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Pharmacology mindmap, Hospital Pharmacology and Therapeutics Committee…
Pharmacology mindmap
Iloprost infusion 36ml/h 50microg diluted in 250ml of compatible fluid.
Iloprost is a medication administered according to the protocol to improve blood flow for the treatment of conditions compromising blood circulation such as peripheral vascular disease, PAH, Buerger's disease, PAOD with rest pain or tissue loss where revascularization is not possible and Raynaud's syndrome. It is commonly used to enhance healing to non-healing peripheral wounds.
Iloprost acts by binding to the prostacyclin receptors in various target cells causing vasodilation, inhibit platelet aggregation and decrease tumor cell adhesion endothelium among many other effects.
The dose of Iloprost is individualized and titrated based on patient weight rounded to the nearest 10kg over time in conjunction with monitoring side effects as per the dose nomogram and monitoring form.
Iloprost is administered as an intermittent infusion over 6 hours once daily via a peripheral or central venous catheter.
Contraindications include pregnancy, lactation, hypersensitivity to Iloprost or other excipients, severe coronary heart disease, any cerebrovascular events within the last three months, unstable angina, MI within the last six months, congestive heart failure, conditions where there is a increased risk of haemorrhage, congenital or acquired valvular defects or pulmonary hypertension due to venous occlusive disease. It should not be administered in patient's with systolic arterial hypotension less then 85mmHg.
Iloprost should be administered with precaution in patients with liver cirrhosis, or dialysis patients, patients who are current smokers, patients with increased risk of bleeding and in patients with low blood pressure. Avoid skin contact with the medication as it may provoke long-lasting erythema.
Side effects of Iloprost include flushing or excessive sweating, pains including headache and jaw pain, gastrointestinal symptoms such as diarrhoea, and vomiting, and changes in blood pressure and heart rate. These side effects can be vigilantly managed using the side effect management guide attached to the protocol.
This patient's benefit from the prescribed infusions were determined to outweigh the patients contraindication risks present
Patients receiving Iloprost should be monitored as per the protocols monitoring guide and observations should be recorded on the monitoring form attached to the protocol and dosage nomogram. Monitor and manage side effects accordingly, if severe reactions occur the infusion should be stopped immediately then one hour after the symptoms have resolved restart the infusion at half the rate.
Legal guidelines for medication administration
A year 3 nursing student is not able to administer intravenous Iloprost as it is outside the year 3 scope of practice. The administration of this medication requires two RN checks. If the infusion rate requires altering this must also be checked by a second RN to check and co-sign.
Before administering any medication the 6 rights of medication administration is required to be completed to ensure safe administration including; right time, right dose, right patient, right indication, right drug and right route. The patient's name, date of birth and identification wristband should be checked against the prescription chart. Allergies should also be checked prior to administration.
A nurse is required to obtain adequate knowledge and understanding of the polices and procedures for the administration of a medication including the use of controlled drugs. They must also understand the legal, professional and ethical issues around the administration of a medication. The Medicines Act 1981 outlines the law related to the manufacturing, sale and supply of medications, medical devices and related products in NZ.
The Health Practitioners Competence Act 2003 aims to protect the health and safety of the public by providing mechanisms to ensure that health professionals are competent and safe to practice their professions. This act sets guidelines for the way practitioners are registered, monitors education institutes, degrees and courses of study, prescribes the qualifications for scopes of practice and how professional competence and safety is maintained in practice.
Medications such as Iloprost and oxycodone are required to be checked by two RNs. This requires the second RN to double check the medication, dose and expiry date against the patients prescription and co-sign the medication prior to administration. All controlled, intravenous, subcutaneous and intramuscular medications require a co-sign by another RN
Health care professionals must understand and practice in accordance to their scope of practice. To do so they must understand their responsibilities, activities, function and decision making within their specified role. Registered Nurses have a responsibility for all actions towards their patients including the administration of medications. Therefore, students have the responsibility when administering medications to be under the direct supervision of the RN preceptor at all times during the administration. If this does not occur it is a breach of the districts health board's, learning institute's and Nursing Council of NZ's guidelines and policies.
Furthermore the Misuse of Drugs Act 1975 classifies that nurses are required to be aware of controlled drugs, the correct storage and local workshop policies and procedures on how to store them, decreasing the risk of harm and public access to these controlled drugs
The Code of Health and Disability Services consumers rights (2004) outlines the importance of informing all health care consumers of their rights. It is a nurses responsibility to adhere to this code when providing health care to all consumers. The nurse must understanding and respect the patient's right to refuse treatments such as medications and the right to be fully informed about the health care they are receiving including all information about the medications they are taking.
Bumetanide 1mg once daily
Bumetanide is a loop diuretic medication.
This medication is used in the treatment of acute heart failure, acute pulmonary oedema, hypertension and oedema of HF, renal disease or liver disease.
Loop diuretics act within the loop of Henle. They act to block the chloride pump within the descending loop of Henle, where 30% of all filtrated sodium is reabsorbed decreasing the reabsorption of sodium and chloride. These medications have a similar effect in both the descending loop of Henle and in the distal convolute tubule resulting in the production of large amounts of sodium rich urine. This drug can produce a fluid loss of approximately 10L a day therefore are typically the drug of choice when a rapid diuresis is required.
Bumetanide is available as an oral tablet. It reaches peak levels in 60-120 minutes. It is metabolized with a half life of 30-60 minutes and excreted in the urine.
Contraindications include hypersensitivity or allergies to loop diuretics, severe renal failure and electrolyte depletion. This medication should not be used with pregnant women unless the benefit severely outweighs the risk to the fetus. This medication should also be used with caution in diabetics, and those with gout.
Adverse effects are generally related to electrolyte and fluid imbalances in the body that loop diuretics cause. Hypokalaemia, alkalosis, hypocalaemia and hypotension. Long term use of the drug can also effect blood glucose levels.
This medication should be used with extreme caution with NSAID such as ibuprofen. Anticoagulant effects increased when combine with loop diuretics. The risk if ototoxicity increases if combined with aminoglycosides or cisplatin.
Oxycodone 10-20mg PO Q6Hourly.
Oxycodone is a opioid agonist used in the treatment of moderate to severe pain in adults. Dose range is usually 5-30mg PO 6 hourly.
Opioid agonists target and act on specific opioid receptor sites within the central nervous system to cause analgesia, sedation or a sense of euphoria.
Opioid agonists hold an increased risk of the development of physical dependence and are therefore classified as a controlled drug. When selecting an opioid, all aspects of a persons condition must be considered as every person is different and everyone's response to a medication is different.
These medications undergo hepatic metabolism and are typically excreted in the urine and bile.
Opioid agonists are known to cross the placenta and enter breast milk. Oxycodone is a pregnancy category B while all other opioid agonists are category C therefore is considered the drug of choice for pregnant women of one is required.
Oxycodone extended release tablets have been linked to drug abuse as if the tablet is crushed, cut or chewed the entire dose of the drug is released at once. Caution must be used in people with respiratory dysfunction, known opioid intolerances or allergies, recent GI or GU surgeries, head injuries, alcoholism or cerebral vascular disease. Also in people with renal or liver dysfunction which can alter the metabolism or excretion of the drug.
Adverse effects include mild abdominal upset including diarrhea, vomiting or pain, drowsiness or feeling dizzy, fatigue, slow or abnormal heart beats, muscle spasms or changes in urination.
Insulin-Lantus OD+ Novorapid PRN pre meals-units determined by BSL checks.
Insulin is available in many various types for short term and long term coverage. It is the only parenteral hypoglycaemic agent for exogenous replacement. Insulin is used to treat type 1 and type 2 diabetes in adults who have no response to alternative treatments such as diet, exercise and other agents.
Insulin is a hormone usually produced in the beta cells of the pancreatic islets. It promotes the storage of body fuels, facilitates the transport of various metabolites and ions across cell membranes and also stimulates the synthesis of glycogen from glucose, of fats from lipids and proteins from amino acids. Insulin does this by reacting with specific cell receptor sites. In people with diabetes insulin production is either compromised or non-existent.
Insulin preparations, both long term and short term are processed within the body like endogenous insulin. The peak, onset and duration of each vary due to the placement or addition of glycine or arginine chains.
Insulin maintenance is administered subcutaneously. Administration sites are required to be rotated regularly to avoid damage to muscles and to prevent subcutaneous atrophy.
As insulin is a hormone replacement medication there are no contraindications. Insulin does not close the placenta, it does enter breast milk however is destroyed by the GI tract and does not effect the infant. People with beef and pork allergies should only use human made insulins as insulin can be produced from cow and pig pancreas.
The most common adverse effects are hypoglycaemic and ketoacidosis which can be managed and controlled with proper dose adjustments.
Novorapid has a inset of 15 minutes, a peak at 1-3 hours and a duration of 3-5 hours. Lantus has an onset of 60-70 minutes, no peak and a duration of 24 hours.
Paracetamol 1g 4houly no more than 4 times daily.
Paracetamol is a commonly used medication used to treat mild to moderate pain and fever. It is also commonly used to treat the signs and symptoms of the common cold or flu, musculoskeletal pain associated with arthritis and rheumatic disorders.
This medication is one of the most commonly used medications and is easily accessible over the counter and is found in many combination drugs. However, this medication is extremely toxic causing severe liver toxicity that when used in high doses can cause death. This medication can be administered 1gram every four hours however dosage should not exceed 4grams within 24 hours.
This medication acts directly on the hypothalamus in the brain to cause vasodilation and sweating which reduces fever. The exact mechanism of action of paracetamol is not understood.
This medication is metabolized in the liver and excreted in the urine.
Adverse reactions include rash, fever, chest pain, liver toxicity and failure, bone marrow suppression.
Oral paracetamol peaks within 0.5-2 hours and has a duration of 3-6 hours. This medication is also available for IV administration commonly used in patient's who are NBM or absorption or metabolism is compromised.
Aspirin 100mg OD
Aspirin has an onset of 5-30 minutes, Peaking between 25minutes to 2 hours and lasts 3-6 hours, the drug is metabolized in the liver and excreted in the urine.
This medication interacts with other medications that affect blood clotting. When aspirin is combine with other similar medications the risk of excessive bleeding is drastically increased.
Aspirin is a antiplatelet medication that is commonly prescribed to individuals at risk of recurrent TIA's, myocardial infarctions or strokes. This medication acts by inhibiting platelet synthesis of thromboxane A2 therefore inhibiting platelet aggregation.
Adverse effects: hyperpnoea, fever, cardiovascular collapse, hepatic impairment, nausea, GI bleeding or distress, heartburn, blood loss, dizziness, epigastric discomfort, tinnitus, anaphylaxis or skin rash.
Dose range 30mg-325mg once daily.
This medication should be used with caution in pregnant women as aspirin can increase the risk of bleeding. It should only be used if the benefit to the mother outweighs the risk to the fetus. Aspirin is also contraindicated in breastfeeding.
Atorvastatin 40mg OD
This medication acts by blocking the HMG- CoA reductase enzyme which is involved in the early rate-limiting step in the synthesis of cellular cholesterol. When this enzyme is blocked, serum cholesterol and LDL levels are decreased as more LDLs are being absorbed into the cells to make for the production of cholesterol. HDL levels in contrast increase due to the alteration in fat metabolism. HMG-CoA reductase inhibitors block HGM-CoA reductase from completing cholesterol synthesis.
Atorvastatin is absorbed from the GI tract and then metabolized in the liver. It is excreted in the urine and faeces. The peak effect of this drug and others within the statin drug class is usually seen within 2-4 weeks. this drug is most effective when taken at night as this is when the liver is processing the most lipids.
Used in adjunct to diet as a treatment of high levels of cholesterol, triglycerides and LDL.
This patient had a drug intolerance to majority of medications within the statin drug class however tolerated Atorvastatin. This drug was the determined the best option to treat his hypercholesterolemia without causing harm to the patient's health and well-being.
Atorvastatin belongs to a group of medications called HMG- CoA reductase inhibitors.
Dose range 10mg- 80mg orally once daily.
The patient is a 70 year old man admitted to the general surgical ward after presenting to ED with a non-healing wound from a 2nd toe amputation 5 months prior. The patient was admitted for pain management and medical intervention to enhance healing. He had a history of type one diabetes (since age 10), hypercholesterolemia, congestive heart failure, ischemic heart disease-NSTEMI 2017, and ischemic stroke. This patient's history of ischemia events and congestive heart failures contraindicates the use of Iloprost however in this case the benefits outweighed the risks for this patient's recovery.
Hospital Pharmacology and Therapeutics Committee TDHB. (2020). Iloprost Administration Guidelines. TDHB
References:
New Zealand Nurses Organisation. (2018). Guidelines for nurses on the administration of medicines. New Zealand Nurses Organisation.
McKenna, L. & Lim, A. G. (2014). McKenna's Pharmacology for nursing and Health Professionals (2nd Ed.). Lippincott William & Wilkins.
MIMS Ethics. (2016). MIMS. MIMS Limited.
Health and Disability Commissioner. (2004). Health and Disability Commissioner (Code of Health and Disability Services Consumers' Rights) Regulations 1996. New Zealand Legislation.