The nurse should administer approximatelyhow many microdrops of fluid per minute?A. 21B. 40C. 63D. 125

DRUG COMPUTATIONS

Child’s dose=

Applies to:

Fried’s Rule:

PEDIATRIC DRUG COMPUTATIONS

Children 1 year of age below

Infant’s age in months

150 months

Adult dose is used on ages: 12.5 years old above

X average adult dose

inFants: Fried’s

Child’s dose=

Applies to:

Young’s Rule:


Children ages 1 – 12 years old

Child’s age in years

Child’s age in years + 12

Young’s Years


Child’s dose=

Applies to:

Clark’s Rule:


Any pediatric client

Weight of child in lbs.

150 pounds

Clark’s Calories (weight)


Child’s dose=

Applies to:

Surface area calculation:


Any pediatric client

Surface area in square meters

1.73X average adult dose

The usual adult dose of Benadryl is 50 mg. What would be a safe dose for a child weighing 27 1bs?

a. 0.9 mgb. 1.8 mgc. 9.0 mgd. 18 mg


The average adult dose of meperidine is 75 mg. What dose would be appropriate for a 10-month-old infant?a. 50 mgb. 5 mgc. 25 mgd. 0.5 mg


Principles in Drug Administration

Medication Orders / Forms of Meds

Standing order:

Single order:

Stat order:

Types:

MEDICATION ORDERS

Given immediately and only once

Given once at a specified time

Carried out indefinitely until an order cancels it

May be carried out for a specified # of days

PRN order: Given as necessary according to nurse’s own judgment

June 2007 Board Exam question:

A drug is to be given every 4 hours as necessary for pain. It was last given at 8:00 a.m. When should it be given next?

a. 12:00 noon when the client complains of pain

b. Anytime as necessary whenever the client complains of pain

c. 4:00 p.m.

d. 12:00 noon with/ without pain

MEDICATION ORDERS

Name of drug to be given:

Date the order was written:

Client’s full name:

SIX Essential parts:

DRUG ORDER

First,middle initials and last name

Day,month and year

Generic names, Trade names

SIX Essential parts:

DRUG ORDER

Drug dosage: Amount and frequency

Method of administration

Signature of physician/ NP

Telephone orders – signed 1st by the nurse then by the physician within 24- 48 hours

Capsule:

FORMS OF MEDICATION

Why is the capsule colored? To aid in product identification

Is it necessary to open the capsule? Gelatin shell dissolves in stomach

Douches:

FORMS OF MEDICATION

Forms: Powder or liquid concentrations

Elixirs:

FORMS OF MEDICATION

Contents: Water+ alcohol+ Sorbitol + sweeteners

Suppositories:

FORMS OF MEDICATION

Position upon insertion: Left sims

Troches:

FORMS OF MEDICATION

Other names: Lozenges; Pastilles

Basic Principles

Cloudy medications?

Relabelling of med containers?

Unfamiliar medications? Never administer

Pharmacist

Return to pharmacy

Medication @ bedside? Never! Leave until client swallows the meds

Basic Principles:

ADMINISTERING MEDICATIONS

Pre-op meds during post-op?

Client vomits?

Endorsement of meds?

The nurse who prepares the drug is the only one who can give it.

Report to charge nurse/ physician

Assumed discontinued unless otherwise ordered

Medication error: Report to charge nurse/ physician

Basic Principles:


Always assess client status before giving meds

Double check:

Identify the client:

Process:


Check wristband with Medication Administration Record

Ask the client or another nurse to identify client

Process:


Give the medication

Never leave @ bedside

Evaluate and document

Pharmacy:

Systems:

Physician:

Medication errors:

Illegible order

Interrupted to do other duties

Not all doses delivered

Individual: Order not transcribed properly

Knowledge: Similar medication names


Short exercise:ADMINISTERING MEDICATIONS

e. Determining the appropriate way to administer a drug

Right patient

d. Using appropriate math when calculating drug

Right time

c. Checking the order and a drug handbook for appropriate use

Right dose

b. Giving a sleeping pill at 9 PM when order reads “HS”

Right route

a. Checking name band against drug administration form

Right drug

ADMINISTERING ORAL MEDICATIONS

Emulsion:

Suspension:

Syrup: Sugar-based liquid medication

Water-based liquid medication

Oil-based liquid medication

Elixir: Alcohol-based liquid medication

Drug forms for oral administration:


Sustained release:

Enteric coated: Irritating to GIT if crushed

Shorter duration of action if crushed

Drug forms for oral administration:


Trivia Time

What guideline should be followed to allow for maximum absorption

of elixirs after giving?


Trivia Time: ANSWER

Allow 30 minutes to elapse before giving water


Measurement guide when reading liquid medications:

How many times do you verify the “right drug”?

Commonly asked questions?


3x

Read at the bottom of the meniscus at eye level

Before, during and after giving the drug

Commonly asked questions?


If there’s difficulty swallowing:

Place at back of mouth (stimulates swallowing reflex)

If client states that the drug you’re giving looks unfamiliar:

Withhold and double check the order

Trivia Time

Why are honey and essential food items avoided when mixing medications

for pediatric clients?


Trivia Time: ANSWER

To prevent botulism; to ensure adequate nutrition


To prevent nausea…

Pediatric clients:

Give chilled carbonated beverage before or immediately after giving the drug

If using a syringe to give a liquid med:

Place it along the side of the infant’s tongue


I

Qu Quinidine

Isoniazid

E Erythromycin

T Tetracycline

Normally taken on an empty stomach with a full glass of water:


A

C

R

P

S

Normally taken on an empty stomach with a full glass of water:


Cephalosporin

Acetaminophen, Aspirin

Rifampin

Sulfonamides

Penicillin, Proprantheline

G

C Cimetidine, Carbamazepine

Griseofulvin

f food

N

S Spironolactone

Nitrofurantoin

Normally taken with food to improve absorption:


H

P Propranolol

Hydralazine

I Indomethacin

L. Lithium

Normally taken with food to improve absorption:


ADMINISTERING SUBLINGUAL MEDICATIONS

Sublingual/ Buccal:

Rapidly absorbed in the bloodstream, bypasses liver

Swallowing it may deactivate the drug


ADMINISTERING TOPICAL MEDICATIONS

Ophthalmic:


Maximum number of drops at a time:

Where to instill?

Technique used: (sterile or clean?) Sterile

Lower conjunctival sac

Two

Interval between instillations?

5 minutes for proper absorption

Ophthalmic:


To prevent systemic absorption:

Closing of eyes: Gently but not tightly to avoid spillage

Press firmly on nasolacrimal duct for at least 30 secs.

Ophthalmic:


Otic:


Posn:

Using hot/cold soln:

Solution temperature: Warm/ body temperature

Nausea, vertigo, pain

Side-lying with ear being treated up

Straighten ear canal: pinna down & back: 0-3 y.o.

Otic:


Straighten ear canal: pinna up & back: Above 3

Pos’n after:

To assist medication flow:

Where to instill: Along side of auditory canal

Press on tragus

Side-lying for another 5 minutes

To prevent spillage:

Place cotton loosely at auditory canal for 15-20 mins

Otic:


Nasal:


Upon inhalation:

Position:

Usual purpose: Astringent effect (shrinking effect)

Head tilted back (sit/lie)

Administer the spray

Position after: Keep head tilted back for an additional 5 minutes

Nasal:


Daily sprays: Use alternate nares

Nebulization/ MDIs:


After pressing canister:

Mouthpiece position:

Position: Semi/ high-fowler’s

1-2 inches away from mouth

Hold breath for 10 secs

A-B-C mnemonic


Nebulization/ MDIs:

Time interval in between next dose: 1 minute

Trivia Time

What should you instruct the client to do if steroid medications

were given via MDI


Trivia Time: ANSWER

Rinse mouth to prevent oral fungal infection


Rectal Instillations/ Suppositories


What to instruct the patient?

Position: Left- sims

Relax: breath thru mouth

What to wear? Gloves

How far do we insert?

Why that far? It’s beyond the internal sphincter

Instructions post- insertion:

Remain side-lying for at least 5-20 mins

Adult: 4 inches; child/ infant: 2 inches


Rectal Instillations/ Suppositories

ADMINISTERING PARENTERAL MEDICATIONS

Sites:

Intradermal Injection:

Inner lower arm, upper chest/back, beneath scapulae


To massage or not to massage? Don’t massage the site after

Needle gauge: 25-27

Upon insertion, needle is at… 10-15 degree angle, bevel up


Intradermal Injection:

Needle length: 3/8” to ½”


What is the angle of the needle bevel when performing intradermal injections?

a. Parallel to the skin

b. 10-15 degrees

c. 30-45 degrees

d. 90 degrees

MEDICATION ORDERS


What is gauge of the needle used for intradermal injections?

a. 27

b. 23

c. 18

d. 20

MEDICATION ORDERS

Sites:

Subcutaneous:

ID sites+ anterior thighs, abdomen, gluteal areas


When injecting at 45 degrees:

Dosage:

Meds given SQ: Vaccines, insulin, heparin, narcotics

0.5-1mL

5/8 needle

Needle gauge: 25-27

Subcutaneous:


When injecting at 90 degrees: 1/2 needle

For obese patients:

For thin patients: 45 degree angle of needle

90 degree angle of needle


Subcutaneous:

For heparin injection: Do not aspirate nor massage

For insulin injections: Inject @ 90 but don’t massage

For other injections: Aspirate before injecting

Trivia Time

What should be ideally done if blood is seen upon withdrawal of the plunger?


Trivia Time: ANSWER

Remove the needle and discard the medication/equipment


Intramuscular:


Possible sites:

Length:

Gauge: 20-23

1-2 inches

Gluteal, Vastus lateralis, deltoid

Intramuscular:



Intramuscular: VENTROGLUTEAL SITE

Abduct middle finger

Place index finger over ASIS

Hand heel over greater trochanter

Triangle formed below crest is the site



Muscle: Gluteus medius

Degree of contamination:

Lesser since it’s farther from rectal area



Ventrogluteal:

Von Hochsteter’s Site: Ventrogluteal

formed is the V site

Vessel-free

Purpose of above instructions:

Instructions when side-lying:

Instructions when prone: Curl toes inward

Flex knee/hip

Relax muscles




Intramuscular: DORSOGLUTEAL SITE

Imaginary line from PSIS to GT



4 quadrants– Upper outer quadrant

Risks:

Contraindicated age: Below 3 years old

Injury to sciatic nerve/ major blood vessel



CHULOU H. PENALES, RN


Vital fact:

Recommended site for infants

Intramuscular: VASTUS LATERALIS


Intramuscular: DELTOID MUSCLE

Acromion Process (2 inches below)

Site is approx 2 inches from AP

Midpoint between AP & axillary fold

Acromion Process



Risks:

Deltoid: 0.5 – 2 mL


Gluteus Medius: 1-5 mL

Relatively small muscle; possible injury to radial nerve & artery


Z-track method:


To massage or not to massage?

When is it used?

Z-track IM method:

Irritating meds (eg: Iron)

Do not massage.


How to minimize discomfort pre-inj.:

Needle introduction:

Air lock technique: 0.2 mL air bubble

Introduce in a quick thrust

Cold compress

How to minimize discomfort upon needle withdrawal:

Support the tissues with cotton swabs

General Principles: Parenteral Medicatons


The type of physician’s order that is carried out upon the judgment of the nurse, as required by the patient is:

a. Standing order

b. Single order

c. STAT order

d. PRN order

PRACTICE QUESTIONS

The most accurate method of identifying a client before drug administration is by:

a. Asking the client to state his name

b. Calling the client by his name

c. Asking a relative to identify the client

d. Checking the identification band/ bracelet of the client

PRACTICE QUESTIONS

Which of the following are true about absorption of medications

1. Rich blood flow promotes faster absorption of medications

2. Exercise enhances absorption of oral medications

3. High concentration of drugs promote a rapid effect

4. Liquid medications are more rapidly absorbed than solid medications

f. 1,2,3 b. 2,3,4 c. 1,3,4 d.1,2,3,4

PRACTICE QUESTIONS

During application of medication into the ear, which of the following is an inappropriate nursing action?

a. Warm the medication at room or body temperature

b. In an adult, pull the pinna upward

c. Instill the medication directly into the tympanic membrane

d. Press the tragus of the ear a few times to assist the flow of medication into the ear canal

PRACTICE QUESTIONS

Parenteral Medications and IV fluids

Extracellular fluidsIntracellular fluids

Division of Body fluids

40% of body weight 20% of body weight

PARENTERAL MEDICATION/ IV FLUIDS

Diffusion

Movement of Fluids


Osmosis

Movement of Fluids


Filtration

Movement of Fluids


Exercise Question:

What is the mechanism by which Mannitol decreases IOP in patients with Glaucoma?

a. Diffusion

b. Osmosis

c. Filtration

d. Diuresis


Exercise Question:

The movement of air from the environment into the lungs follows what principle of gas movement?

a. Diffusion

b. Osmosis

c. Respiration

d. Filtration


Exercise Question:

Who among the following are at highest risk for dehydration?

a. A breastfeeding 8-month old infant

b. A 17 year-old with fever

c. A 61 year-old man jogging

d. A pregnant woman


Above 40 y.o.: 40-50%

Fast fact: Body fat is inversely proportional to body fluids.

Adult: 50-60%

Infant: 60-70%

Neonate: 70-80 %

Fluids as Percentage of Body weight


Urine

Lungs (Insensible)

Average daily adult output:

1400-1500 mL

350-400 mL

350-400 mL

100 mL

Skin (Insensible)

Sweat

Feces

Total

100-200mL

2,300-2,600 mL


Osmotic/ Oncotic pressureHydrostatic pressure

Pressures within the Blood vessel

Pushing force of a fluid against the walls that contain it

Pulling power of a solution for water


Trivia Time

What happens when hydrostatic pressure exceeds osmotic/oncotic

pressure?


Trivia Time: ANSWER

3rd space fluid shift: manifested by decreased urine output. Occurs in

burns, peritonitis, massive bleeding into a joint/cavity.


Trivia Question:

Are osmolality and Osmolarity the same?


Osmolarity:

Osmolality:

Osmolality vs Osmolarity

Solute / Kg of Water

Solute/ Kg of a solution


Osmolality vs Osmolarity

Can we use the terms interchangeably? Yes

If osmolality is high, what is the osmotic pressure of that solution?

High


Osmolality And Sodium

Major plasma solute that determines Osmolality: Na

Formula for estimated Osmolality: 2 x Serum Na

Na: 135-145 mEq/L

Serum Osmolality: 270-290 mOsm/L


Isotonic solution

Types of solutions:


Indications: Dehydration or any ECF volume deficit

Types of solutions: ISOTONIC

Same osmolality as plasma Osmolality:


Normal Saline(PNSS; 0.9% NaCl): NaCl

ISOTONIC Solutions:

Ringer’s Sol’n.: Na,K,Ca

Lactated Ringer’s: Ringer’s + Lactate & Chloride


Trivia Question:

Do most isotonic fluids contain dextrose,

magnesium or bicarbonate?

NO


5% Dextrose in water (D5W)

Lactated Ringer’s Solution

0.9% Saline (NS)

Memory tip: commonly used solutions

Isotonic Solutions

5% Dextrose in .225% Saline (5% D/ 1.4 NS)

Exceptions to the memory tip on hypertonic solutions


Hypertonic solution

Types of solutions:


Indications: Hyponatremia

Types of solutions: HYPERTONIC

Used in limited doses in carefully controlled settings via an infusion pump

Precaution:

Hypernatermia & FVORisks:

Close monitoring (V/S; Lungs; Neuro; Na)

Nursing action:


Sample Question:

This hypertonic solution may be given via IV push for hypoglycemia in a code situation:

a. 50% Dextrose

b. 10% Dextrose

c. PNSS

d. 5% Saline


Sample Question:

This hypertonic solution is used to treat newborns with hypoglycemia as part of the treatment protocol:

a. 5% Dextrose

b. 10% Dextrose

c. Plain LR

d. 5% Saline


TYPES OF INTRAVENOUS SOLUTIONS

10 % Dextrose in water (D10W)

5% Saline (5% NS)

3% Saline (3% NS)

Memory tip: anything that’s above 0.9% or any combinations

Hypertonic Solutions

5% Dextrose in 0.9% Saline (5% D/NS)

5% Dextrose in 0.45% Saline (5% D/ 1/2NS)

5% Dextrose in lactated ringer’s solution

Trivia Question:

Do most hypertonic solutions provide calories to cells?

Yes


Hypotonic solution

Types of solutions:


Indications: Cellular dehydration

Types of solutions: HYPOTONIC

Acute brain injuryMajor contraindication:


TYPES OF INTRAVENOUS SOLUTIONS

0.33% Saline (1/3 NS)

0.225% Saline (1/4 NS)

0.45% Saline (1/2 NS)

Memory tip: anything that’s below 0.9%

Hypotonic Solutions

Sample Question:

If 1 liter of 0.45 saline/ 0.225 saline is given to patient, how much of it actually enters the cells

a. 1 Liter

b. 800 mL

c. 500 mL

d. 200 mL


Sample Question:

Does D5W provide adequate nutritional calories?

No, but it does prevent ketosis


Colloid volume expanders

Types of solutions:


Indications: Acute volume loss

Types of solutions: Colloid volume expanders

Albumin, Dextran, HetastarchExamples:


Air embolism prevention by: Priming IV tubing

Change IV tubing every: 72 hours

Change IV needle insertion site every:

15-20 minutes


IV Fluid therapy guidelines:

Regulate IV every:

72 hours

Infiltration:

IV INFUSION COMPLICATIONS

Skin appearance:

Skin temp:

Definition:

Infiltration:

Needle out of vein, accumulates in SQ tissue

Cold

Pale with edema

IV flow rate: Decreases or stops

Backflow of blood: Absent

Nursing action: Change the IV site and apply warm compress


Thrombophlebitis:


Skin appearance:

Skin temp:

Causes:

Thrombophlebitis:

Irritating solutions, overuse of vein

Warm

Redness and edema

Palpation findings: Vein feels hard and cordlike

Prevention: Change IV site every 72 hours

Nursing action: Change site and apply cold compress then warm compress


Circulatory Overload:


Patient position:

Action:

Symptoms:Increased BP,HR, Dyspnea, Crackles, Weight gain

Slow infusion to KVO rate then call doctor

High-fowler’s position

Possible medications: Diuretics and bronchodilators

Circulatory Overload:


Drug Overload:


Action:

Symptoms: Dizziness, shock, fainting

Slow infusion to KVO rate then call doctor

Drug Overload:


Pulmonary Embolism:


Prevention:

Action:

Symptoms:Chest pain, hypo-tachy, Dyspnea, Loss of consciousness

Turn patient to left side in a trendelenburg position

Prime the IV tubing and don’t allow it to run dry

Amount of air that may cause embolism: 5mL


Pulmonary Embolism:

Prevention:

Possible cause:

Due to rapid IV push administration

Give IV push medications over 3-5 minutes


Speed shock:

Insulin Therapy and Oral Hypoglycemics

Combination Insulin (Regular / Intermediate)

Long-acting

Intermediate- Acting

Short-acting

Rapid/ultra-short

INSULINTypes of Insulin:

Ultra- Lente

Lente

Semi- Lente

Humulin U

Humulin N

Humulin R

Humulin 70/30, Humulin 50/50

Combination Insulin (Regular / Intermediate)

Insulin Glargine (Lantus)

Long-acting

NPH/Isophane Insulin

Intermediate- Acting

Regular Insulin

Short-acting

Insulin Aspart, Insulin Lispro

Rapid/ultra-short

INSULINTypes of Insulin:

Long-acting

Intermediate acting

Short acting

Rapid

DurationPeakOnset Insulin type

INSULIN IN ACTION

x2x3 +10/ 3Long-acting

x3x3 + 10/ 2Intermediate acting

x32-4 hoursKEY VALUE

/ 2Short acting

x3.5-1.5 hours

/ 2Rapid

DurationPeakOnset Insulin type

INSULIN IN ACTION

MIXING INSULIN (R. N. Mnemonic)

R=

N=

Note: never shake the vial ‘cos it creates bubbles leading to inaccurate dosing. Roll it between your palms instead.

Draw Regular Insulin First (Clear)

Draw NPH Insulin Next (Cloudy)

INSULINDawn phenomenon vs. Somogyi Effect

INSULIN & DAWN PHENOMENON

Too little Insulin or Too early administration of Insulin before bedtime

Normal Glucose until about 3 am when Glucose rises

Morning Hyperglycemia

INSULIN & SOMOGYI EFFECT

Too much Insulin or too little bedtime snack before bedtime

Normal Glucose until about 3 am when Glucose lowers to HYPOGLYCEMIC levels

Morning Hyperglycemia

Counterregulatory hormones

SNS Rebound effect

Decrease Insulin before bedtime or increase bedtime snack.

Too much Insulin or too little bedtime snack before bedtime

SOMOGYI EFFECT

Increase Insulin or give Insulin when one is not in use.

Too little Insulin or No Insulin at all before bedtime

INSULIN WANING

Increase Insulin before bedtime or administer Insulin close to bedtime.

Too little Insulin or too early administration of Insulin before bedtime

DAWN PHENOMENON

TreatmentCauseCauses of Morning Hyperglycemia

Treatment

Significance

Appearance

HYPERTROPHYATROPHY FEATURES

INSULIN & LIPODYSTROPHY: TYPES

Rotate injection sites

Inject pure human insulin into atrophic area

Treatment

Impaired insulin absorption

Cosmetic only, physiologically harmless

Significance

Scar tissue at the injection site

Dimpling/ pitting at injection site

Appearance

HYPERTROPHYATROPHY FEATURES

INSULIN & LIPODYSTROPHY: TYPES

INSULIN & LIPODYSTROPHY

Non-rotation of Insulin SQ injection sites

Constant trauma to fatty tissues results in Lipodystrophy

Continued use of THICKENED site

Decreased Insulin effects

Hyperglycemia

Use of another site

Body got used to low Insulin levels

Increased Insulin effects= hypoglycemia

Etiology:

Abdomen

Anterior thighs

Hips

Posterior arms

INSULIN SQ INJECTION SITES (note: size of circle= speed of insulin absorption)

Trivia Time

How frequent should injection sites be rotated?

INSULIN SQ INJECTION SITES

INSULIN SQ INJECTION SITES

Trivia Time: ANSWER

Every 2-3 weeks

INSULIN USE in the PREGNANT WOMAN

1ST TRIMESTER

Baby uses up mommy’s glucose for its rapid development

Mommy’s serum glucose decreases

Insulin requirements:

Most common time for HYPOGLYCEMIC REACTIONS

Decrease

2nd-3rd month


2nd TRIMESTER

Mommy’s placenta begins to produce Human Placental Lactogen

HPL has an anti-insulin effect. It doesn’t want mommy to use up her glucose because it

wants the baby to use it instead.

Insulin requirements: Begin to increase


3rd TRIMESTER

Mommy’s Placenta continues to produce HPL

High HPL levels significantly decrease Insulin’s effectivity

Insulin requirements:

Most common time for INSULIN RESISTANCE

Rise significantly

6th month


IMMEDIATE POST-PARTUM

HPL is gone.

Insulin resistance:

Insulin Requirements:

Disappears

1st 24 hours: NO INSULIN NEEDED Thereafter: PRE-PREGNANT INSULIN REQUIREMENTS

ORAL HYPOGLYCEMICS

Why?

S/e to look out for:

Major suffix: -mide, -ride, -zide

Anorexia

It may potentiate hypoglycemia

Pregnancy alert:

Oral hypoglycemics are teratogenic!

SULFONYLUREAS

Vital facts:

SULFONYLUREASCommon names:

• *Chlorpropamide(Diabinese)

• Tolbutamide (Orinase)

• Glimepiride (Amaryl)

• Glipizide (Glucotrol)

• Glyburide (DiaBeta)

First Generation

Second Generation

2nd:

1st: Urine

Urine & bile

SULFONYLUREAS

1 st generation versus 2 nd generation: Mode of Excretion

Implications: 2nd is safer for patients with renal dysfunction

2nd:

1st: Shorter

Longer (1-2x/day dosing)

SULFONYLUREAS

1 st generation versus 2 nd generation: Duration of Action

Implications: The more frequent a patient has to take the drug, the lesser the compliance

2nd:

1st: High

Low

SULFONYLUREAS

1 st generation versus 2 nd generation: Cardiovascular disease risk

Stimulate beta cells to produce Insulin

Increase the number of insulin receptors

Improve Insulin binding to insulin receptors

Insulin levels rise

Glucose deposited into the cells

SULFONYLUREAS

Hypoglycemic effect

Action:

Hypovolemia

Extreme dehydration

HHNK

Prevent hypovolemia

Fluid conservation

SULFONYLUREAS

Action: HHNK Palliative treatment

Sulfonylureas increase ADH effectiveness

So what if it’s short?

Half-life:

Major suffix: -glinide

Very short

Lesser hypoglycemic effect

Indication: Adjuncts to sulfonylureas

MEGLITINIDES

Vital facts:

MEGLITINIDESCommon names:

• Nateglinide (Starlix)

• Repaglinide (Prandin)

Time taken (meals):

Duration of effect:

Main action: Similar to Sulfonylureas

Short-lived

30 minutes a.c.

Main goal of drug: Lower post-prandial blood glucose

MEGLITINIDES

Action and other facts:

Common s/e:


Major suffix: None

Liver toxicity

GIT disturbances


ALPHA- GLUCOSIDASE INHIBITORS

Vital facts:

ALPHA- GLUCOSIDASE INHIBITORS.

Common names:

• Acarbose (Precose)

• Miglitol (Glyset)

ALPHA- GLUCOSIDASE INHIBITORS

Alpha- glucosidase inhibition

Delayed glucose absorption from GIT into blood

Mild hypoglycemic effects

Adjunct to Sulfonylureas

Temporary prevention of complex Carbohydrates breakdown

Decreased hyperglycemia after eating

Action:

Common s/e:


Major suffix: None

Liver toxicity

GIT disturbances


BIGUANIDES

Vital facts:

BIGUANIDESExample:

• Metformin (Glucophage)

BIGUANIDES

Increases ability of Insulin to bind to peripheral tissues

Increased glucose uptake by cells

Mild hypoglycemic effect:

Adjunct to Sulfonylureas

Action:

Trivia Time

What acid-base imbalance could occur with the intake of Biguanides?

BIGUANIDES

Trivia Time: ANSWER

Lactic acidosis

BIGUANIDES

S/e #2:

S/e #1:

Major suffix: -glitazone

Fluid retention edema

Hepatotoxicity Jaundice


THIAZOLIDINEDIONES

Vital facts:

THIAZOLIDINEDIONESCommon names:

• Pioglitazone (Actos)

• Rosiglitazone (Avandia)

THIAZOLIDINEDIONES

Decreases peripheral resistance to Insulin

Increased glucose uptake by cells

Mild hypoglycemic effects

Action:

ANTI-HYPOGLYCEMICSMajor Suffix: none

Major considerations:

Common names:

• Dextrose (Glucose, Glutose, Insta-glucose)

• Diazoxide (Proglycem)

• Glucagon (Glucogen)

• Octreotide (Sandostatin)

Each medication has its own unique way of working and also has its own set of side-effects.

DIAZOXIDE

Diazoxide as a Vasodilator:

Venous stasis:

Dependent edema = weight gain

Low Venous return = Hypotension

blood pools in veins

DIAZOXIDE

Inhibits B-cells from producing Insulin: Anti-sulfonylurea

Increase peripheral insulin resistance

Reduced Insulin action

Hyperglycemic effect

Diazoxide as an anti-hypoglycemic agent:

DEXTROSE

LOW DOSE:

Purpose:

Risk for irritation at IV site:

10% glucose maximum

Nutrition/ hydration

Low risk for irritation at IV site

Dextrose @ low doses:

DEXTROSE

HIGH DOSE:

Purpose:

Risk for irritation at IV site:

70% glucose maximum

Treatment of Hypoglycemia

High risk for irritation at IV site

Dextrose @ low doses:

Sample Question:

The nurse teaches a type 2 DM client how to recognize and report adverse drug reactions. Which of the following is a common adverse reaction to Glipizide?

a. Headache

b. Constipation

c. Hypotension

d. Photosensitivity

ORAL HYPOGLYCEMICS

HYPOGLYCEMIA

Tachycardia, sweating, tremors, nervousness, hunger

Think of Sx when you feel extremely hungry

SNS stimulation

Hypoglycemic reaction:

High insulin but low glucose intake

HYPOGLYCEMIA: SIMPLE PATHOPHYSIOLOGY

Blood glucose < 60 mg/dl

HYPOGLYCEMIA

Trivia Time

What may be the only sign of hypoglycemia in an unconscious person?

Trivia Time: ANSWER

Diaphoresis

HYPOGLYCEMIA

Brain is depleted of glucose

Hypoglycemic coma

HYPOGLYCEMIA: SIMPLE PATHOPHYSIOLOGY

Brain damage: paralysis, cognitive impairment

Dangers of Hypoglycemia:

Inadequate glucose to support brain activity

Trivia Time

Between a DKA coma and Hypoglycemic coma, which one is

more serious and why?

HYPOGLYCEMIA

Trivia Time: ANSWER

Hypoglycemic coma

HYPOGLYCEMIA

Sx resolved:

If regular meal is within 60 minutes:

Sx unresolved:

Retest blood glucose in 15 minutes

10-15g of fast-acting CHO

Blood glucose 41-60 mg/dL

MILD HYPOGLYCEMIA: TREATMENT

Repeat tx

Snacks containing CHO & CHONs (milk/cheese)

Omit the snack

Same with Mild Hypoglycemia

Blood glucose 21-40 mg/dL

MODERATE HYPOGLYCEMIA: TREATMENT

Upon arrival @ hospital:

Once conscious:

Still unconscious after ten minutes:

Unconscious:

Blood glucose 20 mg/dL below

SEVERE HYPOGLYCEMIA: TREATMENT

SQ/ IM Glucagon

2nd dose of Glucagon

Give small meal

Give IV 25-50 mL of Dextrose 50% in water

A client is taking NPH insulin every morning. The nurse instructs the client that the most likely time for a hypoglycemic reaction to occur is:

a. 2-4 hours after administration

b. 6-14 hours after administration

c. 16-18 hours after administration

d. 18-24 hours after administration

PRACTICE QUESTIONS

A client is brought to the ER in an unresponsive state, and a diagnosis of HHNK is made. The nurse would prepare immediately to initiate which of the following anticipated physician orders?

a. 100 units of NPH insulin

b. Endotracheal intubation

c. IV replacement of Sodium Bicarbonate

d. IV infusion of Normal Saline

PRACTICE QUESTIONS

A client is admitted with a diagnosis of DKA. The initial blood glucose level was 950 mg/dL. A continuous IV infusion of regular insulin is initiated along with intravenous rehydration with normal saline. The serum glucose level is now 240 mg/ dL. The nurse would next prepare to administer which of the following?

a. IV fluids containing 5% dextrose

b. NPH insulin SQ

c. An ampule of 50% dextrose

d. Phenytoin for seizure prevention

PRACTICE QUESTIONS

A client with DM visits a health care clinic. The client’s DM previously had been well controlled with glyburide (Diabeta), 5mg PO daily, but recently the fasting blood glucose has been running to 180-200 mg/dl. Which medication ,if added to the client’s regimen, may have contributed to the hyperglycemia?

a. Prednisone (Deltasone)

b. Atenolol (Tenormin)

c. Phenelzine (Nardil)

d. Allopurinol (Zyloprim)

PRACTICE QUESTIONS

If NPH insulin has been injected SQ at 6:00 am, the client would be assessed for any hypoglycemic reaction at:

a. 12NN to 2:00 pm

b. 6:00am the following day

c. 8:00am -10:00 am

d. 1:00 pm – 7:00pm

PRACTICE QUESTIONS

Oxygen Therapy

Anemic hypoxia:

Circulatory hypoxia:

Hypoxemic hypoxia:

Indication: Hypoxia

OXYGEN THERAPY

VP imbalances, Hypoventilation

Cardiogenic shock

Anemia

Histotoxic hypoxia: CO, Cyanide poisoning

25-50

90 above

60-90

40-60

20-40

O2 %(FiO2)

Oxygen Tent

5-10Venturi Mask

6-15Non- Rebreather

6-15Partial Rebreather

6-8Face Mask

2-6Nasal Cannula

LPMDELIVERY SYSTEM

OXYGEN THERAPY

Low Flow Systems High Flow Systems

Non-constant O2% delivered

Contributes partially to the gas the patient breathes

Oxygen is delivered independent of the pt’s. breathing

Constant O2%

FiO2 varies with pt’s breathing Constant FiO2

e.g. :Face mask T-piece, Tracheostomy collars

Low-Flow vs. High Flow Systems

OXYGEN THERAPY

LPM% of O2 (FiO2)

Mnemonic: 24 hours in 1 day

OXYGEN THERAPY (% of O2 DELIVERED : LPM)

540

436

332

228

124

LPM% of O2 (FiO2)

Mnemonic: 24 hours in 1 day

OXYGEN THERAPY (% of O2 DELIVERED : LPM)

True or false:

Oxygen is a medication. Hence, it must be prescribed by a physician.

There is no danger of fire when oxygen is used since it is contained in a green tank

Oxygen administration may be done at the client’s home.

There is no such thing as oxygen toxicity

OXYGEN THERAPY

Build-up of oxygen free radicals

Cells metabolize oxygen

O2 > 50% for more than 48 hours

Oxygen toxicity:

Free radicals can damage/ kill cells

OXYGEN THERAPY

Signs and Symptoms:

Why?

Ideal diet: Rich in Vitamin E, C & Beta-Carotene

It’s rich on anti-oxidants

Oxygen toxicity:

OXYGEN THERAPY

Substernal discomfort

Dyspnea & Fatigue

X-ray: Alveolar infiltrates

Progressive Resp.

Difficulty

OXYGEN THERAPY

Nasal cannula

OXYGEN THERAPY

Skin integrity alert:

Duration of use:

Recommended LPM:

Nasal cannula

Water-soluble jelly to nares as needed

Long-term use

Flow rates higher than 6 LPM are useless.

OXYGEN THERAPY

Consequence of flow rates>6-8lpm:

Nasal cannula

Air swallowing, mucosa drying

OXYGEN THERAPY

Face mask

OXYGEN THERAPY

Recommended LPM:

Safety alert:

Limitations:

Face mask

Minimum of 5 LPM to prevent rebreathing of exhaled air

Watch for aspiration

Limited ability to clear mouth

Partial Rebreather maskOXYGEN THERAPY

Why rebreathe?

Mechanism:


1/3 of exhaled tidal volume is rebreathed.

Such air is O2 rich.

The initial 1/3 exhaled air was mainly

the dead space

Deflation means :

Safety alert!


R.B. must be 2/3 full with inhalation

Deflation means decreased O2 delivered.

Reservoir bag must not deflate completely!

OXYGEN THERAPY

Non- Rebreather mask

OXYGEN THERAPY

Guidelines:

Air inhaled:

O2 delivered:

Non- Rebreather mask

Bag deflation consequence:

Same guidelines with partial rebreather masks

Only Pure O2 is inhaled

Highest amount of O2 delivered

Suffocation can result with bag deflation

OXYGEN THERAPY

Venturi mask

OXYGEN THERAPY

Mechanism:

Oxygen delivery:

Venturi mask

Exact proportion of room air + o2 is inhaled

Most accurate oxygen delivery system

The oxygen administration device preferred for patients with COPD is:

a. Nasal cannula

b. Oxygen tent

c. Venturi mask

d. Oxygen hood

PRACTICE QUESTIONS

Which of the following is not to be included in the nursing interventions for a client receiving oxygen therapy?

a. Place a “No Smoking” sign at the bedside

b. Place the client in semi-fowler’s position

c. Place sterile water into the oxygen humidifier

d. Lubricate the nares with oil to prevent dryness of the mucous membrane

PRACTICE QUESTIONS

Which of the following is the most accurate oxygen delivery system?

a. Nasal cannula

b. Oxygen tent

c. Venturi mask

d. Oxygen hood

PRACTICE QUESTIONS

Which of the following oxygen delivery system would be ideal to use in someone who has just been diagnosed with CO poisoning?

a. Nasal cannula

b. Oxygen tent

c. Venturi mask

d. Non-rebreather face mask

PRACTICE QUESTIONS

After exposure in the clinical area, you know that the color of the oxygen tank is:

a. Gray

b. Blue

c. Green

d. Light pink

PRACTICE QUESTIONS

Blood Transfusion

TYPES OF BLOOD DONATION

Homologous

Blood salvage

Autologous

Homologous: Other person’s blood

Blood salvage: Autologous donation

Autologous: Patient’s own blood

Plasmapheresis

Stem Cell harvest

Erythrocyta-pheresis

Leukapheresis

Platelet pheresis

PURPOSE: to remove…TYPE

TYPES OF APHERESIS

Plasma proteinsPlasmapheresis

Circulating stem cellsStem Cell harvest

RBCsErythrocyta-pheresis

WBCsLeukapheresis

PlateletsPlatelet pheresis

PURPOSE: to remove…TYPE

TYPES OF APHERESIS

Single donor plateletsFresh Frozen Plasma

Random platelets

Packed RBCs

Whole blood

INDICATION/SCOMPOSITIONTYPE

BLOOD/ BLOOD COMPONENTS

Decreased alloimmunization risk

Platelets from a single donor

Single donor platelets

Bleeding d/oAll coagulation factors

Fresh Frozen Plasma

Increased alloimmunization risk

Platelets from multiple donors

Random platelets

Symptomatic anemia

75% Hct (only RBCs are functional)

Packed RBCs

Significant bleeding

Cells and plasmaWhole blood



Albumin

Cryoprecipitate



Burns AlbuminAlbumin

Hemophilia A&B, VWD

Von Will. Fx, Fx VIII, Fibrinogen

Cryoprecipitate



Blood Components

A single unit of whole blood contains ___ ml and __ ml of an anticoagulant.

PRBCs are stored at __ degrees Celsius and can be stored up to ___ days with special preservatives.

Platelets must be stored at ____ temperature and can last only __ day/s.

To prevent clumping, platelets are gently _______ while stored.

Fresh frozen plasma can last up to __ year/s as long as it remains ______.


• A single unit of whole blood contains 450 ml and 50 ml of an anticoagulant.

• PRBCs are stored at 4 degrees Celsius and can be stored up to 42 days with special preservatives.

• Platelets must be stored at room temperature and can last only 5 day/s.

• To prevent clumping, platelets are gently agitated while stored.

• Fresh frozen plasma can last up to 1 year as long as it remains frozen.


A history of close contact with a dialysis patient or hepatitis patient within the past 6 months.

A history of untreated malaria/syphilis.

Pregnancy within the past 6 months

Tooth extraction or oral surgery w/in the past 72 hours.

Whole blood donation within 2 months (56days).

Aspirin within 3 days

Oral temperature > 37.5 degrees Celsius

Irregular heart rate, bradycardia/ tachycardia

Body weight less than 50 kg for a standard 450 mL donation

BLOOD DONATION CHECKLIST

• A Fresh Frozen Plasma unit usually has a volume of 200-250 mL.

• APTT and PT are evaluation parameters for effectiveness of PRBC transfusions

• Albumin can be stored for up to 2 years

• Cryoprecipitates can be stored up to 1 year.

• BT duration should not exceed four hours to prevent septicemia.

• Blood not administered within 20-30 minutes should be returned to the Nurse’s station or hospital pharmacy

• NSS and medications may be added to blood components

BLOOD/ BLOOD COMPONENTS (T or F)

• A Fresh Frozen Plasma unit usually has a volume of 200-250 mL. T

• APTT and PT are evaluation parameters for effectiveness of PRBC transfusions. F: Fresh Frozen Plasma(APTT and PT)

• Albumin can be stored for up to 2 years. F: 5 years

• Cryoprecipitates can be stored up to 1 year. T

• BT duration should not exceed four hours to prevent septicemia. T

• Blood not administered within 20-30 minutes should be returned to the Nurse’s station or hospital pharmacy. F: Blood bank

• NSS and medications may be added to blood components. F: only NSS may be added if blood is highly viscous


3. Baseline data:

2. Lab results:

1. Doc’s Order

Cross-matching and Blood typing

Vital signs

4. At least 2 nurses should check:

Serial number, BT, Rh factor, Expiry date, Screening tests (VDRL & HBsAg)

The Procedure:

BLOOD TRANSFUSION

7. Initial BT rate:

6. Needle gauge & filter:

5. Warm blood to room temp:

Gauge 18

10 gtts/ min for 15-20 mins

8. Duration (Whole blood, Packed RBC): 4 hours

20 mins.

The Procedure:

BLOOD TRANSFUSION

Rewarmer/ towel

8. Duration (platelets, cryoprecipitates):

Can I stop the BT in the presence of an adverse reaction?

Can I give dextrose with the BT?

Can I mix medications with the BT? No

No -- hemolysis

Yes

Drill Questions:

BLOOD TRANSFUSION

3. Collect!

2. Start!

1. Stop! Stop the BT

Start an IV line (0.9% NaCl)

Collect urine specimen

4. Monitor! Monitor V/S

5. Send! Send unused blood and set to blood bank

Transfusion reaction guidelines:

BLOOD TRANSFUSION

7. Document!

6. Administer!

Antihistamines, diuretics, bronchodilators

Transfusion reaction guidelines:

BLOOD TRANSFUSION

Sx

Allergic

Acute Hemolytic

Febrile, Non-Hemolytic

TxETIOLOGYTYPE

TRANSFUSION COMPLICATIONS

Generalized Itching/ Urticaria

Fever,chills, low back pain, chest tightness, dyspnea

Fever w/in 2 hours of BT.

Sx

AntihistaminesSensitivity to plasma proteins

Allergic

Urine/blood specimens. Prevent shock & DIC

ABO incompatibility (most dangerous)

Acute Hemolytic

Antipyretics. Non-life-threatening

Antibodies to donor RBCs (90% of cases)

Febrile, Non-Hemolytic

TxETIOLOGYTYPE


Sx

Circulatory Overload

Bacterial Contamination

TxETIOLOGYTYPE


Fever chills and hypotension, esp. psot BT

Neck vein distention. Dyspnea.

Sx

Upright position with feet dependent. O2. Diuretics. KVO.

Fast BT rate + pt. With heart failure

Circulatory Overload

IVF and antibiotics. Or else, septic shock may occur.

Bacteria Bacterial Contamination

TxETIOLOGYTYPE


• Crossmatching for platelets is usually not required.

• The volume in a unit of platelets may vary from 50 –70 ml to 200-400 ml.

• Platelets can be administered up to 48 hours after receipt from the blood bank

• Platelets should be administered over 1-2 hours only

• Platelet counts are normally evaluated at 1 hour and 1 day post-transfusion.

• Fresh frozen plasma are usually infused within 6 hours of thawing.


• Crossmatching for platelets is usually not required. T

• The volume in a unit of platelets may vary from 50 –70 ml to 200-400 ml. T

• Platelets can be administered up to 48 hours after receipt from the blood bank. F: immediately upon receipt

• Platelets should be administered over 1-2 hours only. F: 15-30 minutes only.

• Platelet counts are normally evaluated at 1 hour and 1 day post-transfusion. T

• Fresh frozen plasma are usually infused within 6 hours of thawing. T


After obtaining a unit of blood from the blood bank, the nurse next looks for which of the following members of the health care team to assist in checking the unit of the blood?

a. Blood bank technician

b. Registered nurse

c. Medical Student

d. Phlebotomis

PRACTICE QUESTIONS

After checking the unit of blood with another nurse, the nurse would assess for which of the following items just before beginning the transfusion?

a. Vital signs

b. Latest hematocrit level

c. Skin color

d. Urine output

PRACTICE QUESTIONS

A nurse has just received an order to transfuse a unit of packed RBCs for an assigned client. In planning coverage for the client assignment, the nurse asks if another nurse will be available to check on the other assigned clients for how long when the unit of blood is hung?

a. 5 minutes

b. 15 minutes

c. 30 minutes

d. 45 minutes

PRACTICE QUESTIONS

A client has an order to receive a unit of packed RBCs. A nurse would obtain which of the following IV solutions from the IV storage area to hang with the blood product at the client’s bedside?

a. 0.9% Sodium Chloride

b. Lactated Ringer’s

c. 5% dextrose in 0.9% Sodium Chloride

d. 5% dextrose in 0.45% Sodium Chloride

PRACTICE QUESTIONS

A nurse who is about to begin a blood transfusion knows that blood cells start to deteriorate after a certain period of time. The nurse checks which of the following items carefully before beginning the transfusion to ensure that this has not happend?

a. Blood identification number

b. Expiration date

c. Blood group and type

d. Presence of clots

PRACTICE QUESTIONS

DAVE MANRIQUEZ, RN

End of LectureThank you so much for your attention!!!

pharmacology

Health & Medicine

drug administration

drug effects

drug categoriespharmacy

drug companies

rt pregnancysafe unsafe

orphan drugs

nursing teachings

rt pregnancyrisk