Describe about the Medications for Excerting Aspect of Drug.
Pharmacokinetics- It is referred to as the study of the time- course of absorbing, distributing, metabolizing and excreting aspect of a drug (ASHP- chapter 1). The clinical pharmacokinetics involves applying the principles of pharmacokinetics to administer the drugs safely and effectively for a patient.
Pharmacodynamics- It involves the study of the bio-chemical and physiological effect of a drug. It refers to the interrelationship between the concentration of drug at the required site of action and the outcome effect that includes the time- course, intensity (therapeutic and adverse effects) of a drug (ASHP- chapter 1, American Psychiatric Publishing, Chapter 8).
‘Generally pharmacokinetics is what human body does to a drug whereas pharmaco dynamics involves what a drug does to human body (Association of prescribers, 2016)’.
Pharmacotherapeutics- It involves the study of the beneficial (therapeutic) and desired effects of drugs (Nursing pharmacology chronicle, 2011).
Toxicology- It is the study of the side (adverse) effects of a drug in a human body due to the chemicals. It includes observing the adverse effects and reporting the effects, identifying the mechanisms, detecting and treating the toxic substances (Smith, 2016).
A is on Digoxin with dosage of 250mcg/day which means that she is in high-dose digoxin therapy. Digoxin is taken as safe to use in the old age people as long as the dose is no greater than 0.125 milligram or 125 mcg per day (Wiley, 2015). She is 71 year old woman with 250mcg/day of dosage ahs increased her adverse effects. The kidney functions of elderly people slows down as their age increase which may lead to decreased excretion of certain drugs as digoxin leading to stagnation of drugs (Wiley, 2015). This has resulted in digoxin overdose in Mrs.A expressing the adverse effects as unusual behavior, confusion, easily fatigability, irritability, obsessive and compulsive behavior with yellowish green moldy appearance (Wiley, 2015, Micromedex, 2016). Mrs. A is both on digoxin and furosemide (loop diuretics) which may cause hypokalemia that may increase toxicity in older persons (Lewis, 2004, Davis, 2016). The patient should be instructed to discontinue digoxin and electrolyte disturbances, thyroid dysfunction should be corrected and digoxin antidote (digoxin immune Fab- Digibind), should be given which binds with digitalis- glycoside molecule and is excreted from renal tubules (Davis, 2016).
Increasing age causes changes in pharmacokinetic and pharmacodynamic aspects of drugs. The pharmacokinetic changes involves reduced kidney and liver clearance and an increased distribution of lipid- soluble drugs (hence prolonging the half-life of elimination) whereas pharmacodynamic changes involves alterations (commonly increased) in sensitivity to many drug classes such as anti-coagulants, cardio-vascular and psycho-tropic drugs (Mangoni, 2004). In elderly, the timing of absorption rate may be delayed, peak concentration may be lowered and delay in timing of peak concentration and the absorption of overall amount of drug (bioavailability) remain changed. Further, the metabolic clearance of medications by the liver might be reduced because of reduced liver blood- flow, reduced size and mass of liver. Even ageing decreases size of kidney, its blood flow, functional nephrons, tubular secretion and ultimately decreasing glomerular filtration rate. Due to ageing, drug clearance of certain drugs as atenolol, digoxin, etc may be decreased. Overall, the age induced changes in pharmacodynamics include increased sensitivity to sedative drugs, increased psycho-motor impairment with certain drugs, increased timing of pain relief, increased drowsiness, decreased heart rate to beta- blockers, increased cardiac sensitivity to digoxin (Farho, 2016).
Case study- Mr. B
WHO defines the adverse- drug reaction (ADR) as the noxious, un-intentional and un-desirable effect of a medication/ drug that happens at doses, which are used in case of prophylactic treatment, diagnostic procedures and collaborative therapies for the human. ADR is also stated as an identifiable harmful or any un-pleasant reaction that results due an intervention that is based on medicinal product. It is of two types as Type-A and B (Edwards, 2000). Type- A reactions are expected type of exaggeration of the drug with known effect whereas type B reactions are idio-syncratic and not known type of allergy. The adverse- drug reactions are divided into 6 types as dose- related (augmented), not dose- related (bizarre), dose- related as well as time- related (chronic), time- related (delayed), with-drawal (end-of-use) and failure of therapies (failure).
The main goal of allergic drug reaction involves recognition of clinical features of allergic reaction at the earliest, maintenance of patent airway, administering drugs and treating shock. As Mr. B already has IV cannula, disconnect the IV flow (but don’t remove the IV access) and inform to the physician. Perform quick assessment for circulation, breathing and airway. Obtain oxygen saturation by pulse oximetry and check for progression of symptom.
Continuously monitor vital signs of Mr. B. Monitor the respiratory rate, effort, depth and use of accessory muscle for respiration. Assess the oxygen saturation level by using pulse oximetry to know the level of saturation and PO2 less than 92 mm Hg indicates severe oxygen insufficiency which requires endo-tracheal intubation or tracheostomy (Lewis, 2004). Assess the level of consciousness and his cardiac rhythm as any changes may indicate requiring hypovolemic shock treatment. Monitor the urine output of Mr. B, as decreased flow will indicate progression to severe anaphylactic shock.
A nurse should inform the physician and follow his orders. Based on his orders, start intra venous infusion of 0.5 ml of epinephrine by diluting it as 1: 10,000 at an interval of 5 to 10 minute. Administer oxygen (high flow oxygen) through non- re breather oxygen mask (Lewis, 2004). Administer drug di-phenhydramine (Benadryl) through intra muscular or intravenous injection. Administer histamine- H2 receptor blockers such as Tagamet (cimetidine). Maintain blood pressure of Mr. B by administering fluids (normal saline), volume expanders, vasopressors as dopamine- Inotropin, nor- epinephrine bitartrate- levophed. Place the patient in recumbent position and elevate the legs of Mr. B to increase brain perfusion. It has to be informed to allergy specialist where they will educate Mr. B about its prevention and avoidance later (ASCIA, 2016). The presence of allergy should be informed to all his care givers, other staff nurses and para- medicals.
The Patient should be instructed to document the features of allergic episode to find out the avoidable causes of allergy in the next 6 to 8 hours after the onset of allergic reaction. If Mr. B is unable to document, the doctor or nurse practitioner can document it. The ASCIA- anaphylaxis event record should be used while collecting the information (ASCIA, 2016). The name of the patient (Mr. B), date and time of allergic reaction, general practitioner and specialist attended during the allergic event, suspected triggers (drug- amoxicillin), type of adverse reactions as itching in chest region, tightness in chest and throat, difficulty and noisy breathing, difficulty to speak and tongue swelling should be recorded. The place of allergic reaction (hospital), activity before allergic reaction, medical condition (community- acquired pneumonia) and past reactions (nil for Mr. B), known allergens and any adrenaline auto-injector has been prescribed (ASCIA, 2015).
B should be instructed about the presence of allergy for drug amoxicillin. He should be instructed to avoid this drug. He should be explained that he has to inform the presence of intolerance to drug amoxicillin to the physicians and nurses while giving care. In case of new admission to any hospital he has to inform about the presence allergic reaction to amoxicillin at the time of history collection and fill the allergy form with type, location, previous adverse events, etc in the admission form He has to wear a medic- alert bracelet with listing about the allergy for drug which helps medical professionals to understand about his allergy (Lewis, 2004, Douglas, 2012). He should be referred to allergy specialist where the allergy specialist will educate about prevention and avoidance of allergy and managing co morbidities. Allergy specialist will instruct about ASCIA- action plan for combating anaphylaxis and preparing for future attacks (ASCIA, 2016).
I will get feedback from Mr. B about the type of allergic reaction he has and about his allergy to amoxicillin. I will ask Mr. B to fill the event- record for allergic reactions with the description of his allergies and adverse events. (ASCIA, 2015). This will help me to get feedback as what he knows about his allergic reactions.
The allergy and adverse reactions should be documented in two separate boxes. The allergy box should be marked in case of mild allergy to anaphylaxis and adverse- drug reaction (ADR) box should be marked when there is unintended after administration of drugs. These information on should be marked as Yes or No and the appropriate medication should be documented and the allergies/ adverse reaction box documented in the last page reminds the prescriber or administrator of medication about these reactions (NMCU, 2012).
The nursing assessment of fluid overload is important. EN should assess for airway obstruction due to edema caused by fluid overload to maintain patent airway. She should assess the respiratory, rate, rhythm, pattern and depth of respiration, use of accessory and visible intercostal muscles and nasal flaring to rule out the presence of dypnoea. Auscultation to rule out presence of pulmonary edema (crackle and wheezing sound) should be done (Douglas, 2012). The circulatory status should be assessed by checking for bounding pulse, oxygen saturation with pulse oximetry. Blood pressure should be recorded as hypertension may occur. The neurological status (level of consciousness, orientation, GCS), skin (edema) should be assessed.
The focus of this problem is pain. Notice the way how the D, A, and R are written.
|
Date/Hour |
Focus |
Progress Notes |
|
11/30/2016 1100hrs |
Pain |
D: · Reports sudden, unbearable sharp pain on the incision site with pain score of 8/10 · Shows facial grimace · Guards the incision site · Crying with pain · Highly restless and irritable A: · Administered Tab. Paracetamol, 1 gm PO as per doctor’s order. · Encouraged to perform deep breathing exercises · Demonstrated relaxation techniques · Patient felt comfortable and remain safe R: · Amelia reports relief from pain · Looks calm and comfortable. · Pain score- 0/10 |
Complementary therapies such as guided imagery, hypnotherapy, music therapy, medication, yoga, relaxation therapy, art therapy, biofeedback, breathing exercises, prayer techniques, etc should be given to relieve pain. These techniques will relieve relax the Amelia’s mind and divert her. This will help to get relief from pain (Douglas, 2012).
On 30.11.2016 at 09.00 am. Endone, 5 mg 6Hrly and Tab. Paracetamol, 1 gm 4 Hrly was administered orally as per doctor’s order. Kept patient comfortable and safe. No complications noted.
Aboriginal people use centering approach to manage pain. It causes stimulated sleep in patients with pain in which withdrawal of pain psychologically and spiritually (Queensland government, 2014). The nurse should give respect to their traditional medicine. She has to discuss pain management strategies without hurting their cultural feelings. They should be involved in the pain management strategies.
Case study- Marshall
Every patient has a right to refuse the treatment. No treatment and diagnosis should be made without consent. A nurse should explain Mrs.Marshall about importance of atorvastatin, side effects and methods to overcome it. She should explain about the management of side effects. A detailed explanation with complete and sufficient information should be given to Mrs.Marshall to help them to understand the uses of taking atorvastatin. The patient is refusing to take atorvastatin due to its side effects, so methods to overcome it should be explained (NCMIC, 2007).
10. There are many risk factors and complications of IV therapy. The main complication is circulatory overloaded which means the intra vascular fluid compartment contains more fluid than that of normal. It occurs when the fluids are infused more rapidly and more amounts are given than needed level. This overload may lead to heart failure then pulmonary edema and if not controlled leading to death of an individual. The next complication is infiltration in which escape of fluid into sub-cutaneous layer due to improper insertion of IV cannula. It may cause development of swelling, pain, numbness, coldness and hardness around insertion site. Extravasations may also occur in which blood from the veins may flow out of the vessels due to the damage of blood vessels leading to hematoma formation. Thrombophlebitis may occur due to the physical trauma or mechanical trauma by chemicals (Douglas, 2012). Pyrogenic reactions such as increased temperature, nausea, vomiting and circulatory collapse may occur within 30 minutes of infusion. Air embolism is a serious complication in which small air particles may enter into the blood vessels during needle insertion and circulates in the blood vessels blocking the blood supply to vital organs. Infection at insertion site, allergic reactions, hepatitis, osmotic diuresis and nerve damage may occur.
Strict aseptic technique should be followed. The IV cannula and bottles should be sterile. The hand with cannula should be placed flat on the bed to avoid dislodgement. The infusion rate should not be too rapid or slow. The patient should be advice to keep hand out of water. It should be used only for 3- 4 days to prevent infection and for blood transfusion, IV cannula has to be changed daily (Douglas, 2012). Before and after administration of drugs IV cannula has to be flushed with hepflush. Blood sample for investigations should be taken from new IV line.
The indications are to save the life of the patient as in case of hemorrhage, shock, etc and to provide fluid in case of dehydration, to supply nutrients to patients with oral disorders, vomiting, etc. It is indicated to dilute toxins in case of septicemia and poisoning and administer drugs as a treatment method (Douglas, 2012). It is given to restore fluid and blood volume, to meet nutritional and fluid requirement and to treat shock by providing electrolytes.
Reference
American Psychiatric Publishing. Chapter 8. Principles of Pharmacokinetics and Pharmacodynamics. Retrieved from https://dx.doi.org/10.1176/appi.books.978158623860.as08
ASCIA. (2016). ASCIA Guidelines – Acute management of anaphylaxis. Retrieved from https://www.allergy.org.au/health-professionals/papers/acute-management-of-anaphylaxis-guidelines
ASCIA. (2015). Event Record for Allergic Reaction. Retrieved from https://www.allergy.org.au/images/pcc/ASCIA_event_record_allergic_reactions_2015.pdf
ASHP. (n. d.). Introduction to Pharmacokinetics and Pharmacodynamics: Pharmacokinetics: Chapter-1. Retrieved from https://www.ashp.org/doclibrary /bookstore/ p2418-chapter1.aspx 1-12
Association of prescribers. (2016). Pharmacokinetics and Pharmacodynamics: Edge Hill university. Retrieved from https://www.associationforprescribers.org.uk/images/ Pharmacokinetics_and_Pharmacodynamics_the_basics.pdf
Davis. (2016). Davis’s drug guide. Retrieved from https://www.drugguide.com/ddo/view/Davis-Drug-Guide/51218/all/digoxin
Douglas, C. (2012). Potter and Perry’s Fundamentals of Nursing- Australian version. (4th ed.). St. Louis, Missouri: Elsevier
Edwards, I.R. (2000). Adverse drug reactions: definitions, diagnosis, and management: Lancet. 356(9237):1255-9. doi: 10.1016/S0140-6736(00)02799-9
Farho, L. (2016). Geriatric Pharmacotherapy: University of Nebraska Medical Center. Retrieved from https://pharmacologycorner.com/category/therapeutic-groups/cardiovascular-drugs/antiarrhythmics/
Lewis, S.M., Heitkemper, M. M., & Dirksen, S.R. (2013). Medical Surgical Nursing: Assessment and Management of Clinical Problems. (9th ed.). Missouri: Mosby
Mangoni, A.A. (2004). Age-related changes in pharmacokinetics and pharmacodynamics: basic principles and practical applications: Br J Clin Pharmacol. 57(1): 6–14. doi: 10.1046/j.1365-2125.2003.02007.x
Micromedex (2016). Drugs- Digoxin. Retrieved from https://www.mayoclinic.org/drugs-supplements/digoxin-oral-route/side-effects/drg-20072646
NCMIC. (2007). What Should I Do If My Patient Refuses My Recommendations?. Retrieved from https://www.ncmic.com/prc/risk-management/clinical-risks/what-should-i-do-i-my-patient-refuses-my-recommendations.aspx
NMSP- NATIONAL MEDICATION SAFETY PROGRAMME. (2012). National Medication Chart USER GUIDE: Health Quality & Safety Commission. Retrieved from https://www.hqsc.govt.nz/assets/Medication-Safety/NMC-PR/NMC-UserGuide-Oct2012.pdf
Nursing pharmacology Chronicle. (2011). Pharmacotherapeutics- Definition. Retrieved from https:// nuring +phramocolgy= chronicle/ Pharmacotherapeutics
Queensland government. (2014). Aboriginal and Torres Strait Islander patient care guideline. Retrieved from https://www.health.qld.gov.au/atsihealth/documents/patient_care_guideline.pdf
Smith, Y. (2016). What is Toxicology?. Retrieved from https://www.news-medical.net/health/What-is-Toxicology.aspx
Wiley, F. (2015). Drug- Digoxin. Retrieved from https://www.everydayhealth.com/drugs/digoxin
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