Transcript Pharmacology for Graduate Nurses

Pharmacology for Graduate Nurses
John Foley, Pharm.D.
John Foley, Pharm.D.
• List of Important Accomplishments
– Pending
– In Progress
– Unlikely
– To be determined
Who is here today?
•
•
•
•
•
•
Faculty
Physicians
Attorneys
Insurance Company Reps
Drug Sales Representatives
Political Candidates
Groupers versus Splitters
Phylum: Chordata
Subphylum: Vertebrata
Class: Mammalia
Order: Carnivora
Family: Felidae
Genus: Felis
Species: Felis catus
or a feline
Learning Objectives
After attending this lecture and discussion, the graduate
nurse will be able to:
1. Understand drug actions better by grouping medications
by their similarities
2. Identify High Risk / High Alert Medications
3. Outline a simple safety routine for medication
administration
4. List important considerations when giving a med for the
first time
5. Predict, avoid and manage side effects
6. List reliable resources / references for drug information
Short Version of Objectives
• What drugs are important?
• What do I need to know?
• How can I find what I need to know?
Distinguishing one drug from
another….You know you can do it.
“Update in Pharmacology”
• Pharmacodynamics
– What the drug does to the body
• Pharmacokinetics
– What the body does to the drug
Pharmacodynamics
what the drug does to the body
• Action at receptor sites
• Some receptors in blood stream (central
compartment)
• most receptors in tissues
• receptors are already there - drugs just take
advantage of physiology
• Action at receptor can be long or short
Receptors
• Receptor activated by agonist
• Turns on a cascade of events
• Agonist can be endogenous or exogenous
Examples:
Your own T4 hormone or levothyroxine medication
Or
Your own epinephrine or the epinephrine the nurse
gives as a drug
What happens at receptor?
• Agonist: fits into receptor and turns it on
– ex: morphine
• Antagonist: fits into receptor and does not
turn it on. Causes reversal of agonist…
– ex: Naloxone (Narcan)
• Partial agonist: fits into receptor and turns it
part way on
Pharmacokinetics
what the body does to drug
A. Absorption
D. Distribution
M. Metabolism
E. Excretion
Pop Quiz PharmacoDynamics or Kinetics?
Omeprazole (Prilosec) blocks the Proton Pump (H+/K+ ATPase
exchange pump) in the stomach
The active metabolite of meperidine called normeperidine
accumulates in a person that has significant renal dysfunction.
Vancomycin serum levels reach their peak about 1 hour after the
IV infusion begins.
Ciprofloxacin concentration becomes very high in the urine.
Isoniazid (an antibiotic for tuberculosis) is poorly absorbed when
taken with food
Phenylephrine (Neosynephrine) increases vascular resistance
What drugs should I learn about?
• ISMP (Institute for Safe Medication Practice)
– High Alert Drugs (High Risk Drugs)
• Top 200 Drug List
• Generics
• Brand
Who is the ISMP?
www.ismp.org
•
•
•
•
Non-profit Medication Safety Resource
Share Medication events
Make recommendations
Newsletters
What is a High Alert Medication
• One where a mistake can be life changing or
fatal
• One that can really save a patient’s life
• One where your safety routine will make a
huge impact
A more Updated List
• See excel file (nice study tool)
High Alert Meds
• IV agents work fast and cannot be taken back
– See the problem quickly
– But they also help quickly 
• PO meds
– Problems seen with repeated dosing (usually)
IV Adrenergic Agents
• Increase work of cardiovascular system
– Push the pump or tighten the pipes
• Epinephrine
• Norepinephrine
• Phenylephrine
• Dopamine
• Dobutamine
IV Adrenergic Antagonists
• Slow down work of cardiovascular system
– Slow HR and Drop BP
• Labetalol
• Metoprolol
Anesthetic Agents
•
•
•
•
•
Used in Procedural Areas
Sometimes in EDs and ICUs
With Anesthesia Provider
Inhaled anesthestics
Propofol (Diprivan)
Antiarrhythmics
• To treat arrhythmias (dysrhythmias)
• If a med messes with rhythm what should we
be most worried about?
– Messing with rhythm
• If your patient has a histrory of a rhythm
problem find out what med he or she is taking
for the problem
– amiodarone, sotalol, etc
Antithrombotics
• Antithrombotic means preventing a clot
• Includes
– Anticoagulants
•
•
•
•
•
•
•
Heparin
Enoxaparin (Lovenox)
Fondaparinux (Arixtra)
Warfarin (Coumadin) (Jantoven)
Dabigatran (Pradaxa)
Rivaroxaban (Xarelto)
Apixaban (Eliquis)
Cardioplegics
• Irrigation with high potassium to stop heart
• Used in Cardiac Surgery
Chemotherapy
• IV agents used by “experts”
• Biologic products
– Amazing specificity for the cancer
– Can cause life threatening allergic reactions
• Most IV chemo risks are delayed
– Bone marrow suppression
– Neuropathies
Oral Chemotherapy
• Use GLOVES ! ! ! ! !
• Do not underestimate
• Prescribing errors
– “Methotrexate”
– Chlorambucil
• Hormones
– Risks to moms / babies
Water, Sugar and Salt can be deadly
• Water (i.e. sterile water) should never be
injected
– It is used only as diluent for drugs
– Your pharmacy should not let you have it in large
amounts (limit to 10 mL)
– It has no dissolved particles - will explode blood
cells
Water, Sugar and Salt are Deadly
• Dextrose 5% and 10% peripheral IV OK
• Higher percentages in Central Line only
– Exception if patient with severe HYPOglycemia
– Can give D50 (that is dextrose bristojet)
• How do you know it is a central line?
Water, Sugar and Salt are Deadly
• SALTS
• Sodium Chloride 0.9% is safe
• Concentrations higher than that
– Sclerose veins
– Fatal to fetus
• Pharmacy should not let you touch high
concentrations of saline
Water, Sugar and Salt are Deadly
• SALTS
• Potassium – too fast is FATAL
– Potassium Chloride
– Potassium Phosphate
• Magnesium Sulfate – too fast is FATAL
• Concentrated electrolytes are used for mixing by
pharmacy - that is why there should be no vials
around!
Dextrose and saline can also save lives
• Dextrose for HYPOglycemia
• Normal Saline (0.9% NaCl) can bring BP up
nicely
Spinal Meds
• Epidurals – wrong med may be fatal /
paralyzing
• Intrathecals - wrong med is FATAL in minutes
Sedatives / Opiates
• CNS and Respiratory Effects depressant effects
are Additive
– Dose matters
– Multiple drugs matters
– Patient med profile often has potential unsafe
combos on it
•
•
•
•
Morphine
Promethazine (Phenergan)
Lorazepam (Ativan)
Zolpidem (Ambien)
Neuromuscular Blockers
• Stop respiration
• Fatal if patient not ventilated
Parenteral Nutrition
• Extremely high osmolarity
• Lots of dissolved particles
• Once dextrose > 10% must be central line
Radiocontrast dyes
• Allergies – immediate and serious
• Renal Failure – pretty quick
– Elderly
– Diabetes
– Known renal dysfunction
Insulin
• HYPOglycemia is life threatening can cause brain
damage
• Brand Names confusing
• Generic Names worse
• Faster acting the more dangerous
–
–
–
–
Humalog
Novolog
Apidra
Regular
• IV regular dangerous
Insulin
• Involve the patient
– likely they know more than us
•
•
•
•
•
Independent double check
Practice with pens
Practice with insulin syringe
Practice with “TB” syringe
Call me 
Insulin concentrations
• U-100 typical
• U-500 – super potent
– for Very Insulin Resistant only
– Patients learn and are taught to “misread” the
syringe on purpose
Medications by Groups
High Alert Meds is one way.
By Therapeutic Class is another way
Antibiotics
Autonomic System Meds
GI Meds
Respiratory Meds
Cardiac
Central Nervous System
Hormones - Anti-Inflammatory and Sex Hormones
Safe Medication Routine
• Why not give a med?
– Right patient?
– No related allergies?
– Dose and frequency OK?
– Vital Signs OK?
– Sedation Level OK?
Safe Medication Routine
• Involve the patient
• Does the patient know how potent insulin is?
• Does patient know that med errors can
happen when professionals are taking care of
him / her?
Safe Medication Routine
• What do I expect to happen when I give this
drug?
• Good things – say them out loud –
• Bad things – say them out loud -
Safe Medication Routine
• Learn from your peers
– “I am not afraid. I am just careful”
• Let no one rush you!
- “You will have to work much faster than that to
be successful” Ugh!
Managing “Side Effects”
•
•
•
•
Side effect
Adverse Drug Reaction
Adverse Drug Event
Unintended Effect
Managing “Side Effects”
• Listen to the Patient
• Know when something should happen
– When will the sedation kick in?
– When would the allergic reaction happen?
• What will I do when it happens?
• If you are surprised by bad reaction
– “stop” the drug (you may need permission)
– re-read all the medication labels
Antidotes
• Opiates reversed by Naloxone (Narcan)
• Benzodiazepines reversed by Flumazenil
(Romazicon)
• Heparin and Lovenox (enoxaparin) reversed by
Protamine (usually not necessary)
• Warfarin (Coumadin) reversed by Vitamin K
(phytonadione)
“Grouping” to study meds
• Consider if there seems like a million drugs in
one category, then one drug probably doesn’t
stand out as unique and they are more similar
than different.
• A benzodiazepine is a benzodiazepine
– Diazepam, oxazepam, lorazepam, alprazolam
Drug Class:
Benzodiazepines and Similar
Good
Relieves anxiety
Promotes sleep
Sedation
Treats seizures
Generic
Lorazepam
Alprazolam
Zolpidem
Eszopiclone
Bad
Morning Hangover
Over Sedation
CNS / Respiratory Depression
(Brand)
got this list from Top 100 or so
(Ativan)
(Xanax)
(Ambien)
(Lunesta)
Using Resources
• Practice with the book or smart phone or
website
• Make sure you are reading the right page.
• Try and compare to Global RPh
www.globalrph.com
• Look for Pharmacodynamics first.
– What does drug it do the body?
– That will tell you what to expect. Good and Bad
• For side effects
– Look for 2 common things (everyone gets) and 1
rare one you don't want to miss (like anaphylaxis)
For you
Warranty Information 
John Foley
Southern NH Medical Center
(603) 577-2867
[email protected]