This document provides an overview of pharmacology basics including definitions of key terms, drug categories, pharmacodynamics, pharmacokinetics, drug computations, and examples of nursing teachings related to over-the-counter medications and sample patient cases. Key concepts covered include drug absorption, distribution, metabolism, excretion, factors influencing drug effects, allergic reactions, and conversions between units of measurement for drug dosages.

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

2. Basic concepts and Drug Categories

3. 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

4. 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:

5. 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

6. Brand/ Trade name Generic name Chemical name DEFINITION OF TERMS

7. 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

8. 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

9. 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? Nursing teachings for OTCs: SAMPLE CASE

10. 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? Nursing teachings for OTCs: SAMPLE CASE

11. 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? Nursing teachings for OTCs: SAMPLE CASE

12. od,bid,tid,qid ad lib ac, pc Vital facts: COMMON ABBREVIATIONS OD, OS, OU Rx take

13. elix Tr ss , ss Vital facts: COMMON ABBREVIATIONS dil One half tincture Dilute or dissolve

14. Category A According to the Food and Drug Administration: DRUG CATEGORIES (in r/t PREGNANCY) Safe for human fetus

15. Category B According to the Food and Drug Administration: DRUG CATEGORIES (in r/t PREGNANCY) Risk to animal fetus Safe to animal fetus Safe for human fetus Inadequate studies on H.F.

16. According to the Food and Drug Administration: DRUG CATEGORIES (in r/t PREGNANCY) Category C Adverse effects on animal fetus Inadequate studies on H.F.

17. According to the Food and Drug Administration: DRUG CATEGORIES (in r/t PREGNANCY) Category D Risk to human fetus Given if benefits outweigh the risk

18. Category X According to the Food and Drug Administration: DRUG CATEGORIES (in r/t PREGNANCY) 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

19. Tetracycline? Streptomycin? Penicillin? Ampicillin? Cephalosporins? Erythromycin? Can RIP be given to a TB gravida client? Safe/ Unsafe drugs:    DRUG CATEGORIES (in r/t PREGNANCY)

20. Safe/ Unsafe drugs: Antihistamines, Decongestants, Acetaminophen?  Quinine antimalarials?  Non-quinine only General anesthetics? Metronidazole?  DRUG CATEGORIES (in r/t PREGNANCY)

21. Isotretinoin: Streptomycin: Anticonvulsants (Phenytoin) Unsafe drugs: CHD, Cleft lip/ palate (steroids) Nerve deafness CNS defects DRUG CATEGORIES (in r/t PREGNANCY)

22. Unsafe drugs: Iodides: Goiter and mental retardation Lithium: Congenital heart defects Barbiturate, Aspirin: Bleeding problems DRUG CATEGORIES (in r/t PREGNANCY)

23. Pharmacodynamics

24. 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

25. 2 mechanisms: Def’n: Vital facts: Process by which drug alters cell physiology Being an agonist or an antagonist PHARMACODYNAMICS

26. Receptor sites: PHARMACODYNAMICS Areas on the cell membranes where drugs act

27. Antagonist: Agonists: Receptor sites PHARMACODYNAMICS Example: Insulin Curare antagonizes Ach @ Ach Receptor sites

28. Other concepts: PHARMACODYNAMICS Selective toxicity: Drug attacks only those foreign cell systems Example: Penicillin vs. Bacterial infections Chemothera-peutic drugs vs. Rapidly multiplying cells

29. Pharmacokinetics

30. 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

31. PHARMACOKINETICS: ABSORPTION

32. Def’n.: Vital facts: Process by which drug passes into the bloodstream PHARMACOKINETICS: ABSORPTION

33. 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: PHARMACOKINETICS: ABSORPTION

34. 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: PHARMACOKINETICS: ABSORPTION

35. Ideal time for giving oral drugs: Safest way to deliver drugs: Oral route 1 hour ac/ 2 hours pc Vital facts: PHARMACOKINETICS: ABSORPTION

36. IM & gender differences: Males  more muscles  reaches peak levels faster IM & heat to injection site: Increased absorption Vital facts: PHARMACOKINETICS: ABSORPTION

37. PHARMACOKINETICS: DISTRIBUTION

38. Eg: 1 st 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 PHARMACOKINETICS: DISTRIBUTION

39. 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 PHARMACOKINETICS: DISTRIBUTION

40. 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: PHARMACOKINETICS: DISTRIBUTION

41. 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: PHARMACOKINETICS: DISTRIBUTION

42. ? Trivia Time What anti-inflammatory drug is ideal for meningitis? PHARMACOKINETICS: DISTRIBUTION

43. ? Trivia Time: ANSWER Dexamethasone PHARMACOKINETICS: DISTRIBUTION

44. Critical thinking question: Would you consider a person who has malnutrition at a higher risk for Aspirin toxicity? Why? PHARMACOKINETICS: DISTRIBUTION

45. PHARMACOKINETICS: BIOTANSFORMATION

46. 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

47. Drugs that increase metabolism: Alcohol, nicotine, glucocorticoids Drugs that may decrease metabolism: Ketoconazole, Quinidine PHARMACOKINETICS: METABOLISM AKA: Detoxification Vital facts:

48. PHARMACOKINETICS: EXCRETION

49. 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 PHARMACOKINETICS: EXCRETION

50. Half- life: Useful concepts: Half-life x 8= removal from body PHARMACOKINETICS: EXCRETION Peak level: Trough level: 15-30 minutes after giving the dose 15-30 minutes before giving the next dose

51. 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? PHARMACOKINETICS: EXCRETION

52. Drug effects and Misuse

53. 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)

54. 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

55. 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

56. Cross- allergies: Drug allergy: Succeeding allergic reactions are usually much worse than the 1st Sulfa drugs Allergic Reactions DRUG EFFECTS

57. The Normal Distribution: DRUG EFFECTS

58. 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

59. Dermatological rxns: Mild: skin care. Severe: Stop & call doc Blood dyscrasias: Ensure periodic CBCs DRUG EFFECTS Allergic Reactions

60. 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

61. 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

62. 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

63. 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

64. Lesser dose of Codeine needed More pain relief Aspirin is added Codeine for pain relief Additive effect: An example

65. Example: Iatrogenic disease: Disease unintentionally caused by medical therapy Hepatotoxicity, Fetal malformations Different types: DRUG EFFECTS

66. Physiologic dependence Drug dependence Drug abuse Different types: DRUG MISUSE Psychologic dependence Drug habituation

67. 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:

68. Drug habituation: Pyschological d.: DRUG MISUSE Emotional dependence on a drug Mild psychological dependence Different types:

69. Drug Computations

70. Formula: DRUG COMPUTATIONS Dose on hand Dose Desired = Quantity on hand Quantity desired(x)

71. Formula: DRUG COMPUTATIONS Erythromycin 500 mg is ordered. It is supplied in a liquid form containing 250 mg in 5 ml.

72. Formula: DRUG COMPUTATIONS Dose on hand Dose Desired = Quantity on hand Quantity desired(x) 250 mg 5 mL 500 mg

73. 1 Liter=__ quarts Vital conversion values: DRUG COMPUTATIONS 1 quart 1 Liter=__ pints 2 pints

74. 1cup=___ mL Vital conversion values: DRUG COMPUTATIONS 240 mL

75. 1 mL=__ drops/minims Vital conversion values: 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

76. Vital conversion values: DRUG COMPUTATIONS 1 tablespoon=___mL or ___teaspoons 15 mL= 3 teaspoons

77. 1 gram(g)=___ grains Vital conversion values: DRUG COMPUTATIONS 60 grains (gr)= 1 mL Grains= basic unit of solid measurement in Apothecary system

78. 1 kg=__ lbs Vital conversion values: DRUG COMPUTATIONS 2.2 lbs

79. Vital conversion values: DRUG COMPUTATIONS 1 gallon=___Liters/ quarts 4 Liters= 4 quarts

80. Vital conversion values: DRUG COMPUTATIONS 1 mg =___ mcg 1,000 mcg

81. 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!!! 

82. 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/minute B) 20 microdrops/minute C) 30 microdrops/minute D) 40 microdrops/minute DRUG COMPUTATIONS

83. 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

84. 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 hour B) 30 ml per hour C) 50 ml per hour D) 60 ml per hour DRUG COMPUTATIONS

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

86. An infant who weighs 11 lb (5 kg) is to receive 750 mg of antibiotic in a 24-hour period. The liquid antibiotic comes in a concentration of 125 mg per 5 ml. If the antibiotic is to be given three times each day, how many milliliters would the nurse administer with each dose? A. 2 B. 5 C. 6.25 D. 10 DRUG COMPUTATIONS

87. 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

88. A patient who weighs 14 kg has a left lower leg cellulitis. The drug ordered is ceftriaxone sodium (Rocephin), 75 mg/ kg/day IV piggy-back in two divided doses. Which of the following amounts is correct for each dose? A. 105 mg B. 250 mg C. 525 mg D. 1050 mg DRUG COMPUTATIONS

89. A patient with a deep vein thrombosis is receiving 1200 units of heparin per hour, intravenously by infusion pump. The solution available is heparin 25,000 units/500 ml. Which of the following is the correct pump setting? A. 20 ml/hr B. 58 ml/hr C. 24 ml/hr D. 13 ml/hr DRUG COMPUTATIONS

90. A client has an order to receive 1000 ml of intravenous fluids in 8 hours. The intravenous set delivers 60 microdrops per ml. The nurse should administer approximately how many microdrops of fluid per minute? A. 21 B. 40 C. 63 D. 125 DRUG COMPUTATIONS

91. 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 in F ants: F ried’s

92. Child’s dose= Applies to: Young’s Rule: PEDIATRIC DRUG COMPUTATIONS Children ages 1 – 12 years old Child’s age in years Child’s age in years + 12 Y oung’s Y ears X average adult dose

93. Child’s dose= Applies to: Clark’s Rule: PEDIATRIC DRUG COMPUTATIONS Any pediatric client Weight of child in lbs. 150 pounds C lark’s C alories (weight) X average adult dose

94. Child’s dose= Applies to: Surface area calculation: PEDIATRIC DRUG COMPUTATIONS Any pediatric client Surface area in square meters 1.73 X average adult dose

95. The usual adult dose of Benadryl is 50 mg. What would be a safe dose for a child weighing 27 1bs? a. 0.9 mg b. 1.8 mg c. 9.0 mg d. 18 mg PEDIATRIC DRUG COMPUTATIONS

96. The average adult dose of meperidine is 75 mg. What dose would be appropriate for a 10-month-old infant? a. 50 mg b. 5 mg c. 25 mg d. 0.5 mg PEDIATRIC DRUG COMPUTATIONS

97. Principles in Drug Administration

98. Medication Orders / Forms of Meds

99. 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

100. 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

101. 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

102. SIX Essential parts: DRUG ORDER Drug dosage: Amount and frequency Method of administration Signature of physician/ NP Telephone orders – signed 1 st by the nurse then by the physician within 24- 48 hours

103. 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

104. Douches: FORMS OF MEDICATION Forms: Powder or liquid concentrations

105. Elixirs: FORMS OF MEDICATION Contents: Water+ alcohol+ Sorbitol + sweeteners

106. Suppositories: FORMS OF MEDICATION Position upon insertion: Left sims

107. Troches: FORMS OF MEDICATION Other names: Lozenges; Pastilles

108. Basic Principles

109. 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

110. 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: ADMINISTERING MEDICATIONS

111. Always assess client status before giving meds Double check: Identify the client: Process: ADMINISTERING MEDICATIONS Check wristband with Medication Administration Record Ask the client or another nurse to identify client

112. Process: ADMINISTERING MEDICATIONS Give the medication Never leave @ bedside Evaluate and document

113. 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 ADMINISTERING MEDICATIONS

114. 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

115. ADMINISTERING ORAL MEDICATIONS

116. 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: ADMINISTERING ORAL MEDICATIONS

117. Sustained release: Enteric coated: Irritating to GIT if crushed Shorter duration of action if crushed Drug forms for oral administration: ADMINISTERING ORAL MEDICATIONS

118. ? Trivia Time What guideline should be followed to allow for maximum absorption of elixirs after giving? ADMINISTERING ORAL MEDICATIONS

119. ? Trivia Time: ANSWER Allow 30 minutes to elapse before giving water ADMINISTERING ORAL MEDICATIONS

120. Measurement guide when reading liquid medications: How many times do you verify the “right drug”? Commonly asked questions? ADMINISTERING ORAL MEDICATIONS 3x Read at the bottom of the meniscus at eye level Before, during and after giving the drug

121. Commonly asked questions? ADMINISTERING ORAL MEDICATIONS 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

122. ? Trivia Time Why are honey and essential food items avoided when mixing medications for pediatric clients? ADMINISTERING ORAL MEDICATIONS

123. ? Trivia Time: ANSWER To prevent botulism; to ensure adequate nutrition ADMINISTERING ORAL MEDICATIONS

124. 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 ADMINISTERING ORAL MEDICATIONS

125. I Qu Quinidine Isoniazid E Erythromycin T Tetracycline Normally taken on an empty stomach with a full glass of water: ADMINISTERING ORAL MEDICATIONS

126. A C R P S Normally taken on an empty stomach with a full glass of water: ADMINISTERING ORAL MEDICATIONS Cephalosporin Acetaminophen, Aspirin Rifampin Sulfonamides Penicillin, Proprantheline

127. G C Cimetidine, Carbamazepine Griseofulvin f food N S Spironolactone Nitrofurantoin Normally taken with food to improve absorption: ADMINISTERING ORAL MEDICATIONS

128. H P Propranolol Hydralazine I Indomethacin L. Lithium Normally taken with food to improve absorption: ADMINISTERING ORAL MEDICATIONS

129. ADMINISTERING SUBLINGUAL MEDICATIONS

130. Sublingual/ Buccal: Rapidly absorbed in the bloodstream, bypasses liver  Swallowing it may deactivate the drug ADMINISTERING MEDICATIONS

131. ADMINISTERING TOPICAL MEDICATIONS

132. Ophthalmic: ADMINISTERING MEDICATIONS

133. 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: ADMINISTERING MEDICATIONS

134. 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: ADMINISTERING MEDICATIONS

135. Otic: ADMINISTERING MEDICATIONS

136. 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: ADMINISTERING MEDICATIONS Straighten ear canal: pinna up & back: Above 3

137. 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: ADMINISTERING MEDICATIONS

138. Nasal: ADMINISTERING MEDICATIONS

139. 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: ADMINISTERING MEDICATIONS Daily sprays: Use alternate nares

140. Nebulization/ MDIs: ADMINISTERING MEDICATIONS

141. 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 ADMINISTERING MEDICATIONS Nebulization/ MDIs: Time interval in between next dose: 1 minute

142. ? Trivia Time What should you instruct the client to do if steroid medications were given via MDI ADMINISTERING MEDICATIONS

143. ? Trivia Time: ANSWER Rinse mouth to prevent oral fungal infection ADMINISTERING MEDICATIONS

144. Rectal Instillations/ Suppositories ADMINISTERING MEDICATIONS

145. 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 ADMINISTERING MEDICATIONS Rectal Instillations/ Suppositories

146. ADMINISTERING PARENTERAL MEDICATIONS

147. Sites: Intradermal Injection: Inner lower arm, upper chest/back, beneath scapulae ADMINISTERING MEDICATIONS

148. 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 ADMINISTERING MEDICATIONS Intradermal Injection: Needle length: 3/8” to ½”

149. June 2006 Board Exam question: 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

150. June 2006 Board Exam question: What is gauge of the needle used for intradermal injections? a. 27 b. 23 c. 18 d. 20 MEDICATION ORDERS

151. Sites: Subcutaneous: ID sites+ anterior thighs, abdomen, gluteal areas ADMINISTERING MEDICATIONS

152. When injecting at 45 degrees: Dosage: Meds given SQ: Vaccines, insulin, heparin, narcotics 0.5-1mL 5/8 needle Needle gauge: 25-27 Subcutaneous: ADMINISTERING MEDICATIONS When injecting at 90 degrees: 1/2 needle

153. For obese patients: For thin patients: 45 degree angle of needle 90 degree angle of needle ADMINISTERING MEDICATIONS Subcutaneous: For heparin injection: Do not aspirate nor massage For insulin injections: Inject @ 90 but don’t massage For other injections: Aspirate before injecting

154. ? Trivia Time What should be ideally done if blood is seen upon withdrawal of the plunger? ADMINISTERING MEDICATIONS

155. ? Trivia Time: ANSWER Remove the needle and discard the medication/equipment ADMINISTERING MEDICATIONS

156. Intramuscular: ADMINISTERING MEDICATIONS

157. Possible sites: Length: Gauge: 20-23 1-2 inches Gluteal, Vastus lateralis, deltoid Intramuscular: ADMINISTERING MEDICATIONS

158. ADMINISTERING MEDICATIONS Intramuscular: VENTROGLUTEAL SITE

159. Abduct middle finger Place index finger over ASIS Hand heel over greater trochanter Triangle formed below crest is the site ADMINISTERING MEDICATIONS Intramuscular: VENTROGLUTEAL SITE

160. ADMINISTERING MEDICATIONS Intramuscular: VENTROGLUTEAL SITE

161. Muscle: Gluteus medius Degree of contamination: Lesser since it’s farther from rectal area ADMINISTERING MEDICATIONS Intramuscular: VENTROGLUTEAL SITE Ventrogluteal: V on Hochsteter’s Site: V entrogluteal formed is the V site V essel-free

162. Purpose of above instructions: Instructions when side-lying: Instructions when prone: Curl toes inward Flex knee/hip Relax muscles ADMINISTERING MEDICATIONS Intramuscular: VENTROGLUTEAL SITE

163. ADMINISTERING MEDICATIONS Intramuscular: DORSOGLUTEAL SITE Imaginary line from PSIS to GT

164. ADMINISTERING MEDICATIONS Intramuscular: DORSOGLUTEAL SITE 4 quadrants– Upper outer quadrant

165. Risks: Contraindicated age: Below 3 years old Injury to sciatic nerve/ major blood vessel ADMINISTERING MEDICATIONS Intramuscular: DORSOGLUTEAL SITE

166. CHULOU H. PENALES, RN ADMINISTERING MEDICATIONS Vital fact: Recommended site for infants Intramuscular: VASTUS LATERALIS

167. ADMINISTERING MEDICATIONS Intramuscular: DELTOID MUSCLE Acromion Process (2 inches below)

168. Site is approx 2 inches from AP Midpoint between AP & axillary fold Acromion Process ADMINISTERING MEDICATIONS Intramuscular: DELTOID MUSCLE

169. Risks: Deltoid: 0.5 – 2 mL ADMINISTERING MEDICATIONS Gluteus Medius: 1-5 mL Relatively small muscle; possible injury to radial nerve & artery Intramuscular: DELTOID MUSCLE

170. Z-track method: ADMINISTERING MEDICATIONS

171. To massage or not to massage? When is it used? Z-track IM method: Irritating meds (eg: Iron) Do not massage. ADMINISTERING MEDICATIONS

172. 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 ADMINISTERING MEDICATIONS

173. 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 

174. 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 

175. 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 1,2,3 b. 2,3,4 c. 1,3,4 d.1,2,3,4 PRACTICE QUESTIONS 

176. 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 

177. Parenteral Medications and IV fluids

178. Extracellular fluids Intracellular fluids Division of Body fluids 40% of body weight 20% of body weight PARENTERAL MEDICATION/ IV FLUIDS

179. Diffusion Movement of Fluids PARENTERAL MEDICATION/ IV FLUIDS

180. Osmosis Movement of Fluids PARENTERAL MEDICATION/ IV FLUIDS

181. Filtration Movement of Fluids PARENTERAL MEDICATION/ IV FLUIDS

182. Exercise Question: What is the mechanism by which Mannitol decreases IOP in patients with Glaucoma? a. Diffusion b. Osmosis c. Filtration d. Diuresis PARENTERAL MEDICATION/ IV FLUIDS

183. 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 PARENTERAL MEDICATION/ IV FLUIDS

184. 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 PARENTERAL MEDICATION/ IV FLUIDS

185. 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 PARENTERAL MEDICATION/ IV FLUIDS

186. 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 PARENTERAL MEDICATION/ IV FLUIDS

187. Osmotic/ Oncotic pressure Hydrostatic pressure Pressures within the Blood vessel Pushing force of a fluid against the walls that contain it Pulling power of a solution for water PARENTERAL MEDICATION/ IV FLUIDS

188. ? Trivia Time What happens when hydrostatic pressure exceeds osmotic/oncotic pressure? PARENTERAL MEDICATION/ IV FLUIDS

189. ? Trivia Time: ANSWER 3 rd space fluid shift: manifested by decreased urine output. Occurs in burns, peritonitis, massive bleeding into a joint/cavity. PARENTERAL MEDICATION/ IV FLUIDS

190. Trivia Question: Are osmolality and Osmolarity the same? PARENTERAL MEDICATION/ IV FLUIDS

191. Osmolarity: Osmolality: Osmolality vs Osmolarity Solute / Kg of Water Solute/ Kg of a solution PARENTERAL MEDICATION/ IV FLUIDS

192. Osmolality vs Osmolarity Can we use the terms interchangeably? Yes If osmolality is high, what is the osmotic pressure of that solution? High PARENTERAL MEDICATION/ IV FLUIDS

193. 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 PARENTERAL MEDICATION/ IV FLUIDS

194. Isotonic solution Types of solutions: PARENTERAL MEDICATION/ IV FLUIDS

195. Indications: Dehydration or any ECF volume deficit Types of solutions: ISOTONIC Same osmolality as plasma Osmolality: PARENTERAL MEDICATION/ IV FLUIDS

196. Normal Saline(PNSS; 0.9% NaCl): NaCl ISOTONIC Solutions: Ringer’s Sol’n.: Na,K,Ca Lactated Ringer’s: Ringer’s + Lactate & Chloride PARENTERAL MEDICATION/ IV FLUIDS

197. Trivia Question: Do most isotonic fluids contain dextrose, magnesium or bicarbonate? NO PARENTERAL MEDICATION/ IV FLUIDS

198. 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 PARENTERAL MEDICATION/ IV FLUIDS

199. Hypertonic solution Types of solutions: PARENTERAL MEDICATION/ IV FLUIDS

200. Indications: Hyponatremia Types of solutions: HYPERTONIC Used in limited doses in carefully controlled settings via an infusion pump Precaution: Hypernatermia & FVO Risks: Close monitoring (V/S; Lungs; Neuro; Na) Nursing action: PARENTERAL MEDICATION/ IV FLUIDS

201. 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 PARENTERAL MEDICATION/ IV FLUIDS

202. 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 PARENTERAL MEDICATION/ IV FLUIDS

203. 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

204. Trivia Question: Do most hypertonic solutions provide calories to cells? Yes PARENTERAL MEDICATION/ IV FLUIDS

205. Hypotonic solution Types of solutions: PARENTERAL MEDICATION/ IV FLUIDS

206. Indications: Cellular dehydration Types of solutions: HYPOTONIC Acute brain injury Major contraindication: PARENTERAL MEDICATION/ IV FLUIDS

207. 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

208. 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 PARENTERAL MEDICATION/ IV FLUIDS

209. Sample Question: Does D5W provide adequate nutritional calories? No, but it does prevent ketosis PARENTERAL MEDICATION/ IV FLUIDS

210. Colloid volume expanders Types of solutions: PARENTERAL MEDICATION/ IV FLUIDS

211. Indications: Acute volume loss Types of solutions: Colloid volume expanders Albumin, Dextran, Hetastarch Examples: PARENTERAL MEDICATION/ IV FLUIDS

212. Air embolism prevention by: Priming IV tubing Change IV tubing every: 72 hours Change IV needle insertion site every: 15-20 minutes PARENTERAL MEDICATION/ IV FLUIDS IV Fluid therapy guidelines: Regulate IV every: 72 hours

213. Infiltration: IV INFUSION COMPLICATIONS

214. 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 IV INFUSION COMPLICATIONS

215. Thrombophlebitis: IV INFUSION COMPLICATIONS

216. 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 IV INFUSION COMPLICATIONS

217. Circulatory Overload: IV INFUSION COMPLICATIONS

218. 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: IV INFUSION COMPLICATIONS

219. Drug Overload: IV INFUSION COMPLICATIONS

220. Action: Symptoms: Dizziness, shock, fainting Slow infusion to KVO rate then call doctor Drug Overload: IV INFUSION COMPLICATIONS

221. Pulmonary Embolism: IV INFUSION COMPLICATIONS

222. 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 IV INFUSION COMPLICATIONS Pulmonary Embolism:

223. Prevention: Possible cause: Due to rapid IV push administration Give IV push medications over 3-5 minutes IV INFUSION COMPLICATIONS Speed shock:

224. Insulin Therapy and Oral Hypoglycemics

225. INSULIN Types of Insulin: Combination Insulin (Regular / Intermediate) Long-acting Intermediate- Acting Short-acting Rapid/ultra-short

226. INSULIN Types 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

227. INSULIN IN ACTION Long-acting Intermediate acting Short acting Rapid Duration Peak Onset Insulin type

228. INSULIN IN ACTION x2 x3 +10 / 3 Long-acting x3 x3 + 10 / 2 Intermediate acting x3 2-4 hours KEY VALUE / 2 Short acting x3 .5-1.5 hours / 2 Rapid Duration Peak Onset Insulin type

229. 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 R egular Insulin First (Clear) Draw N PH Insulin Next (Cloudy)

230. INSULIN Dawn phenomenon vs. Somogyi Effect

231. 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

232. 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

233. 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 Treatment Cause Causes of Morning Hyperglycemia

234. INSULIN & LIPODYSTROPHY: TYPES Treatment Significance Appearance HYPERTROPHY ATROPHY FEATURES

235. 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 HYPERTROPHY ATROPHY FEATURES

236. 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:

237. Abdomen Anterior thighs Hips Posterior arms INSULIN SQ INJECTION SITES (note: size of circle= speed of insulin absorption)

238. ? Trivia Time How frequent should injection sites be rotated? INSULIN SQ INJECTION SITES

239. INSULIN SQ INJECTION SITES ? Trivia Time: ANSWER Every 2-3 weeks

240. INSULIN USE in the PREGNANT WOMAN 1 ST 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

241. INSULIN USE in the PREGNANT WOMAN 2 nd 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

242. INSULIN USE in the PREGNANT WOMAN 3 rd 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

243. INSULIN USE in the PREGNANT WOMAN IMMEDIATE POST-PARTUM HPL is gone. Insulin resistance: Insulin Requirements: Disappears 1 st 24 hours: NO INSULIN NEEDED Thereafter: PRE-PREGNANT INSULIN REQUIREMENTS

244. ORAL HYPOGLYCEMICS

245. 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:

246. SULFONYLUREAS Common names: *Chlorprop amide ( Diab inese) Tolbut amide (Orinase) Glimepi ride (Amaryl) Glipi zide (Glucotrol) Glybu ride (DiaBeta ) First Generation Second Generation

247. 2 nd : 1 st : Urine Urine & bile SULFONYLUREAS 1 st generation versus 2 nd generation: Mode of Excretion Implications: 2 nd is safer for patients with renal dysfunction

248. 2 nd : 1 st : 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

249. 2 nd : 1 st : High Low SULFONYLUREAS 1 st generation versus 2 nd generation: Cardiovascular disease risk

250. 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:

251. Hypovolemia Extreme dehydration HHNK Prevent hypovolemia Fluid conservation SULFONYLUREAS Action: HHNK Palliative treatment Sulfonylureas increase ADH effectiveness

252. So what if it’s short? Half-life: Major suffix: -glinide Very short Lesser hypoglycemic effect Indication: Adjuncts to sulfonylureas MEGLITINIDES Vital facts:

253. MEGLITINIDES Common names: Nate glinide (Starlix) Repa glinide ( Pran din)

254. 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:

255. Common s/e: S/e to look out for: Major suffix: None  Liver toxicity GIT disturbances Indication: Adjuncts to sulfonylureas ALPHA- GLUCOSIDASE INHIBITORS Vital facts:

256. ALPHA- GLUCOSIDASE INHIBITORS . Common names: Acarbose (Precose) Miglitol (Glyset)

257. 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:

258. Common s/e: S/e to look out for: Major suffix: None  Liver toxicity GIT disturbances Indication: Adjuncts to sulfonylureas BIGUANIDES Vital facts:

259. BIGUANIDES Example: Metformin (Glucophage)

260. BIGUANIDES Increases ability of Insulin to bind to peripheral tissues Increased glucose uptake by cells Mild hypoglycemic effect: Adjunct to Sulfonylureas Action:

261. ? Trivia Time What acid-base imbalance could occur with the intake of Biguanides? BIGUANIDES

262. ? Trivia Time: ANSWER Lactic acidosis BIGUANIDES

263. S/e #2: S/e #1: Major suffix: -glitazone Fluid retention  edema Hepatotoxicity  Jaundice Indication: Adjuncts to sulfonylureas THIAZOLIDINEDIONES Vital facts:

264. THIAZOLIDINEDIONES Common names: Pio glitazone (Actos) Rosi glitazone (Avandia)

265. THIAZOLIDINEDIONES Decreases peripheral resistance to Insulin Increased glucose uptake by cells Mild hypoglycemic effects Action:

266. ANTI-HYPOGLYCEMICS Major 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.

267. DIAZOXIDE Diazoxide as a Vasodilator: Venous stasis: Dependent edema = weight gain Low Venous return = Hypotension blood pools in veins

268. DIAZOXIDE Inhibits B-cells from producing Insulin: Anti-sulfonylurea Increase peripheral insulin resistance Reduced Insulin action Hyperglycemic effect Diazoxide as an anti-hypoglycemic agent:

269. 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:

270. 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:

271. 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

272. HYPOGLYCEMIA

273. 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

274. HYPOGLYCEMIA ? Trivia Time What may be the only sign of hypoglycemia in an unconscious person?

275. ? Trivia Time: ANSWER Diaphoresis HYPOGLYCEMIA

276. Brain is depleted of glucose Hypoglycemic coma HYPOGLYCEMIA: SIMPLE PATHOPHYSIOLOGY Brain damage: paralysis, cognitive impairment Dangers of Hypoglycemia: Inadequate glucose to support brain activity

277. ? Trivia Time Between a DKA coma and Hypoglycemic coma, which one is more serious and why? HYPOGLYCEMIA

278. ? Trivia Time: ANSWER Hypoglycemic coma HYPOGLYCEMIA

279. 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

280. Same with Mild Hypoglycemia Blood glucose 21-40 mg/dL MODERATE HYPOGLYCEMIA: TREATMENT

281. Upon arrival @ hospital: Once conscious: Still unconscious after ten minutes: Unconscious: Blood glucose 20 mg/dL below SEVERE HYPOGLYCEMIA: TREATMENT SQ/ IM Glucagon 2 nd dose of Glucagon Give small meal Give IV 25-50 mL of Dextrose 50% in water

282. 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 

283. 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 

284. 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 

285. 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 

286. 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 

287. Oxygen Therapy

288. Anemic hypoxia: Circulatory hypoxia: Hypoxemic hypoxia: Indication: Hypoxia OXYGEN THERAPY VP imbalances, Hypoventilation Cardiogenic shock Anemia Histotoxic hypoxia: CO, Cyanide poisoning

289. OXYGEN THERAPY Low Flow Systems High Flow Systems 25-50 90 above 60-90 40-60 20-40 O2 % (FiO2) Oxygen Tent 5-10 Venturi Mask 6-15 Non- Rebreather 6-15 Partial Rebreather 6-8 Face Mask 2-6 Nasal Cannula LPM DELIVERY SYSTEM

290. Non-constant O 2 % delivered Contributes partially to the gas the patient breathes Oxygen is delivered independent of the pt’s. breathing Constant O 2 % FiO 2 varies with pt’s breathing Constant FiO 2 e.g. :Face mask T-piece, Tracheostomy collars Low-Flow vs. High Flow Systems OXYGEN THERAPY

291. Mnemonic: 24 hours in 1 day OXYGEN THERAPY (% of O2 DELIVERED : LPM) LPM % of O2 (FiO2)

292. Mnemonic: 24 hours in 1 day OXYGEN THERAPY (% of O2 DELIVERED : LPM) 5 40 4 36 3 32 2 28 1 24 LPM % of O2 (FiO2)

293. 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

294. Build-up of oxygen free radicals Cells metabolize oxygen O 2 > 50% for more than 48 hours Oxygen toxicity: Free radicals can damage/ kill cells OXYGEN THERAPY

295. 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

296. OXYGEN THERAPY Nasal cannula

297. 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.

298. OXYGEN THERAPY Consequence of flow rates>6-8lpm: Nasal cannula Air swallowing, mucosa drying

299. OXYGEN THERAPY Face mask

300. 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

301. Partial Rebreather mask OXYGEN THERAPY

302. Why rebreathe? Mechanism: Partial Rebreather mask OXYGEN THERAPY 1/3 of exhaled tidal volume is rebreathed. Such air is O2 rich. The initial 1/3 exhaled air was mainly the dead space

303. Deflation means : Safety alert! Partial Rebreather mask OXYGEN THERAPY R.B. must be 2/3 full with inhalation Deflation means decreased O2 delivered. Reservoir bag must not deflate completely!

304. OXYGEN THERAPY Non- Rebreather mask

305. OXYGEN THERAPY Guidelines: Air inhaled: O 2 delivered: Non- Rebreather mask Bag deflation consequence: Same guidelines with partial rebreather masks Only Pure O 2 is inhaled Highest amount of O 2 delivered Suffocation can result with bag deflation

306. OXYGEN THERAPY Venturi mask

307. OXYGEN THERAPY Mechanism: Oxygen delivery: Venturi mask Exact proportion of room air + o2 is inhaled Most accurate oxygen delivery system

308. The oxygen administration device preferred for patients with COPD is: a. Nasal cannula b. Oxygen tent c. Venturi mask d. Oxygen hood PRACTICE QUESTIONS 

309. 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 

310. 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 

311. 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 

312. 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 

313. Blood Transfusion

314. TYPES OF BLOOD DONATION Homologous Blood salvage Autologous Homologous: Other person’s blood Blood salvage: Autologous donation Autologous: Patient’s own blood

315. TYPES OF APHERESIS Plasmapheresis Stem Cell harvest Erythrocyta-pheresis Leukapheresis Platelet pheresis PURPOSE: to remove… TYPE

316. TYPES OF APHERESIS Plasma proteins Plasmapheresis Circulating stem cells Stem Cell harvest RBCs Erythrocyta-pheresis WBCs Leukapheresis Platelets Platelet pheresis PURPOSE: to remove… TYPE

317. BLOOD/ BLOOD COMPONENTS Single donor platelets Fresh Frozen Plasma Random platelets Packed RBCs Whole blood INDICATION/S COMPOSITION TYPE

318. BLOOD/ BLOOD COMPONENTS Decreased alloimmunization risk Platelets from a single donor Single donor platelets Bleeding d/o All 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 plasma Whole blood INDICATION/S COMPOSITION TYPE

319. BLOOD/ BLOOD COMPONENTS Albumin Cryoprecipitate INDICATION/S COMPOSITION TYPE

320. BLOOD/ BLOOD COMPONENTS Burns Albumin Albumin Hemophilia A&B, VWD Von Will. Fx, Fx VIII, Fibrinogen Cryoprecipitate INDICATION/S COMPOSITION TYPE

321. Blood Components

322. 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 ______. BLOOD/ BLOOD COMPONENTS

323. 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 . BLOOD/ BLOOD COMPONENTS

324. 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

325. 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)

326. 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 BLOOD/ BLOOD COMPONENTS (T or F)

327. 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

328. 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):

329. 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

330. 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

331. 7. Document! 6. Administer! Antihistamines, diuretics, bronchodilators Transfusion reaction guidelines: BLOOD TRANSFUSION

332. TRANSFUSION COMPLICATIONS Sx Allergic Acute Hemolytic Febrile, Non-Hemolytic Tx ETIOLOGY TYPE

333. TRANSFUSION COMPLICATIONS Generalized Itching/ Urticaria Fever,chills, low back pain , chest tightness, dyspnea Fever w/in 2 hours of BT. Sx Antihistamines Sensitivity 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 Tx ETIOLOGY TYPE

334. TRANSFUSION COMPLICATIONS Sx Circulatory Overload Bacterial Contamination Tx ETIOLOGY TYPE

335. TRANSFUSION COMPLICATIONS 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 Tx ETIOLOGY TYPE

336. 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. BLOOD/ BLOOD COMPONENTS (T or F)

337. 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 BLOOD/ BLOOD COMPONENTS (T or F)

338. 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 

339. 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 

340. 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 

341. 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 

342. 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 

343. DAVE MANRIQUEZ, RN End of Lecture Thank you so much for your attention!!!