Download CHAPTER 1 The Nursing Process and Drug Therapy

CHAPTER 1
The Nursing Process
and Drug Therapy
Learning Objectives
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1. List the five phases of the nursing
process.
2. Identify the components of the
assessment process for patients receiving
medications, including collection and
analysis of subjective and objective data.
3. Discuss the process of formulating
nursing diagnoses for patients receiving
medications.
4. Identify goals and outcome criteria for
patients receiving medications.
Learning Objectives
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5. Discuss the evaluation process as it relates to
the administration of medications and as reflected
by goals and outcome criteria.
6. Develop a nursing care plan with use of the
nursing process as it is related to medication
administration.
7. Briefly discuss the Five Rights of drug
administration and the related professional
responsibility for safe medication practice.
8. Discuss the additional rights of drug
administration that are ensured in safe medication
practice.
The Nursing Process
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A research-based organizational framework
for professional nursing practice
Central to all nursing care
Encompasses all steps taken by the nurse
in caring for a patient
Flexibility is important
Critical thinking
Ongoing and constantly evolving process
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The Nursing Process (cont’d)
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Assessment
Nursing diagnosis
Planning
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Goals
Outcome criteria
Implementation
Evaluation
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The Nursing Process (cont’d)
Assessment
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Data collection
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Subjective, objective
Medication history
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Prescriptions
OTCs
Herbals
Responses to medications (therapeutic and
adverse responses)
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The Nursing Process (cont’d)
Nursing diagnosis
 Decision about the need/problem
(actual or at risk for) of the patient
 Critical thinking, creativity, and
accurate data collection
 NANDA format
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The Nursing Process (cont’d)
Nursing diagnosis
 Decision about the need/problem
(actual or at risk for) of the patient
 Critical thinking, creativity, and
accurate data collection
 NANDA format
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The Nursing Process (cont’d)
Nursing diagnosis
Three steps
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Human response to illness (actual or risk)
“related to”
“as evidenced by”
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The Nursing Process (cont’d)
Planning
 Identification of goals and outcome
criteria
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Must be specific and measurable
Must be patient-centered
Time frame
Prioritization
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The Nursing Process (cont’d)
Goals
 Objective, measurable, realistic
 Time frame specified
Outcome criteria
 Specific standard(s) of measure
 Patient oriented
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The Nursing Process (cont’d)
Implementation
 Initiation and completion of the nursing
care plan as defined by the nursing
diagnoses and outcome criteria
 Follow the “Five Rights” of medication
administration
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The Five Rights of
Medication Administration
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Right drug
Right dose
Right time
Right route
Right patient
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Another “Right”—Constant
System Analysis
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A “double-check”
The entire “system” of medication
administration
Ordering, dispensing, preparing,
administering, documenting
Involves the physician, nurse, nursing
unit, pharmacy department, and patient
education
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Other “Rights”
 Proper
drug storage
 Proper documentation
 Accurate dosage calculation
 Accurate dosage preparation
 Careful checking of transcription of
orders
 Patient safety
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Other “Rights” (cont’d)
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Close consideration of special
situations
Prevention and reporting of
medication errors
Patient teaching
Monitoring for therapeutic effects,
adverse effects, toxic effects
Refusal of medication
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Six Elements of a Drug Order
1. Patient's name
2. Date order is written
3. Name of medication
4. Dosage (includes size, frequency, and
number of doses)
5. Route of delivery
6. Signature of the prescriber
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Evaluation
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Ongoing part of the nursing process
Determining the status of the goals
and
outcomes of care
Monitoring the patient’s response to
drug therapy

Expected and unexpected responses
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CHAPTER 2
Pharmacologic Principles
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Learning Objectives
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1. Define the common terms used in
pharmacology (see the listing of terms in the
Glossary).
2. Understand the role of pharmaceutics,
pharmacokinetics, and pharmacodynamics in
medication administration and the application
of the nursing process.
3. Discuss the application of the four
principles of pharmacotherapeutics to
everyday nursing practice as they relate to
drug therapy for a variety of patients in
different health care settings.
Learning Objectives
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4. Discuss the use of natural drug
sources in the development of new
drugs.
5. Develop a nursing care plan that
considers the phases of
pharmacokinetics in carrying out drug
therapy and the nursing process.
Drug
Any chemical that affects the physiologic
processes of a living organism
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Pharmacology
The study or science of drugs
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Drug Names
Chemical name
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Describes the drug’s chemical composition and
molecular structure
Generic name (nonproprietary name)
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Name given by the United States Adopted Name
Council
Trade name (proprietary name)
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The drug has a registered trademark; use
of the name restricted by the drug’s patent owner
(usually the manufacturer)
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Pharmacologic Principles
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Pharmaceutics
Pharmacokinetics
Pharmacodynamics
Pharmacotherapeutics
Pharmacognosy
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Pharmaceutics
The study of how various drug forms influence
pharmacokinetic and pharmacodynamic
activities
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Pharmacokinetics
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The study of what the body does to the
drug
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Absorption
Distribution
Metabolism
Excretion
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Pharmacodynamics
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The study of what the drug does to the
body
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The mechanism of drug actions in living
tissues
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Pharmacotherapeutics
The use of drugs and the clinical
indications for drugs to prevent and treat
diseases
Empirical therapeutics
 Rational therapeutics

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Pharmacognosy
The study of natural (plant and animal)
drug sources
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Pharmaceutics
Dosage form design affects dissolution
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Pharmacokinetics: Absorption
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The rate at which a drug leaves its
site of administration, and the extent
to which absorption occurs
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Bioavailability
Bioequivalent
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Factors That Affect Absorption
Absorption characteristics vary according
to the dosage form and route
Food or fluids administered with the drug
 Dosage formulation
 Status of the absorptive surface
 Rate of blood flow to the small intestine
 Acidity of the stomach
 Status of GI motility
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Routes
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A drug’s route of administration affects
the rate and extent of absorption of that
drug
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Enteral (GI tract)
Parenteral
Topical
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Enteral Route
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Drug is absorbed into the systemic
circulation through the oral or gastric
mucosa or the small intestine
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Oral
Sublingual
Buccal
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First-Pass Effect
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The metabolism of a drug and its passage
from the liver into the circulation
– A drug given via the oral route may be
extensively metabolized by the liver before reaching
the systemic circulation (high first-pass effect)
– The same drug—given IV—bypasses the liver,
preventing the first-pass effect from taking place,
and more drug reaches the circulation
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First-Pass Effect and Box 2-1 (Drug
Routes and First-Pass Effect)
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Parenteral Route
 Intravenous
(fastest delivery into the blood
circulation)
 Intramuscular
 Subcutaneous
 Intradermal
 Intrathecal
 Intraarticular
 Transdermal can be considered parenteral,
too
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Topical Route
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Skin (including transdermal patches)
Eyes
Ears
Nose
Lungs (inhalation)
Rectum
Vagina
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Distribution
The transport of a drug in the body by
the bloodstream to its site of action
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Protein-binding
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Water soluble vs. fat soluble
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Blood-brain barrier
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Areas of rapid distribution: heart, liver,
kidneys, brain
Areas of slow distribution: muscle, skin,
fat
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Metabolism
(Also Known as Biotransformation)
The biochemical transformation of a drug into
an inactive metabolite, a more soluble
compound, or a more potent metabolite
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Liver (main organ)
 Skeletal muscle
 Kidneys
 Lungs
 Plasma
 Intestinal mucosa
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Metabolism/Biotransformation
Biologic transformation of a drug into:
An inactive metabolite
 A more soluble compound
 A more potent metabolite
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Metabolism/Biotransformation
(cont’d)
Organs or body tissues
Liver (main)
 Skeletal muscle
 Kidneys
 Lungs
 Plasma
 Intestinal mucosa
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Metabolism/Biotransformation
(cont’d)
Factors that decrease metabolism
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Cardiovascular dysfunction
Renal insufficiency
Starvation
Obstructive jaundice
Slow acetylator
Erythromycin or ketoconazole drug therapy
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Metabolism/Biotransformation
(cont’d)
Factors that increase metabolism
 Fast acetylator
 Barbiturate therapy
 Rifampin therapy
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Metabolism/Biotransformation
(cont’d)
Delayed drug metabolism results in:
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Accumulation of drugs
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Prolonged action of the drugs
Stimulating drug metabolism causes:
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Diminished pharmacologic effects
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Metabolism/Biotransformation
(cont’d)
Cytochrome P-450 enzymes
Also known as microsomal enzymes
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Excretion
The elimination of drugs from the body
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Kidneys (main organ)
Liver
Bowel
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Biliary excretion
Enterohepatic recirculation
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Half-life
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The time it takes for one half of the original
amount of a drug in the body to be removed
A measure of the rate at which drugs are
removed from the body
Most drugs are considered to be effectively
removed after about five half-lives
Steady state
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The Movement of Drugs
Through the Body
Drug actions
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The cellular processes involved in the drug
and cell interaction
Drug effect
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The physiologic reaction of the body to the
drug
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Onset, Peak, and Duration
Onset
 The
time it takes for the drug to elicit a
therapeutic response
Peak
 The
time it takes for a drug to reach its
maximum therapeutic response
Duration
 The
time a drug concentration is sufficient to
elicit a therapeutic response
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Therapeutic Drug Monitoring
Peak Level
 Highest
blood level
Trough Level
 Lowest
blood level
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Ways Drugs Produce
Therapeutic Effects
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Once the drug is at the site of action, it
can modify the rate (increase or
decrease) at which the cells or tissues
function
A drug cannot make a cell or tissue
perform a function it was not designed
to perform
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Pharmacodynamics:
Mechanisms of Action
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Receptor interactions
Enzyme interactions
Nonspecific interactions
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Pharmacotherapeutics:
Types of Therapies
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Acute therapy
Maintenance therapy
Supplemental/replacement therapy
Palliative therapy
Supportive therapy
Prophylactic therapy
Empiric therapy
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Contraindication
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Any characteristic of the patient,
especially a disease state, that makes
the use of a given medication
dangerous for the patient
It is important to assess for
contraindications!
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Monitoring
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The effectiveness of the drug therapy
must be evaluated
One must be familiar with the drug’s:
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Intended therapeutic action (beneficial)
Unintended but potential adverse effects
(predictable, adverse reactions)
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Monitoring (cont’d)
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Therapeutic index
Drug concentration
Patient’s condition
Tolerance and dependence
Interactions
Adverse drug effects
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Monitoring (cont’d)
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Therapeutic index
– The ratio between a drug’s therapeutic
benefits and its toxic effects
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Monitoring (cont’d)
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Tolerance
– A decreasing response to repeated drug
doses
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Monitoring (cont’d)
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Dependence
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A physiologic or psychological need for
a drug
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Monitoring (cont’d)
Interactions may occur with other drugs
or food
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Drug interactions: the alteration of action of
a drug by:
 Other prescribed drugs
 Over-the-counter medications
 Herbal therapies
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Monitoring (cont’d)
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Drug interactions
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Additive effect
Synergistic effect
Antagonistic effect
Incompatibility
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Monitoring (cont’d)

Adverse Drug Events
Medication errors
 Adverse drug reactions

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Monitoring (cont’d)
Adverse Drug Reactions
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Pharmacologic reactions, including adverse
effects
Hypersensitivity (allergic) reaction
Idiosyncratic reaction
Drug interaction
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Monitoring (cont’d)
Adverse effects
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Predictable, well-known reactions that result
in little or no change in patient management
Predictable frequency
Occurrences are related to the size of the
dose
Usually resolve when the drug is
discontinued
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Other Drug-Related Effects
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Teratogenic
Mutagenic
Carcinogenic
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Pharmacognosy
Four main sources for drugs
 Plants
 Animals
 Minerals
 Laboratory synthesis
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Toxicology
The study of poisons and unwanted
responses to drugs and other chemicals
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CHAPTER 3
Life Span Considerations
Learning Objectives
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1. Discuss the influences of the patient’s
age on the effects of drugs and drug
responses.
2. Identify drug-related concerns during
pregnancy and lactation and provide an
explanation of the physiologic basis for
these concerns.
3. Discuss the process of pharmacokinetics
and associated changes in various patient
age groups, such as in pediatrics,
pregnancy, and the elderly.
Learning Objectives
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4. Summarize the impact of age-related
changes on pharmacokinetics in drug
therapy.
5. Calculate a drug dosage for a pediatric
patient using a variety of formulas.
6. Identify the importance of a body surface
area nomogram for pediatric patients.
7. Develop a nursing care plan for drug
therapy and the nursing process for patients
across the life span.
Life Span Considerations
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Pregnancy
Breast-feeding
Neonatal and Pediatric
Elderly
Pregnancy
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First trimester is the period of greatest
danger for drug-induced
developmental defects
Drugs cross the placenta by diffusion
During the last trimester the greatest
percentage of maternally absorbed
drug gets to the fetus
FDA pregnancy safety categories
Breast-feeding
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Breast-fed infants are at risk for
exposure to drugs consumed by the
mother
Consider risk-to-benefit ratio
Neonatal and Pediatric Considerations:
Pharmacokinetics
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Absorption
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Gastric pH less acidic
Gastric emptying is slowed
Intramuscular absorption faster and
irregular
Neonatal and Pediatric
Considerations: Pharmacokinetics
(cont’d)
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Distribution
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The younger the person, the greater the
% of total body water
Greater TBW means fat content is lower
Decreased level of protein binding
Immature blood-brain barrier—more
drugs enter the brain
Neonatal and Pediatric
Considerations: Pharmacokinetics
(cont’d)
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Metabolism
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Liver immature, does not produce enough
microsomal enzymes
Older children may have increased
metabolism, requiring higher doses than
infants
Other factors
Neonatal and Pediatric
Considerations: Pharmacokinetics
(cont’d)
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Excretion
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Kidney immaturity affects glomerular
filtration rate and tubular secretion
Decreased perfusion rate of the kidneys
may reduce excretion of drugs
Factors Affecting Pediatric Drug
Dosages
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Skin is thin and permeable
Stomach lacks acid to kill bacteria
Lungs have weaker mucus barriers
Body temperatures less well regulated and
dehydration occurs easily
Liver and kidneys are immature, impairing
drug metabolism and excretion
Methods of Dosage Calculation
for Pediatric Patients
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Body surface area method
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Using the West nomogram
Body weight dosage calculations
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Using mg/kg
Pediatric Considerations:
Medication Administration
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General interventions
Infants
Toddlers
Preschoolers
School-aged children
Adolescents
The Elderly
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Elderly: older than age 65
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Healthy People 2010: older than age 55
Use of OTC medications
Increased incidence of chronic
illnesses
Polypharmacy
Physiologic Changes
in the Elderly Patient
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Cardiovascular
Gastrointestinal
Hepatic
Renal
The Elderly:
Pharmacokinetics
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Absorption
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Gastric pH less acidic
Slowed gastric emptying
Movement through GI tract slower
Reduced blood flow to the GI tract
Reduced absorptive surface area due to
flattened intestinal villi
The Elderly:
Pharmacokinetics (cont’d)
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Distribution
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TBW percentages lower
Fat content increased
Decreased production of proteins by the
liver, resulting in decreased protein
binding of drugs (and increased circulation
of free drugs)
The Elderly:
Pharmacokinetics (cont’d)
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Metabolism
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Aging liver produces fewer microsomal
enzymes, affecting drug metabolism
Reduced blood flow to the liver
The Elderly:
Pharmacokinetics (cont’d)
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Excretion
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Decreased glomerular filtration rate
Decreased number of intact nephrons
The Elderly:
Problematic Medications
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Analgesics, including NSAIDs
Anticoagulants
Anticholinergics
Antidepressants
Antihypertensives
Cardiac glycosides (digoxin)
Sedatives and hypnotics
Thiazide diuretics