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Polypharmacy (ACTS & LAWS RELEVANT TO MEDICATION ADMINISTRATION The…

- - - - State there are 4 classifications of medicines:
        
        1 Prescription medicine: can only be obtained by a person authorised to prescribe.
        
        Authorised prescribers in NZ include:
        
        Medical practitiorners
        
        Pharmacits
        
        Registered midwives
        
        Nurse practitioners
        
        Optometrsists
        
        Designated preserbibers
        
        Dietitians
        
        Dentists
        
        Nursing implication: when there is poor prescribing practice, for instance ineligible, the NZNO recommends the nurse documents the poor prescribing and reports this to the manager.
        
        Verbal orders write the order as it is being given - read it back to prescriber - colleague to listen to the prescriber's order - write the medication on a medication administration form - write in patient notes that this was required.
        
        2 Restricted medicines AND 3 pharmacy-only medicines
        
        Medication which can only be sold or supplied by a pharmacist from pharmacy or hospital, or in accordance with a standing order.
        
        4 General sale medicines
        
        Are not scheduled or classified and can be supplied from any retail outlet.
    - - The medication process requires therapeutic, diagnostic, or preventive purposes, which involves prescribing, dispensing, administering, receiving, and recording medication storage and handling.
      - As a nurse, it is vital to be familiar with local workplace policies as they may differ between institutions.
  - - - 1) Right medication
        
        Checking the vial of medication, the expiry date and co-signing this with another RN.
      - 2) Right dose
        
        That the correct prescribed amount resembles what you're about to administer
      - 3) Right time
        
        Checking the prescribed time and frequency of administration, also asking the patient what medication they have had in the past 48 hours, and if they have been in theatre, checking the theatre medication administration to avoid any errors.
      - 4) Right route
        
        Ensuring you administer the medication through the prescribed route which is suitable for the patient. IE: if it is prescribed IV, making sure the patient does have an IV cannula insitu.
      - 6) Right to refuse/right patient education
        
        Gaining informed consent prior to administration, this includes ensuring the patient is aware of what medication they are being given, what it is for, and possible adverse effects.
      - 7) Right doucmentation
        
        Completing all documentation in an accurate and timely manner.
      - 5) Right patient
        
        Checking the patients armband, their name and DOB corresponds with your paperwork.
  - - - ANAPHYLXIS - an acute, life-threatening hypersensitivity to an allergen. This reaction quickly causes massive vasodilation, release of vasoactive mediators and an increase in capillary permeability. This increase in capillary permeability causes fluid to leak from the vascular space into the interstitial space
      - Management of anaphylactic shock:
        
        1) recognition of signs and symptoms of anaphylactic reaction
        
        2) maintenance of a patent airway
        
        3) prevention of spread of the allergen by using a tourniquet and stopping treatment if applicable.
        
        4) Administration of drugs
        
        Adrenaline is the drug of choice
        
        Indications : Treatment of anaphylactic reactions, acute asthmatic attacks, and relief from respiratory distress of COPD
        
        Class: SYMPATHOMIMETIC - mimic the effects of the sympathetic nervous system.
        
        Administration For IM use only in acute anaphylaxis. In emergency situations, adrenaline may be injected very slowly IV but only as a dilute solution of 1: 10,000 as opposed to 1: 1000.
        
        Dosage: ADULTS: 0.5mg (0.5ml of 1:1000) REPEAT EVERY 5 MINUTES AS NEEDED. CHILDREN: 10mcg/kg (Min: 0.1mL, Max: 0.5mL of 1,1000).
        
        MOA:
        
        Adrenaline reacts with a- and B-receptor sites in the sympathetic nervous system to cause ... **bronchodilation, increased HR, BP, and RR.
        
        Adrenaline is rapidly distributed to the heart, spleen, several glandular tissues, and adrenergic nerves.
        
        Onset IM: onset is 5-10 minutes with a duration of 20-30 minutes. IV: instant onset, duration of 20-30 minutes. Inhalation: Onset of 3-5 minutes with a duration of 1-3 hours.
        
        Contraindications
        
        Adrenaline is a potent vasoconstrictor therefore the patients BP and HR needs to be stable prior to administration due to its main therapeutic actions being increasing systolic BP, decreasing diastolic BP and increasing HR
        
        VASODILATORS eg: ACE inhibitors, Calcium channel blockers, and nitrates can make adrenaline less effects due to their vasodilator properties.
      - Signs and symptoms of anaphylaxis
        
        Initially the patient will have a sudden onset of panic like they cannot breath, other symptoms include wheeze and/or stridor, dizziness, chest pain, swelling of lips and/or tongue, decreased HR & BP, and incontinence.
        
        A patient can have a severe allergic reaction, possibly leading to anaphylactic shock following contact, inhalation, ingestion, or injection with an antigen (they also could have been fine taking this antigen previously).
- - - - Also blocks potassium channels and slow the outward movement of potassium.
      - Potassium
        
        Potassium is an essential mineral that has many roles in your body. It helps regulate muscle contractions, maintain healthy nerve function and regulate fluid balance.
        
        Potassium plays crucial role in electric signal functioning of the heart's middle thick muscle layer, known as the myocardium.
      - Acts directly on heart muscle cells to prolong repolarisation and the refractory period, increasing the threshold for ventricular fibrillation
      - Also acts on peripheral smooth muscle to decrease resistance
    - - IV - Immediate onset - Peak 20 minutes.
      - Metabolised in the liver
      - Excreted in the urine
    - - When amiodarone is used to treat life-threatening arrhythmia, there are no contraindications.
      - Caution should be used in the presence of shock, hypotension, or respiratory depression.
    - - Nausea, vomiting, GI distress, weakness, dizziness, hypotenstion, HF, liver toxicity.
    - - Can cause serious toxic effects if combined with digoxin or quindine
        
        Digoxin sold under the brand name lanoxin is used for the treatment of **chronic heart failure and/or atrial fibrillation and flutter.
        
        Quindine acts as a class I anti-arrhythmic agent
    - - Treatment of MIke's life threatening ventricular arrhythmias
  - - - Beta-adrenergic blockers inhibit beta receptors, alpha receptors, or both
        
        Beta 1 receptors: primarily located in the heart to mimic the actions of the sympathetic nervous system…fight or flight (increased HR and BP)
        
        Beta 2 receptors: some located in the heart but primarily located in vascular smooth muscle…also mimics that sympathetic nervous system response and causes vasoconstriction of the smooth muscle of the vessel wall
        
        Alpha receptors: located in vascular smooth muscle and induces vasoconstriction via muscle contraction
      - Blocking these receptors means the sympathetic nervous system is inhibited therefore the fight or flight response of increased HR & BP as well as blocking vasoconstriction of the vessels = blocked hypertension.
    - - Oral
        
        Absorbed in the GI tract after oral administration and undergo hepatic metabolism, it has an onset of 15minutes, reaching peak levels in 60-90 minutes with a varying duration of 15-19 hours.
      - IV
        
        Onset is immediate with a peak level being 60-90 minutes and a duration of 15-19 hours.
    - - Contraindicated in individuals with bradycardia, heart block, and cardiogenic shock as blocking the sympathetic response could exacerbate these diseases.
      - Caution should be used in individuals with diabetes, peropheral vascular disease, astham, COPD or thyrotoxicosis due to blocking the sympathetic response blocks normal reflexes necessary for maintaining homeostasis in people with these conditions.
    - - There are many adverse effects associated with the blockage of SNS. Beta blockers are primarily used to treat hypertension and angina. However, they can also be preferred when treating tachycardia as bradycardia is a predominant adverse reaction.
      - CNS: dizziness, fatigue. GI: gastric pain, nausea & vomiting. CVS: HF, reduced CO, arrhythmias, bradycardia. Respiratory: bronchospasm, dyspnoea, cough.
    - - Hypertension occurs when clonidine (an antihypertensive medication) is given with beta-blockers - it is best to avoid this combination.
      - Decreased antihypertensive effect occurs when beta-blockers are given with non-steroidal anti-inflammatory drugs - if this combination is used, the person should be monitored closely and dose adjustment made as required.
      - Potential for a change in BGL if these drugs are given with anti-diabetic agents and the individual will not present the usual signs & symptoms of hypoglycaemia or hyperglycaemia therefore if this combination is used monitor BGL closely.
  - - - Adenosine is another antiarrhythnic agent used to convert Supraventricular Tachycardia (SVT) to sinus rhythm.
      - Often the drug of choice for terminating SVT, including those associated with the use of alternative conduction pathways around the AV node.
      - 1) Suppresses AV node conduction. 2) decreases automaticity in the AV node. 3): resets the SA node by stopping the heart for around 7 seconds. 4) dilates coronary arteries via smooth muscle relaxation.
    - - In patients with high degree AV block or sinus node dysfunction due to its MOA.
    - - Converts out of SVT into NSR
      - May develop a 2nd or 3rd degree heart block
      - Asystole can occur for no more than 1 minute
    - - Adverse effects
        
        Chest pressure
        
        Throat tightness
        
        Numbness
        
        Feelings of doom
        
        Flushing due to vasodilation
    - - Short half life of 5-20 seconds therefore it needs to be given very quickly via rapid IV bolus using 3-way stopcock
      - Give proximal to central circulation and elevate site of administration to give the medication the best chance of reaching central circulation & heart.
- - - - Block the enzyme phosphodiesterase, which is an important enzyme involved with cardiac muscle contraction.
      - This blockage leads to the increase in myocardial cell cyclic adenosine monophosphate (cAMP), which then leads to increases in calcium levels in the cell, thus increasing myocardial contractility.
      - Increased cellular calcium causes a stronger contraction and prolongs the effects of the sympathetic stimulation, which can lead to vasodilation, increased oxygen consumption and arrhythmias.
    - - Available for IV use only. Widely distributed after injection, metabolised in liver, and excreted primarily in the urine.
    - - Contraindicated in the following conditions: severe aortic or pulmonic vascular disease which could be exacerbated by increased contraction. Acute MI, which could be exacerbated by increased O2 consumption & increased force of contraction.
    - - Most common: ventricular arrhythmias, hypotension, chest pain and burning at the IV site following injection.
  - - - 1 "mu" (u) are the primarily pain-blocking receptors. Besides analgesia, mu-receptors also account for a feeling of euphoria, respiratory depression, decreased GI activity, development of dependence, and pupil constriction.
      - 2 Kappa (K) receptors are assocaited with some analegia and pupillary constriction, dysphoria, and sedation.
      - 3 Beta (B) receptors react with enkephalins in the periphery to modulate pain transmission.
      - 4 sigma receptors primarily cause pupillary dilation, are also thought to be responsible for hallucinations, dysphoria, and psychoses occurring with opioid use.
    - - For analgesia before, during, and after surgery or the management of acute or chronic breakthrough pain.
    - - IV administration is the most reliable way to achieve therapeutic levels of opioids. Onset of action is almost immediate when given IV, however maximal analgesic & respiratory depressant effect may not be noted for several minutes. Duration of action is 30 - 60 minutes after single IV dose of up to 100mg.
      - While IM and SC administration can be offered, the onset and therapeutic level is not as effective.
      - Fentanyl is primarily metabolised in the liver, with approx 75% of an IV dose excreted in the urine and the remaining in the faeces.
      - Dose should be individualised according to factors such as age, bodyweight, physical status, use of other medications, and pathological condition.
    - - Known hypersensitivity or intolerance to fentanyl or other opioid analgesics.
      - Children 2 years of age or younger as safe limits have not been established.
      - Caution in hypotensive patients as well as bradycardia as fentanyl may produce bradycardia and possibly asystole.
      - Drug dependance to avoid drug abuse
      - Caution should be used in impaired respiration and respiratory depression as this is a dangerous side effect of fentanyl, patients should be closely monitored for this possibility.
    - - Respiratory depression with apnoea, if prolonged cardiac arrest and shock may result from opioid-induced respiratory centre depression.
      - Common: Orthostatic hypotension, nausea, vomiting, constipation, impaired mental processes, hallucinations, pupil constriction, anxiety, sweating and dependance.
    - - When opioid agonists are given with barbiturate general anaesthetics, or with MAO inhibitors, or some phenothiazines the likelihood of respiratory depression, hypotension, sedation, and coma is increased. If these drug interactions cannot be avoided, individuals should be monitored even more closely with appropriate measures taken.
  - - - Tetracyclines work by inhibiting protein synthesis in a wide range of bacteria, preventing cell replication.
      - Treatment of various infections caused by susceptible strands of bacteria.
    - - Tetracyclines are absorbed, but not completely in the GI Tract - Factors that affect the absorption are: food, iron, calcium & other drugs in the stomach.
      - Concentrated in the liver. Excreted unchanged in the urine.
      - Half-life ranges from 12 - 25 hours.
    - - Fungal, myobacterial, or viral ocular infection as this medication kills the undesired bacteria, and also the normal flora which increases the risk of exacerbation
      - Tetracyclines should NOT be used in children younger than 8 years of age due to the potentially damage of developing bones and teeth
      - People with hepatic or renal failure due to these being concentrated in the bile and excreted in urine.
    - - Irritation of the GI tract - nausea, vomiting, diarrhoea, abdominal pain, dysphagia, and glossitis (inflammation of the tongue).
      - Skeletal effects involves - damage to the teeth and bones, due to tetracyclines affinity for teeth and bones, they accumulate there weakening the structure and causing staining and pitting of teeth and bones.
      - Superinfections, such as yeast infections, as they also destroy normal flora.
    - - When penicillin and tetracyclines are taken together, the effectiveness of penicillin decreases and the penicillin dose should be increased when used together.
      - The effectiveness of *oral contraceptives decreases when taking tetracyclilnes and women should be advised to use an additional form of birth control.
    - - Because oral tetracyclines are not effectively absorbed if taken with food or diary products, they should be administered on an empty stomach 1 hour before or 2-3 hours after any meal or any other medication.
- - - - Mike mentioned to the Dr's that his feet had become numb and he couldn't move them, they were cool to touch and white pallor but they didn't think this was concerning yet.
      - It wasn't until about 2 hours after the Dr's had been and we got the doppler to check his peripheral pulses which is when we discovered he had no popliteal, dorasilis pedial or posterior tibal pulse.
      - An urgent CT revealed that Mike had bilateral blood clots from hips down This meant Mike had to be urgently taken to theatre to attempts to remove these, he came back ventilated and eventually passed away 24 hours later.
        
        It is likely that his clots had developed as a result of his heart failure due to his heart not supplying his demand due to his weakened heart which slowed down his blood flow causing clots to form.
  - - - The medications used in attempt to slow down Mikes heart is discussed in this concept map, However, these were unsuccessful and Mike ended up requiring a synchronised cardioversion which uses a low-voltage shock that is synced with the cardiac cycle, so that is lands on the R wave in the QRS complex. If it were to land on any other waves, such as the T wave this could lead to additional arrhythmias such as V-Fib.