Study Guide for Exam 1.pdf

Study Guide for Exam 1 Please remember that this is just a study guide; you must review the chapters and power points. For all medications, you will need to know: Classification and Prototypes the purpose mechanism of action side effects/adverse reactions 6 rights of preparation and administration I...

Study Guide for Exam 1 Please remember that this is just a study guide; you must review the chapters and power points. For all medications, you will need to know: Classification and Prototypes the purpose mechanism of action side effects/adverse reactions 6 rights of preparation and administration Indications/nursing Implications Patient Education Chapter 1: Safety Medication Practice Error-reduction strategies during medication administration include the following: 1. Having a “quiet zone” to prepare medications. 2. Placing “quiet zone” signs at the entrance to medication room or above the automated medication-dispensing system. 3. Following protocols and checklist outlining medication administration. 4. Wearing a sash or vest to signal others to avoid interrupting the nurse during medication administration. 5. Educating staff to reduce interruptions of nurses administering medications. 6. Having a drug guide available during drug administration. Trade/Generic Names Drug names Generic name: related to the chemical or official name and is independent of the manufacturer. Often indicates the drug group. Brand (trade) name: designed and patented by the manufacturer. Scheduled Drugs/Narcotics Categories of Controlled Substances Schedule I: not accepted, lack of safety, and high abuse potential. Example: heroin, LSD, ecstasy, and peyote. Schedule II: used medically and have high abuse potentials. Example: opioid analgesics (codeine, hydromorphone, morphine, and oxycodone) Schedule III: less potential for abuse than I and II; they may lead to psychological or physical dependence. Example: androgens and anabolic steroids, some depressants. Schedule IV: accepted medically but with some potential for abuse. Example: diazepam, lorazepam. Schedule V: containing moderate amounts of controlled substances. Dispensed by the pharmacists without a physician’s prescription but some restrictions. The Drug Enforcement Administration (DEA) enforces the Controlled Substances Act. They keep accurate records of all transactions, provide for secure storage. Nurses are responsible for strong controlled substances in locked containers, administering them only to people for whom are prescribed recording each dose given and documenting or reporting discrepancies to the proper authorities. Chapter 2: Pharmacokinetics/Pharmacodynamics - Medications effects in body Absorption, Distribution, Metabolism, Excretion of Prototypes Pharmacokinetics Involves drug movement through the body to reach sites of action, metabolism, and excretion. Specific processes are absorption, distribution, metabolism, and excretion. Absorption The process that occurs from the time a drug enters the body to the time it enters the bloodstream to be circulated. Most oral drugs must be swallowed, dissolved in gastric fluid, and delivered to the small intestine before they are absorbed. Drugs injected into the subcutaneous or intramuscular (IM) tissues are usually absorbed more rapidly than are oral drugs because they move directly to the bloodstream. Distribution Involves the transport of drug molecules within the body. Depends largely on the adequacy of blood circulation. Drugs are distributed rapidly to organs receiving a large blood supply, such as the heart, liver, and kidneys. Metabolism Metabolism, or biotransformation, is the method by which drugs are inactivated or bio transformed by the body. Most often, an active drug is changed into inactive metabolites, which are then excreted. The kidneys can excrete only water-soluble substances. One function of metabolism is to convert fat-soluble drugs into water-soluble metabolites. CYP enzymes are complex proteins with binding sites for drug molecules. They catalyze the chemical reactions of oxidation, reduction, hydrolysis. This enzyme induction accelerates drug metabolism because larger amounts of the enzymes allow larger amounts of a drug to be metabolized during a given period. As a result, larger doses of the rapidly metabolized drug may be required to produce or maintain therapeutic effects. Metabolisms also can be decreased or delayed in a process called enzyme inhibition, which most often occurs with concurrent administration of two or more drugs that compete for the same metabolizing enzymes. Excretion Refers to elimination of a drug from the body. Effective excretion requires adequate functioning of the circulatory system and the organs of excretion (kidneys, bowel, lungs, and skin). Factors impairing excretion: severe renal disease, which leads to accumulation of numerous drugs and may cause severe adverse effects of dosage is not reduced. Chapter 3: Overall information of antibiotic classifications Routes of medications/Protypes Chapter 9: Medications: Vitamin K Vitamin K Antagonists / Warfarin (PROTOTYPE) o ▪ ▪ ▪ ▪ ▪ o ▪ ▪ o PHARMACOKINETICS Administration with food may delay the rate but not the extent of absorption. The drug is highly bound to plasma proteins (98%), mainly albumin. Metabolism takes place in the liver. Excretion, primarily as inactive metabolites, occurs in the kidneys. Renal impairment does not affect drug metabolism but may decrease excretion of the drug. VITAMIN K: ANTIDOTE Vitamin K is the antidote for warfarin and may be administered if the INR level is 5 or more and signs of bleeding are present. ACTION Warfarin acts in the liver to prevent synthesis of vitamin K–dependent clotting factors (i.e., factors II, VII, IX, and X). Similar to vitamin K in structure, warfarin therefore acts as a competitive antagonist to hepatic use of vitamin K Warfarin has no effect on circulating clotting factors or on platelet function, so the anticoagulant effects do not occur for 3 to 5 days after warfarin is started because clotting factors already in the blood follow their normal pathway of elimination. USE ▪ Warfarin is most useful in long-term prevention or management of venous thromboembolic disorders, including DVT, pulmonary embolism, and embolization associated with atrial fibrillation and prosthetic heart valves ▪ After cardiac surgery, children receive warfarin to prevent thromboembolism, but there are no established doses and guidelines for safe, effective use. (monitor blood coagulation tests) ▪ Warfarin metabolism may be altered in older adults. As patient age increases, a lower dose of warfarin is usually required to produce a therapeutic effect. ▪ likely to cause bleeding in patients with hepatic disease because of decreased synthesis of vitamin K and decreased plasma proteins. In addition, only the liver eliminates warfarin; thus, it may accumulate in people with hepatic impairment, and dosage adjustment may be necessary. ▪ Because the anticoagulant and antithrombotic effects of warfarin take several days to occur, (LONG TERM THERAPY) patients who are critically ill require concurrent treatment with other anticoagulants, such as heparin or LMWHs. Heparin is usually continued until the international normalized ratio (INR) is the therapeutic range. o ADVERSE EFFECTS: ▪ The primary adverse effect associated with warfarin therapy is hemorrhage. ▪ Additionally, nausea, vomiting, abdominal pain, alopecia, urticaria, dizziness, and joint or muscle pain may occur. o CONTRAINDICATIONS ▪ The US Food and Drug Administration (FDA) has issued a BLACK BOX WARNING ♦ for warfarin because of the risk of its causing major or fatal bleeding. ▪ PREGNANCY CATEGORY X Alteplase (thrombolytic drug) Alteplase (PROTOTYPE) o PHARMACOKINETICS ▪ Administration of alteplase is by IV infusion. ▪ Metabolism occurs predominantly in the liver. Following discontinuation of the infusion, more than 50% of the drug is cleared, with more than 80% clearance within 10 minutes. ▪ Excretion takes place in the urine. ▪ Whether alteplase crosses the placenta or is excreted into breast milk is unknown. o ACTION ▪ Alteplase is a protein that lyses unwanted fibrin blood clots by catalyzing the conversion of plasminogen to plasmin. o USE ▪ Indications for alteplase include lysis of acute coronary arterial thromboembolism associated with evolving transmural myocardial infarction or acute pulmonary thromboembolism. ▪ Clinicians also considered it as first-line therapy for the treatment of acute ischemic stroke in selected people. ▪ Caution is warranted in older patients (65–80 years of age).Alteplase is not recommended in people older than 80 years of age. ▪ Caution is necessary in patients with significant hepatic impairment. o ADVERSE EFFECTS ▪ As with other anticoagulants and antiplatelet agents, bleeding is the main adverse effect of alteplase. To minimize this risk, it is important to select recipients carefully, avoid invasive procedures when possible, and omit anticoagulant or antiplatelet drugs (except for aspirin) while thrombolytics are being given o CONTRAINDICATIONS ▪ Due to an increased risk of bleeding, alteplase is contraindicated in patients with uncontrolled severe hypertension, aneurysm, arteriovenous malformation, known coagulopathy or internal bleeding, intracranial or intraspinal surgery or trauma within the past 3 months, intracranial mass, recent major surgery, or current use of oral anticoagulants. o Only experienced personnel in an emergency department, a critical care unit, or diagnostic/interventional setting with cardiac and other monitoring devices in place should perform thrombolytic therapy. o It is necessary to minimize intramuscular injections in patients who are receiving systemic thrombolytic therapy, because bleeding, bruising, or hematomas may develop. o ADMINISTERING THE MEDICATION ▪ Before a thrombolytic agent is begun, it is essential to check INR, aPTT, platelet count, and fibrinogen to establish baseline values and to determine whether a blood coagulation disorder is present. ▪ Two or three hours after thrombolytic therapy is started, the nurse must ensure that the fibrinogen level is measured to determine that fibrinolysis is occurring. ▪ Alternatively, he or she can check INR or aPTT for increased values because the breakdown products of fibrin exert anticoagulant effects. ▪ Administration is IV as a bolus injection or infusion. The nurse administers all infusions using an IV infusion device. It is necessary to reconstitute alteplase as indicated and not to shake it. Clopidogrel (antiplatelet) Adenosine diphosphate receptor antagonists o clopidogrel (PROTOTYPE) o Clopidogrel and the other ADP receptor antagonists, prasugrel and ticagrelor, have antiplatelet effects similar to aspirin and inhibit the ADP receptor on the surface of platelets. o ▪ ▪ ▪ o ▪ ▪ o ▪ ▪ ▪ o ▪ ▪ ▪ ▪ ▪ ▪ Clopidogrel has three shortcomings: delayed onset of action, irreversible inhibitory effects on platelets with no reversing agent or antidote, and significant individual variability in platelet response. PHARMACOKINETICS Clopidogrel is rapidly absorbed after oral administration and undergoes extensive firstpass metabolism in the liver. Clopidogrel is a prodrug and is converted to its active form by hepatic CYP2C19 (an isozyme of the cytochrome P-450 system). To a lesser extent, activation of the drug also occurs via CYP3A4 enzymes. Platelet inhibition may occur 2 hours after a single dose, but the onset of action is slow, so that an initial loading dose is usually administered. The drug has a half-life of about 8 hours. The drug is excreted in the urine and feces. D ACTION Clopidogrel irreversibly blocks the ADP receptor on platelet cell surface. Effective dose-dependent prevention of platelet aggregation can be seen within 2 hours of a single oral dose, but the onset of action is slow, so that a loading dose of 300 to 600 mg is usually administered. Platelet inhibition essentially lasts for the lifespan of the platelet (7–10 days). With repeated doses of 75 mg/d, maximum inhibition of platelet aggregation is achieved within 3 to 7 days. Platelet aggregation progressively returns to baseline about 5 days after discontinuing clopidogrel. (SLOW) USE Indications for use include reduction of myocardial infarction, stroke, and vascular death in patients with atherosclerosis and in those after placement of coronary stents. Specific uses include prevention of vascular ischemic events in patients with symptomatic atherosclerosis or with acute coronary syndrome (with or without ST-segment elevation) In acute coronary syndrome, clopidogrel is given with aspirin (dual antiplatelet therapy). Patients may also take clopidogrel in conjunction with aspirin to prevent thrombosis following placement of an intracoronary stent. People with atrial fibrillation who are unable to take vitamin K antagonists take clopidogrel instead. Adding clopidogrel to aspirin in people with atrial fibrillation reduces the rate of major vascular events compared with aspirin alone but is associated with a greater risk of bleeding. Prescribers also order clopidogrel as an alternative antiplatelet drug for patients who cannot tolerate aspirin. (ALTERNATIVE OPTION) safety in kids not established Older adults are more likely than younger ones to experience bleeding and other complications of antiplatelet drugs. Clopidogrel is commonly used to prevent thrombotic stroke but can increase the risk of hemorrhagic stroke. A safe loading dose for clopidogrel in patients 75 years of age and older has not yet been established. Because clopidogrel is metabolized in the liver, it may accumulate in people with hepatic impairment. Caution is necessary. o ADVERSE EFFECTS ▪ The most common adverse effects associated with clopidogrel are pruritus, rash, purpura, and diarrhea. (LECTURE POINT) ▪ Thrombotic thrombocytopenic purpura, hemorrhage, and severe neutropenia have also occurred. People with variant forms of CYP2C19 may be poor or ultrarapid metabolizers of clopidogrel. Ultrarapid metabolizers of clopidogrel may have an increased risk of bleeding. With poor metabolizers, the benefits of the drug may not be adequate ▪ recommend an alternative antiplatelet therapy (e.g., prasugrel, ticagrelor) for CYP2C19 poor or intermediate metabolizers if there are no contraindications. o CONTRAINDICATIONS ▪ Contraindications to clopidogrel include hypersensitivity to the drug or any other component. It should not be used in patients with active bleeding in conditions such as intracranial hemorrhage or peptic ulcer disease. A category B medication, the drug requires cautious use in pregnant and lactating women. o ADMINISTERING THE MEDICATION ▪ Patients take clopidogrel once daily without regard to food intake. As previously stated, although the drug may be effective 2 hours after a single dose, the onset of action is slow, and an initial loading dose is usually administered. The FDA has approved a 300-mg tablet as a loading dose for appropriate patients. The effect of the drug is apparent as soon as 2 hours after the 300-mg dose. ▪ It is recommended that patients who receive implants with a bare-metal stent or a drugeluting stent take dual antiplatelet therapy for at least 12 months. If well tolerated, dual antiplatelet therapy can be continued for another 18 months. o Do not double a dose if missed. Coumadin Aspirin (antiplatelet) Heparin Heparins/ Heparin (PROTOTYPE) o pharmaceutical preparation of the natural anticoagulant produced primarily by mast cells in pericapillary connective tissue, and it is the prototype anticoagulant. Endogenous heparin is found in various body tissues, most abundantly in the liver and lungs. o ANTIDOTE: PROTAMINE SULFATE o PHARMACOKINETICS ▪ give heparin intravenously or subcutaneously, because the gastrointestinal (GI) tract does not absorb the drug. ▪ After IV injection, the drug acts immediately. ▪ After subcutaneous injection, heparin acts within 20 to 30 minutes. ▪ Metabolism takes place in the liver and the reticuloendothelial system. ▪ Excretion, primarily in the form of inactive metabolites, occurs in the urine. Hemodialysis does not remove it. o ACTION ▪ Heparin combines with antithrombin III (a natural anticoagulant in the blood) to inactivate clotting factors IX, X, XI, and XII; inhibit the conversion of prothrombin to thrombin; and prevent thrombus formation. ▪ After thrombosis has developed, heparin can inhibit additional coagulation by inactivating thrombin, preventing the conversion of fibrinogen to fibrin, and inhibiting factor XIII (fibrin-stabilizing factor). o USE ▪ Prophylactically, patients at risk for certain disorders take low doses of heparin prophylactically to prevent DVT and pulmonary embolism. These disorders include the following: Major illnesses (e.g., acute myocardial infarction, heart failure, serious pulmonary infections, stroke) Major abdominal or thoracic surgery A history of thrombophlebitis or pulmonary embolism, including pregnant women Gynecologic surgery, especially in patients who have been taking estrogens or oral contraceptives or have other risk factors for DVT Restrictions such as bed rest or limited activity expected to last longer than 5 days patients receive heparin for management of acute thromboembolic disorders (e.g., DVT, thrombophlebitis, pulmonary embolism). In these conditions, the aim of therapy is to prevent further thrombus formation and embolization. Another use is in disseminated intravascular coagulation (DIC), a life-threatening condition characterized by widespread clotting, which depletes the blood of coagulation factors. o The goal of heparin therapy in DIC is to prevent blood coagulation long enough for clotting factors to be replenished and thus be able to control hemorrhage. Heparin does not cross the placental barrier and is not secreted in breast milk, making it the anticoagulant of choice for use during pregnancy and lactation. Use in children based on weight for dosage. patients with renal or hepatic impairment may take usual doses but half-life may be affected. Used in critically ill patients. Patients may take standard heparin at home using the subcutaneous route, and use of LMWHs for home management of venous thrombosis has become standard practice. It is essential to take platelet counts before therapy begins and every 2 to 3 days during heparin therapy. If the platelet count falls below 100,000 platelets per microliter of blood or to less than half the baseline value, it is necessary to discontinue the heparin. o ADVERSE EFFECTS ▪ Hemorrhage ▪ Heparin-induced thrombocytopenia (HIT) (type II) is a potentially life-threatening complication of heparin administration, leading to a decrease in platelet count and detectable HIT antibodies. o CONTRAINDICATIONS ▪ Contraindications include GI ulcerations (e.g., peptic ulcer disease, ulcerative colitis), intracranial bleeding, dissecting aortic aneurysm, blood dyscrasias, severe kidney or liver disease, o ADMINISTERING THE MEDICATION ▪ Traditional anticoagulants have two major limitations: a narrow therapeutic window of adequate anticoagulation without bleeding and a highly variable individual dose–response that requires monitoring by laboratory testing. ▪ use aPTT (activated partial thromboplastin time) to regulate heparin dosage During heparin therapy, the aPTT should be maintained at approximately 1.5 to 2.5 times the control or baseline value. The normal control value is 25 to 35 seconds; therefore, therapeutic values of adequate anticoagulation are 45 to 70 seconds, approximately. With continuous IV infusion, blood for the aPTT may be drawn at any time; with intermittent administration, blood for the aPTT should be drawn approximately 1 hour before a dose of heparin is scheduled. It is not necessary to monitor aPTT with low-dose standard heparin given subcutaneously for prophylaxis of thromboembolism or with the LMWHs (e.g., enoxaparin). Chapter 11: Medications: Epoetin The prototype recombinant form of human erythropoietin that helps the body produce more RBCs. The clinical benefit of treatment of anemia with an ESA is to reduce the need and cost of blood transfusions, lessen the risk of infectious diseases from transfusions, and potentially enhance the overall quality of life as anemia is relieved. Evidence indicates that the patients who benefit consistently from ESAs are prescribed epoetin alfa or another ESA for chemotherapy-associated anemia or those with anemia due to chronic kidney disease. The onset of action is 11 to 14 days. For cancer patients with chemotherapy-associated anemia who have a hemoglobin level that has decreased below 10 g/dL Treatment of anemia associated with chronic kidney disease. Premature infants should not receive epoetin alfa from multidose vials because they contain benzyl alcohol, which can be fatal. Patients with chronic kidney disease may also benefit from an ESA because they have reduced production of erythropoietin. Most common adverse effects are hypertension. Avoid using ESAs in patients with hemoglobin values of 12 g/dL or above. Bolus injection at the end of dialysis Epoetin alfa is not effective unless sufficient iron is present; therefore, patient teaching may need to emphasize the importance of taking an iron supplement. Darbepoetin is a relatively long-acting agent compared to epoetin alfa’s shorter-acting duration. Epoetin beta (Mircera) is used in the treatment of anemia associated with chronic kidney disease in adults—whether or not they require dialysis. BLACK BOX WARNING ♦ for epoetin beta, reporting that it is not indicated and is not recommended for treatment of chemotherapy-induced anemia. Interferon Interferons: alfa, beta, or gamma, are biologic response modifiers that bind to specific cell surface receptors and alter intracellular activities. In viral infections, these immunostimulants induce enzymes that inhibit protein synthesis and degrade viral RNA. As a result, viruses are less able to enter uninfected cells, reproduce, and release new viruses. In addition to their antiviral effects, interferons also have antiproliferative and immunoregulatory activities. ★ Interferons ‘interfere’ with viruses. The virus tries to pass the ball (RNA) and the interferon goes, “nope,” and swats it out of their hands. Increase expression of major histocompatibility complex molecules Augment the activity of NK cells. Increase the effectiveness of antigen-presenting cells in inducing the proliferation of cytotoxic T cells. Aid the attachment of cytotoxic T cells to target cells. Inhibit angiogenesis (formation of blood vessels) Enhance the immune system. They upgrade all the soldiers. Prototype: Interferon alfa 2b (Intron A) Pharmacokinetics🔬 80% absorbed and widely distributed but does not cross the blood–brain barrier. Minimal hepatic metabolism. Excretion is primarily renal. Peak onset of action is 3 to 12 hours. Half-life is approximately 2 to 3 hours. Action 🏃 Both antiviral and antineoplastic activities. Exerts its cellular activities by binding to specific membrane receptors on cell surface enhancing immune response, inhibiting viral replication in virus cells. Enhances function of the immune system by increasing phagocytic activity of macrophages and monocytes, which augments cytotoxicity against cancer cells. Suppresses the growth and reproduction of similar cells by cell division. Use 👾 (Used to KILL) Hairy cell leukemia, chronic hepatitis B and C, Kaposi’s sarcoma, genital warts, malignant melanoma, lymphoma (follicular), and condyloma. Adverse Effects💀 Caution in patients with liver disease; raises their hepatic enzymes so monitor ALT, AST, etc. Flu-like symptoms 😷 (e.g., fever, chills, fatigue, muscle aches, headache, tachycardia. Chest pain and alopecia Hematologic effects include neutropenia, anemia, and thrombocytopenia. Teratogenic! 👶💀 Administering the Medication IV, Sub-Q, IM, or intralesionally. Three times weekly, on a regular schedule (e.g., Monday, Wednesday, and Friday), at about the same time of day, at least 48 hours apart, per manufacturer. Diagnostic Tests 🧪 Liver function tests and WBC, RBC, and platelet values. Chapter 13: General info regarding immunosuppressants and Corticosteroids Cytotoxic Immunosuppressants: Drug therapy - have overlapping mechanisms and sites of action. Older groups of these drugs often depress the immune system of the recipient nonspecifically. Therapeutic use of these drugs increases risk of infection with bacteria, protozoa, or viruses. Slow the proliferation of activated lymphocytes also produce damage to rapidly dividing cells in other tissues (e.g., mucosal cells, intestinal cells, hematopoietic stem cells) Cytotoxic immunosuppressants-Cytotoxic immunosuppressive drugs damage or kill dividing cells, such as immunologically competent lymphocytes. Health care providers use these drugs primarily in cancer chemotherapy. However, in smaller doses, some cytotoxic drugs also exhibit immunosuppressive activities and are useful in the treatment of autoimmune disorders and the prevention of rejection reactions in organ transplantation. Prototype mainly used for autoimmune disorders and immunosuppression for organ transplant recipients: mycophenolate mofetil (CellCept). ▪ Pharmacokinetics- can be taken orally or IV. It is rapidly broken down and metabolized in the liver. It is then excreted through the urine. ▪ Action- interferes with production of DNA and RNA (blocks cellular growth.) inhibits enzyme that synthesizes DNA and reduces proliferation of lymphocytes. ▪ Use- prophylaxis (prevention) of organ rejection (cardiac, renal, hepatic transplants.) ▪ Children- can be used in children 3 months or older. Adverse effects with children with impaired renal function. Monitor tests. ▪ Pts with renal impairment- may produce higher plasma levels. Avoid doses higher than 1g twice a day. ▪ Pts with liver impairment- interferes with metabolism and may increase half-life. ▪ Protection precautions- patients should have their home clean with no plants inside living space. Patients should assess for sources of infection. ▪ Adverse effects- nausea, vomiting and diarrhea. Increased risk of infection and malignancy. ▪ Contraindications- not recommended during pregnancy or lactation. May cause fetal loss or malformations. Contraception is enforced for women. ▪ Therapeutic effect- absence of s/s of rejection reations. ▪ Adverse effects- sore throat, fever, chills, weight changes, fluid and electrolyte balance, rash, bruising, petechiae, jaundice, etc. Corticosteroids are combined with immunosuppressant agents as a front-line therapy for the treatment of clinical GVHD. Can also reduce inflammation in lungs which can be caused by immunosuppressant. Chapter 14 Drug therapy for the treatment of cancer: Methotrexate and chemotherapy Methotrexate o CLASS: Therapeutic class: Antineoplastics, Pharmacologic class: Folate antagonists Interferes with DNA syntheses /repair/ cellular replication Usually, water-soluble so IV is required Most active on rapid dividing cells (good for rapid tumors) Potential tetragons ( kill bebe ) Dosage in kids depends on the body surface.  USE- combinations of cytotoxic drugs with different cytotoxic activities in the cell cycle and different organ toxicities are most effective in certain types of cancer ♦ Weight based dosing to individualize dosing of all cytotoxic drugs to minimize toxicity of the cell  Use in children- risk for certain malignancies: acute leukemia, lymphomas, brain tumors, Wilm’s tumor, and sarcomas of muscle and bone. ♦ Physicians should supervise administration. ♦ Higher cure rates. ♦ Nausea and vomiting  Use in older adults♦ Increasing risk factor for development of cancer ▪ About 10x greater in ages over 65 ♦ Keep in mind decreased renal, hepatic function, decreased blood flow and diminished cardiac reserved. ♦ Reduce dose, may become neurotoxic with impaired renal function. ♦ Increased toxicity risk in adults due decreased hepatic metabolism. ♦ Psychosocial issues.  Renal impairment ♦ Nephrotoxic, risk for accumulation of toxic drug levels. ♦ Monitor renal function carefully ♦ Reduce drug dosages according to CrCl levels ♦ Check status before and after.  Hepatic impairment ♦ May cause acute toxicity (fibrosis or cirrhosis) ♦ Increased ALT and AST  Patients with critical illness ♦ Should be significantly reduced or discontinued with compromised perfusion to the liver and kidneys  Contraindications ♦ Pregnancy and lactation ♦ Myelosuppression ♦ Serious infection and bleeding  Nursing implications ♦ Schedule, route, and dosage ♦ Adhere to schedule.  Patient teaching ♦ Avoid aspirin and alcohol ♦ Avoid prolonged exposure to sunlight ADVERSE EFFECTS Alopecia/Anema/Bleeding/fatigue/ Tumor lysis syndrome (killed cells explode and their contents go into blood making everything go up (aka hyperkalemia, hyperphosmia, and acidosis may occur.) ( make sure you hydrate a lot with IV fluids aggressively to prevent this )  Chemotherapy o A major treatment for cancer, along with surgery and radiation therapy o used to indicate the use of traditional cytotoxic antineoplastic drugs for the treatment of cancer. Except for hormone inhibitors that slow the growth of cancer cells stimulated by hormones, the purpose of all antineoplastic drugs is to damage or kill cancer cells (i.e., be cytotoxic). o Goal is to cure, remission, or palliation o Many use combination drugs o Will calculate dosing with body surface area o Occurs in cycles: specific period with a recovery period following each treatment cycle. This allows body to produce new healthy cells. o Continued as long as it doesnt produce toxicity and until there is no evidence malignancy available. Chapter 15 Overall information of antibiotics - Broad antibiotic spectrum (kills a wide range of bacteria) (try using narrow range due to broad spectrum usually killing normal flora sometimes causing a opportunistic infection. - Opportunistic infection is when normal flora become pathogenic when something is disrupted. (burns, HIV) - Bactericidal (kills the bacterial) (depends on persons immune system, usually used for impaired immune function patients when the have serious infections) - Bacteriostatic (inhibits growth of bacteria) - Antimicrobials are the most used however due to overuse has caused drug resistant bacterial. - Basically, try using a narrow spectrum more often, test for gram bacteria's and prescribe antibiotics when infection is present. Take a full cup of water and try taking 1-2 hrs before eating. Emperic Therapy - When a doctor orders antimicrobial before seeing the test results of the bacteria. Informed estimate due to signs and symptoms. ( for example, oww my stomach hurts, so the doctors assume E. coli and prescribe that. Culture and Sensitivity Match the drug to the bacteria. Basically, testing which drug kills which bacteria and testing if the drug affects the bacteria or is it resistant. Doctor will try prescribing the least toxic drug due to risk benefitting. Combination therapy -Two antibiotics due to two types of bacteria causing infection. Chapter 16: Tylenol Classification and Prototypes Classification: NSAIDs, Prototypes: acetaminophen Generic and Trade Names Generic: acetaminophen Trade names: Abenol, Acephen, Tylenol. Antidote o Acetylcysteine (acetadote), most beneficial given within 8 hours of ingestion but within 36 hours is still helpful. Pharmacokinetics Oral admin absorbed well. Peak plasma concentrations are reached within 30-120min. PO or suppository: 325-650mg every 4-6hrs. IV injection Ofirmev 1000mL over 15min. Duration: 3-4 hrs. Metabolized: Liver Excreted: 94% in urine as non-toxic glucuronate and sulfate conjugates, 2% excreted unchanged. 4% is metabolized by cytochrome P450 enzymes to a toxic metabolite later excreted in urine. Patient-related variables Use in young children: Ibuprofen also has antipyretic properties. Alternating acetaminophen and ibuprofen every 4 hours over a 3-day period to control fever in young children has been shown to be more effective than monotherapy with either agent. Use in older adults: Safe unless liver damage is present or chronic alcohol abuser. Patients with renal impairment: May accumulate in kidneys. Acetaminophen is nephrotoxic in overdose because it is a metabolite that attacks kidney cells and can cause necrosis. Patients with hepatic Impairment: Same problem as renal impairment patients, but can cause fatal liver necrosis in overdose because it forms a metabolite that destroys liver cells. It is stimulated by ingestion of alcohol, smoking and anti seizure meds so they are at a higher risk for hepatotoxicity with usual therapeutic doses. the purpose Analgesic Antipyretic DOES NOT HAVE ANTI-INFLAMMATORY EFFECTS. mechanism of action Reduce fever, acts directly on hypothalamus to increase vasodilation and sweating. Diminishes pain. Given to children with side effects/adverse reactions Hepatotoxicity and renal failure. Hypersensitivity reactions marked by rash and fever may occur in patients with allergy to drug. Myocardial damage💔may develop in patients when doses of 5 to 8 g/d are ingested over several weeks or when 4 g/d have been ingested over 1 year. ASSESS For: Jaundice, urinary output, BUN, creatine, rash, fever. If rash develops stop drug. Indications/nursing Implications Antidote: acetylcysteine Prevent interactions Drugs increasing acetaminophen effects: carbamazepine, phenytoin, rifampin Drugs decreasing acetaminophen effects: carbamazepine, phenytoin, and rifampin. LOL they are the same, this book is useless. Herbs increasing effects: Willow and meadow root, Ginkgo. Alcohol: causes hepatotoxicity, no more than 2g daily if drinking. Administer meds: Oral or suppository Given with food to reduce GI upset. Do not go over max dose of 4g for adults. Limit duration of medication to 5 or less for children, 10 for adults, 3 for adults and children when used to reduce fever. Assess Assess temperature every 2-4 hours Assess for jaundice related to hepatoxicity. Assess urinary output, BUN, creatinine, for risk of renal toxicity. Assess for rash, fever in case of hypersensitivity reaction. Patient Education Do not exceed recommended dose, do not take other meds containing acetaminophen. Report rash or fever after taking acetaminophen. Only chew “chewable” tablets and do not swallow these labeled “chewable” whole. Aspirin Classification and Prototypes Classification: salicylates Prototypes: aspirin Other drugs in class: Choline magnesium trisalicylate, Salsalate, Magnesium salicylate (Doans Pills) Generic and Trade Names Generic: aspirin Trade name: Aspir-81, Bayer, Durlaza, Ecotrin, Empirin, Miniprin, Novasen, St. Joseph Children’s Supasa, Vazalore, Zorprin. Pharmacokinetics Oral: onset: 5-30 min Peaks at 15-120 minutes. Duration of action: 3-6 hours. Rectal onset: 1-2 hours. Peaks at 4-5 hours Duration of action: 6-8 hours. Metabolized at the liver. Half-life of 15 minutes to 12 hours Excretion in the urine CAN cross the placenta and enter breast milk. Serum drug levels Therapeutic serum levels of salicylate is 100-300 mcg/mL Toxicity occurs above 300 mcg/mL Overdose Treatment Stopping or reducing dose for mild toxicity Gastric lavage and activated charcoal reduce absorption if still in the GI tract. Sodium bicarbonate, produces alkaline urine, causing increased excretion. Hemodialysis Patient-related variables For children: not recommended due to association with Reye’s syndrome, a life-threatening illness characterized by encephalopathy, hepatic damage, other serious condition. Usually caused after viral infection (influenza and chickenpox) when aspirin was given for fever. Older adults: Safe in therapeutic doses. Safe for prophylaxis of MI, TIA, CVA. Pt with Renal Impairment: Nephrotoxic in high doses Protein binding of aspirin is reduced in patients with Renal failure. Causing high serum drug level. Decreases blood flow to kidneys due to dilation of renal blood vessels. Decreases renal blood flow, glomerular filtration rate, and retention of salt and water. Low serum albumin levels: Lower-than-average doses Drug Preparation For fever and pain, PO 325-650 mg every 4 h PRN, or single dose of 650 mg For osteoarthritis or rheumatoid arthritis, PO 2-6 g/d in divided doses. For acute rheumatic fever, PO 5-8 g/d in divided doses. Prophylaxis of MI, TIA, CVA: PO 81-325 mg/d TIA: PO 1300 mg/d in divided doses, (650 mg twice a day or 325 mg four times a day.) Pregnant women with polycythemia vera: PO 75 mg daily during pregnancy. Route of administration PO Should be administered with full glass of water or with other fluid. With food or just following food. Low doses (325mg initially and 75-81mg daily) the purpose Relieve mild to moderate pain. Antipyretic (for only adults) Anti-inflammatory agent. Antiplatelet. mechanism of action Inhibits prostaglandins, causing anti-inflammatory effects and antirheumatic effects. Antipyretic, cause unknown, believed that aspirin acts on the thermoregulatory center of the hypothalamus which blocks the effects of the endogenous pyrogens and inhibiting ht synthesis of prostaglandins. Also has a antiplatelet effect, low doses blocks synthesis of thromboxane A2 to inhibit platelet aggregation side effects/adverse reactions Common: nausea, dyspepsia, heartburn, epigastric discomfort MORE LIKELY ON ASPIRIN: decreased platelet aggregation causing GI blood loss and hemorrhage, petechiae, bruising, ASPIRIN TOXICITY: respiratory alkalosis, hyperpnea, tachypnea, hemorrhage, confusion, pulmonary edema, seizures, TETANY, metabolic acidosis, fever, coma, cardiovascular collapse. Renal and respiratory failure (doses of 20-25g in adults and 4g in children): Salicylism (toxicity related to salicylates): dizziness, TINNITUS, difficulty hearing, mental confusion. Contraindications: Those sensitive, those allergic to tartrazine, those with risk of bleeding. BLACK BOX WARNING: for children and teenagers should not take aspirin if they are experiencing chickenpox or flu-like symptoms because of Reye’s syndrome. This can cause encephalopathy, fattly liver accumulations. Administered cautiously in pt with impaired renal function. If aspirin crosses placenta, adverse effects include: Intrauterine growth retardation, salicylate toxicity, risk of bleeding, neonatal acidosis. Mothers who took aspirin late in pregnancy adverse effects: low birth weight, increased intracranial pressure, stillbirth. Indications/nursing Implications Alcohol and Gingko increase effects of aspirin. Administration: Taken with full glass of water or other fluid. Following food or with food. Assess: Pain Fever every 2-4 hours s/s of inflammation Patient Education Out of reach of children Use as directed, do not over administer. Take meds with food or after meals to prevent stomach upset. Do not crush enteric-coated or sustained-release. Watch for adverse effects and report them. Avoid aspirin 2 weeks before and after major surgery or dental procedures. If pregnant, do not take 2 weeks before estimated delivery date. Report known allergies, severe GI symptoms, rash, or skin disorder after taking aspirin. Avoid alcohol due to GI irritation, and risk of bleeding. Aspirin contains 553 mg of sodium per tablet, advise patients in low-sodium diet. Ibuprofen Classification and Prototypes Classification: NSAID, propionic acid derivatives Prototype: ibuprofen Generic and Trade Names Generic: ibuprofen Trade: Motrin, Advil, Excedrin OTHER drugs in class: Diflunisal, Fenoprofen (Fenortho, Nalfon), Flurbiprofen, ketoprofen, meclofenamate sodium, mefenamic acid, Nabumetone, Naproxen sodium (Aleve, Anaprox), Oxaprozin, tolmetin sodium. Pharmacokinetics 80% absorbed in the GI tract. Onset of 1 hour. Causing antipyretic effects. Peak at 1-2 hours. Duration of action 6-8 hours. Metabolized in the liver. Eliminated in the urine. Small percentage through in biliary excretion Drug related variables Children: Reduction of fever for children over the age of 6 months. Alternated with acetaminophen to reduce fever. Older adults: Safe in therapeutic doses for analgesic or antipyretic. Evaluate for GI blood loss, renal disfunction, edema, hypertension, drug-drug interaction Gastroprotective agent is recommended for pt risk for upper GI bleeding. Renal Impairment: Can cause or aggravate renal impairment. It dilates renal blood vessels, decreasing blood flow to kidneys. Those highest risk are those 50 years of age, taking diuretics, hypertension, diabetes, or heart failure. Hepatic Impairment: Ibuprofen is metabolized at the liver. Dosage needs to be decreased with those with hepatic problems. Those with hepatitis have the maximum daily dosage of 2g. Pt with critical illness: BLACK BOX WARNING: Contraindicated for the treatment of perioperative pain after coronary artery bypass graft. the purpose Relieve mild to moderate pain, including dysmenorrhea (painful menstruation). Treat inflammation rt rheumatoid arthritis and osteoarthritis. Reduces fever. Also for initial attacks of acute gout. mechanism of action Blocks prostaglandin synthesis and modulates T-cell production. Inhibits inflammatory cells by the process of chemotaxis to destroy the cells of inflammation. Categorized as first generation, blocking COX-1 and COX-2. side effects/adverse reactions Dry mouth, gingival hyperplasia, dyspepsia, heartburn, nausea, epigastric pain, constipation, and GI ulceration with occult blood loss. Nephrotoxicity, elevated BUN, elevated creatinine, edema. Dyspnea, bronchospasm, hemoptysis, pharyngitis. BLACK BOX WARNINGS: NSAIDs cause increase risk of serious cardiovascular thrombotic events, including stroke or myocardial infarction. Indications/nursing Implications Interactions Increasing effects of Ibuprofen: Anticoagulant: increase risk of bleeding. Codeine, oxycodone, and hydrocodone: additive analgesic effect. Corticosteroids: Have additive gastric irritant and possible ulcerogenic effects. Herbs: garlic, ginger, ginkpo, feverfew Alcohol Administering: PO and daily dose should not exceed 3200 mg. IV concentration should be diluted in a concentration of 4 mg/mL or les using SN, D5W, or LR. Pt should be well hydrated prior to administration. Assess: Temperature every 2-4 hours Assess pain using pain scale Anti-inflammatory effects. adverse effects: GI bleeding, hemoptysis, melena (dark tarry stools). CBC and clotting times of anticoagulation. s/s of hypersensitivity: rash and bronchospasm. Patient Education Take drug with food or liquid to decrease gastric irritation. Drink 2-3 quarts of fluid daily when taking drug regularly. Report signs of bleeding, (epistaxis, hemoptysis, petechiae, bruising, hematuria, dyspnea, stomach upset, swelling, weight gain. Chapter 18: Penicillin -Beta Lactamase = enzyme produced by bacteria that attacks beta lactam ring, making the drug ineffective and leads to resistance in beta lactase antibiotics. Pharmakinetics -widely distributed (if infected mengies then it goes to chf ) Kidneys excrete ampicillin. (be careful with hepatic impairment) Present in breast milk Old people check creatinine clearance Half-life is one to two hours Adverse effects High doses can cause CNS effects ACTION - Inhibits bacterial wall synthesis by binding to one or multiple penicillin binding - More effective on the gram-positive bacteria Patient Education - Give penicillin 1-2 hours before meal - Glass of water - Complete full course - Follow Instructions You know how bacteria resist antibiotics using beta-lactamase? It's some bacteria's secret weapon against antibiotics. So we made beta-lactamase inhibitors designed to counter that. It's usually when you see an antibiotic with a second name like 'piperacillin-tazobactam'. The second name, tazobactam, is the beta-lactamase inhibitor. Prototype: Ampicillin Pharmacokinetics After absorption, ampicillin is widely distributed. Penetration into the cerebrospinal fluid (CSF) occurs only with inflamed meninges. The kidneys rapidly excrete ampicillin, largely as unchanged drug, and it produces high drug concentrations in the urine. It is present in breast milk, and the volume of distribution increases during pregnancy, when the half-life, generally 1-2 hours, is increased. Action Ampicillin, like all penicillin, inhibits bacterial cell wall synthesis by binding to one or multiple penicillin-binding proteins Use Clinical indications for use of ampicillin include bacterial infections caused by susceptible microorganisms. Health care providers use the drug in the treatment or prophylaxis of infective endocarditis. The drug’s broad spectrum is often useful in skin, soft tissue, respiratory, GI, and genitourinary infections. The broad-spectrum coverage of ampicillin extends its activity against gram-negative bacilli. Note that the incidence of resistance among streptococci, staphylococci, and other microorganisms continues to increase. Use in Children o Widely used to treat infections and are generally safe. Caution is necessary in neonates because immature kidney function slows drug elimination. Dosage should be based on age, weight, severity of infection being treated, and renal function. Use in Older Adults o Relatively safe but decreased renal function/other disease processes with concurrent drug therapies increase risks of adverse effects. o Prior to administration of any antibiotic, verify if the dosage should be adjusted based on the patient’s creatinine clearance. Elderly patients are susceptible to superinfections when given any anti-infective agent. Use in Patients with Renal Impairment o Ampicillin is excreted primarily by kidneys, use caution Use in Patients with Hepatic Impairment o Can be used, as can almost all penicillins. o Caution is necessary when using amoxicillin-clavulanate (Augmentin) in patients with hepatic injury/destruction. o Development of cholestatic jaundice and hepatic dysfunction with previous use of drug are contraindications. Cholestatic liver impairment usually subsides when drug is stopped Use in Patient with Critical Illness o The extended-spectrum drugs (piperacillin, which is a derivative of ampicillin) and penicillin-beta-lactamase inhibitor combinations (Zosyn), which have bactericidal activity against a wide range of bacteria, are most likely to be used in critical care units for the treatment of respiratory diseases such as pneumonia, blood, or other infections. With cephalosporins, third- and fourth-generation drugs are commonly used and usually given by intermittent IV infusion every 8-12 hours. Blood levels of penicillins need to be maintained above the minimum inhibitory concentration (MIC) of the microorganisms causing the infection. Continuous or extended infusions may be of benefit w/ serious infections, especially Pseudomonas/Acinetobacter. o Necessary to monitor function of kidneys, liver, and other organs in critically ill patients and reduce drug dosages when indicated Adverse Effects Most common AE is hypersensitivity rxns, including rash/anaphylactic rxn. GI adverse effects: abdominal pain, diarrhea, gastritis, and nausea and vomiting Nephropathy, such as interstitial nephritis, has occurred with all penicillins. Most often associated with high dosages of parenteral penicillins and attributed to hypersensitivity rxn. Penicillin G irritates the CNS. AE r/t CNS toxicity includes confusion, lethargy, twitching, dysphagia, seizures, and coma Penicillinase-resistant penicillins may result in hepatotoxicity o o o ▪ ▪ ▪ ▪ o ▪ ▪ ▪ Extended-spectrum penicillins may lead to hypokalemia and hypernatremia BBW♦: alert healthcare provider that inadvertent IV administration of PENICILLIN G BENZATHINE may result in cardiopulmonary arrest/death. Long-acting repository forms have additives that decrease their solubility in tissue fluids and delay absorption. Contraindications Include hypersensitivity/allergic reactions to any penicillin formulation (an allergic rxn to one penicillin = rxn to all penicillins) Cephalosporins and carbapenems each have a bicyclic core structure. This chemical unity is thought to be most responsible for beta-lactam hypersensitivity. Nursing Implications Preventing Interactions Ampicillin inhibits renal tubular secretion of methotrexate, which may lead to prolonged and higher drug concentrations of methotrexate. Penicillins are often given with aminoglycosides for serious infections (caused by Pseudomonas aeruginosa). They are not to be admixed in a syringe, given in IV solution, or administered via Y-site, because the penicillin inactivates the aminoglycoside. Dose separation is ideal! Drugs That Increase the Effects of Ampicillin Allopurinol: Increases the incidence of skin rash Clavulanic acid: Overcomes resistance in bacteria that secrete beta-lactamase Probenecid: Inhibits the renal tubular secretion Uricosuric drugs: Block renal excretion Drugs That Decrease the Effects of Ampicillin Chloroquine: Decreases the serum concentration Fusidic acid: Diminishes the therapeutic effect Tetracycline derivatives: Diminish the therapeutic effect Administering the Medication Necessary to give ampicillin (like most oral penicillins) on empty stomach, approximately 1 hour before or 2 hours after a meal; with a full glass of water to promote absorption and decrease inactivation (can occur in acidic environment). Can be taken with food but absorption decreases. Oral suspensions are stable for 7 days at room temp and 14 days refrigerated. When diluted with 0.9% NaCl, ampicillin is stable for 8 hours for concentrations up to 30 mg/mL. only stable for 1 hour when diluted with dextrose solutions for concentrations of 10-20 mg/mL. it is necessary to give IV penicillins for full, prescribed course of treatment to prevent complications such as rheumatic fever, endocarditis, and glomerulonephritis; IV concentrations should NOT exceed 30mg/mL. o o o o o o o o o o Assessing for Therapeutic Effect Not necessary to obtain drug levels ✅ It is recommended that serum creatinine and BUN be monitored Assessing for Adverse Effects Assess characteristics of rash if present Distinguish hypersensitivity from a nonallergic ampicillin rash Patient Teaching General considerations Do not take any penicillin if you have ever had an allergic reaction to penicillin in which you had difficulty breathing, swelling, or skin rash. However, some people call a minor stomach upset an allergic reaction, which is incorrect, and they are not given penicillin when that is the best antibiotic in a given situation. Complete the full course of drug treatment for greater effectiveness and prevention of secondary infection with drug-resistant bacteria. Follow instructions carefully about how much of the drug you are supposed to take and how often you are supposed to take it. Drug effectiveness depends on maintaining adequate blood levels. Penicillins often need more frequent administration than some other antibiotics, because they are rapidly excreted by the kidneys. Self- or Caregiver Administration Take most penicillins on an empty stomach, 1 hour before or 2 hours after a meal. Penicillin V, amoxicillin, and Augmentin can be taken with food. 🍲(Take Augmentin with meals to increase absorption and decrease GI upset.) Take each dose with a full glass of water; do not take with orange juice or with other acidic fluids (they may destroy the drug). Take at even intervals, preferably around the clock. Shake liquid penicillins well, so they are mixed thoroughly, and measure the dose accurately. Discard liquid penicillin after 1 week if it is stored at room temperature or after 2 weeks if it is refrigerated. Liquid forms deteriorate and should not be taken after their expiration dates. Report skin rash, hives, itching, severe diarrhea, shortness of breath, fever, sore throat, black tongue, or any unusual bleeding to your health care provider. These symptoms may indicate an allergy to penicillin. 🌿🌿Herb Interactions: Food: decreases absorption Khat 🐈🐱 decreases absorption Concentrate on: Pharmakinetics (Add metabolism, Action, Use, Excretion in summery) Vitamin K Alteplase Clopidogrel Coumadin (Warfin) Aspirin Heparin Epoetin Interferon Corticosteroids Tylenol (Trade names: Abenol/Acephen/Tylenol) (Generic: Acetaminophen) ▫ Antidote (Acetylcysteine aka acetadote) ▫ PharmaKinetics (Oral admin absorbed well) o Duration 3-4 hours o Metabolized in LIVER o Excreted in urine o Used for reduction in fever/pain/anti-inflammatory (analgesic and antipyretic) Aspirin (Salicylates classified as) (Trade names: Aspir-81, Ecotrin, Miniprin, Novasen) ▫ PharmaKinetics (oral) o Onset 5-30 min o Peaks at 15-120 min o Duration 3-6hrs o Metabolized in LIVER o Excretion in Urine o CAN CROSS PLACENTA and BREAST MILK o Serum drug levels are 100-300 mcg (toxicity above 300 mcg) NEPHROTOXIC Opioids Ibuprofen Penicillin High Alert Medications Drug Sources Drug Approval Processes Serum Drug Levels Serum drug level- lab measurement of the amount of a drug in the blood at a particular time; reflects dosage, absorption, bioavailability, half-life, and the rates of metabolism and excretion · Minimum effective concentration MUST be present before a drug exerts its pharmacologic action on body cells o Prevents toxicity · Measuring serum drug levels: · When drugs with a narrow margin of safety are given because their therapeutic doses are close to their toxic doses (e.g., digoxin, aminoglycoside antibiotics, lithium) · To document the serum drug levels associated with particular drug dosages, therapeutic effects, or possible adverse effects · To monitor unexpected responses to a drug dose such as decreased therapeutic effects or increased adverse effects · When a drug overdose is suspected Cell Membranes and Receptors Serum Half-life 8. Serum Half-Life Serum half-life: time required for the serum concentration of a drug to decrease by 50%; also called elimination of half life Half-life is determined by the drug’s rate of metabolism and excretion. Drugs with short half-lives requires more frequent administration than one with a long half-life. When a drug is given at a stable dose, four or five half-lives are required to achieve steady-state concentrations and to develop equilibrium between tissue and serum concentrations. To maintain steady-state concentration, the amount of drug given must equal the amount eliminated from the body. When a drug is changed, it requires four to five half-lives to reestablish equilibrium. When a drug is discontinued, it is eliminated gradually over several half-lives. Drug-related variables Patient-related variables Drug Preparations and Dosage Forms Drug dosage Calculations Routes of Administration Medication Administration Process Health Education on Medications to Adults and Geriatric Patients Physiological Changes in Geriatrics in Relationship with Medications Safety in Administering Medications to Adults and The Elderly