May 30, | nursing, med, NURS, Paper
Foundations of EBP eMAR Paper
Foundations of EBP eMAR Paper
Identify a project from a department at your place of employment that demonstrates a commitment to an improvement in patient care. (A project – introduction of eMAR, electronic medical record)
Why is this project/study important?
What role would an APN play in this project?
Identify a PICOT question that you could use to guide the research of the identified problem.
Provide 5 databases that you might use for your research, and give a short description of each.
What barriers do you foresee in implementing this project?
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The purpose of this paper is to get students thinking about what EBP is and how they would go about identifying and implementing a project. The directions state: 4 pages in length, not including the title and reference page. (points will be deducted for papers over or under required length)
references on the project topic should be < 5 years old Foundations of EBP eMAR Paper.
Foundations of EBP Paper
Foundations of EBP Paper
RUBRIC
Ratings
Pts
This criterion is linked to a Learning Outcome Project Identification
Clearly identifies a project or study demonstrating a commitment to improvement in care. Department, key players, goals are identified.
3.0 pts
This criterion is linked to a Learning Outcome Identifies Importance of Project/Study
The purpose of the project/study is clearly identified Foundations of EBP eMAR Paper
2.0 pts
This criterion is linked to a Learning Outcome Evaluates the role of the APN in this project
All key elements are present: the role of the APN specific to this project. How does the scope of practice, standards of care, social, legal and economic factors influence the research project or study?
5.0 pts
This criterion is linked to a Learning Outcome PICOT Question r/t the project/Study
All key elements of a PICOT question are present:
P- Patient, problem or population
I – Intervention
C – Comparison
O – Outcome
T- Time
5.0 pts
This criterion is linked to a Learning Outcome Identifies Databases
Identifies 5 appropriate databases available for research with a short description of each
3.0 pts
Foundations of EBP eMAR Paper
This criterion is linked to a Learning Outcome Identifies Barriers to Implementation
All key elements are present
2.0 pts
This criterion is linked to a Learning Outcome APA Format
Paper is the required length and consistently documented in APA format
1.0 pts
Introduction of eMAR, electronic medical record
Electronic health records have been adopted in the healthcare system for about decade now. Their development sought to improve the quality and safety of the patients through efficient paperless record keeping. Electronic medication administration records (eMAR) describe the server-based electronic medication administration system designed to replace the paper form of medical recording. eMAR is useful in rehabilitation facilities, long-term care, assisted living and institutional pharmacies. Its main roles include automating the medical tracking, distribution and re-ordering process as well as safe treatment (Vicente et al., 2017) Foundations of EBP eMAR Paper. It also saves time and labor force as well as reduces medical errors that might otherwise undermine the safety of the patient. This paper describes a project on the introduction of eMAR, its importance, the APN related roles and a PICOT question that guides the research as well as the relevant databases employed in this research. Consequently, the paper presets the foreseen barriers to the implementation of the project.
Importance
Poor record keeping has resulted in the increase of healthcare cost over the years due to the occurrence of errors, cumbersome storage of medical records and job burnout among other factors. However, the introduction of Health Information Technology for Economic and Clinical Health (HITECH) Act ten years ago has seen notable adoption of multiple technologies in the healthcare sector. For instance, eMAR introduction has brought about a revolution in patient care with its rapid replacement of the paper medical administration recording. This has helped in saving time, labor, increasing efficiency and reduction of errors as well as maintenance of confidentiality. Moreover, the introduction of the technology is crucial in maintaining a seamless flow of information via integrated systems that decrease the possibilities of medical errors, duplication of data entry and also saves time in the healthcare facility (Seibert et al., 2014). Therefore, it also increases safety of the patient and the quality of healthcare provided Foundations of EBP eMAR Paper.
Role of the APN
Advanced practice nurse play notable roles in the introduction of organizational change. The professional practice of APNs is derived from a reflective experience characterized by a wide range of nursing skills and knowledge. They are involved in the admission of patients, prescription of drugs as well as referrals. Considering that the electronic medical administration records are designed to improve the safety of the patient in these areas, the APN will be actively engaged in the change process. Their roles will include interdisciplinary collaboration geared towards ensuring the effectiveness of the project in increasing the safety of the patients. This will involve advisory and consultative services that will promote evidence-based practice and use of the new technology (ED Management, 2018) Foundations of EBP eMAR Paper. Moreover, APNs will be involved in planning, implementing and evaluating the health programs involved in the eMAR systems to ensure efficiency.
PICOT questions helps in finding the best available evidence to influence the nursing practice. PICOT stands for P-Patient/Problem, I-Intervention, C-comparison, O-Outcome and T-Time. The problem demanding the organizational change is the increase in healthcare cost for patient due to lack of a standardized and efficient medical administration recording system. The intervention addressed by the project is the introduction of eMAR system in the healthcare organization. Consequently, the project is comparing the intervention with the paper electronic medical administration records on the comparison section of the question. On the other hand, the anticipated outcome of the project is the increased efficiency with regard to safety and healthcare cost reduction for a period of six months through which the project is expected to run. Therefore, the PICOT question guiding the research study is, “Does the introduction of the electronic medical administration records increase the efficiency and safety of the patients within six months?” Foundations of EBP eMAR Paper.
Databases and Description
Elsevier Science Direct provides a wide range of access to medical research materials. The database is a subscription-based website containing four categories of journals namely the health sciences, life sciences, engineering and physical sciences. It provides multiple e-books, academic journals which exceed 12 million pieces (Friedlander & Khan, 2016) Foundations of EBP eMAR Paper. The articles present are interdisciplinary, high quality and help find answers to research questions in wide range of areas including my project on the introduction of the electronic medical administration records. I was able to research on patient’s safety in the automation era.
Another database used in this research is the Cochrane Library-Wiley online library. This database provides independent, high quality collection of healthcare evidence that informs decision-making and helps answer various research questions. The collection of databases is published by Wiley and hosts material science, health science and peer reviewed journals and is accessed through subscription. The database provided articles on the effects of eMAR application on the safety of the patients.
Notably, CINAHL is the most in-depth and largest database for nursing research. It refers to the Cumulative Index of Nursing and Allied Health Literature and is effective particularly in qualitative research studies. It covers all fields of nursing including the electronic medical record area which makes it relevant for this project. Further research was conducted in the MEDLINE via PubMed database. This site contains online books, science journals, citations and other literature material for life sciences and biomedical subjects through the free search engine access, PubMed. This site was effective in understanding the organizational and quality changes brought about by the project introduction. Lastly, I used the ERIC database. This is the Education Resources Information Center that provides full-text and indexed education literature material on the online digital library. It is run by the U.S. National Library of Education (NLE) and contains documents, synopsis, reports, books, studies, tests and pamphlets relevant in multiple study fields including healthcare (Friedlander & Khan, 2016). This site was crucial in providing an overview of the eMAR system Foundations of EBP eMAR Paper.
Barriers to Implementation
The implementation of the eMAR is challenged by several barriers including the hospital culture (ED Management, 2018) Foundations of EBP eMAR Paper. The hospital staff is used to the use of paper medical administration recording which might affect the implementation of the electronic system. The change in the organization culture might cause stress and low productivity as well as resistance from workers. According to Relias Media (2019), poor usability of EMR results in concerns of staff burnout as well as patient safety concerns. This is evident in the increased number of medical errors discovered in various health organization departments that placed the patients’ lives at risk.
The privacy concerns may also act as barriers to the implementation of the project. This is because, the confidentiality of the sensitive medical records is legally demanded and thus, cyberattacks such involving data mining and hacking can undermine the privacy and security of the patients information (Aldosari, 2017). The cost of purchase, training, hiring and installation of electronic medical health record is also high which could limit the implementation of the electronic medical administration records Foundations of EBP eMAR Paper.
References
Aldosari, B. (2017). Patients’ safety in the era of EMR/EHR automation. Informatics in Medicine Unlocked, 9, 230-233.
ED Management. (2018). Hospitals Leverage Safety Huddle to Reduce Patient Harm, Boost Transparency, and Drive Culture Change.
Friedlander, R. R., & Khan, A. M. (2016). U.S. Patent No. 9,230,060. Washington, DC: U.S. Patent and Trademark Office.
Relias Media. (2019). Poor EMR Usability Linked to Patient Safety Concerns, Clinician Burnout. Retrieved from www.reliasmedia.com/articles/144399-poor-emr-usability-linked-to-patient-safety-concerns-clinicianburnout on September 11,2019
Seibert, H. H., Maddox, R. R., Flynn, E. A., & Williams, C. K. (2014). Effect of barcode technology with electronic medication administration record on medication accuracy rates. American Journal of Health-System Pharmacy, 71(3), 209-218.
Vicente Oliveros, N., Gramage Caro, T., Pérez Menendez‐Conde, C., Álvarez‐Díaz, A. M., Martín‐Aragón Álvarez, S., Bermejo Vicedo, T., & Delgado Silveira, E. (2017). Effect of an electronic medication administration record application on patient safety. Journal of evaluation in clinical practice, 23(4), 888-894 Foundations of EBP eMAR Paper.
May 30, | nursing, med, NURS, Paper
NSG 6005 Advanced Pharmacology Midterm & Final Exam Study Guide
NSG 6005 Advanced Pharmacology Midterm & Final Exam Study Guide
NSG 6005 Advanced Pharmacology Midterm—Study Guide
There will be 75 questions on the Midterm. Most will be multiple choice. There are a couple True/False and 5 matching questions. I suggest you review your PowerPoints and Textbook Assignments. I hope this study guide is helpful
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Make sure you know the following topics very well.
When a medication is listed below, make sure you know all about it and how to apply it to different patient situations: What disease process it is used for?, how does it work?, when should it not be used?, adverse effects, pros/cons, interactions, patient education factors (should it be taken w/ food? At bedtime?), tapering, preliminary and post treatment labs, black box warnings/CI, etc. NSG 6005 Advanced Pharmacology Midterm & Final Exam Study Guide.
If a disease process is mentioned below—know how to diagnose and recommended treatment guidelines.
General principles of pharmacokinetics and dynamics?
PHARMACOKINETICS- What the body does to the drug”
Absorption –Entry of drug to the blood stream. Usually depends on passive diffusion of drug through cell membranes.
Absorption depends on: blood flow at site, drugs lipid soluability (> lipic, > soluabililty that directly penetrate the memebrane), local PH and drug ionization (non-ionized absorb better), pharmaceutical processing (coatings and additives.
Blood brain barrier: allow lipid soluable only. May pump out any drug that it sees as foreign, hard to treat CNS infections.
Placenta: allows lipid drugs so does not protect from lipid soluable drugs, which is why pregnant women are limited to drugs. Know gestation age. NSG 6005 Advanced Pharmacology Midterm & Final Exam Study Guide.
Distribution
: fat ratio changes may alter distribution, especially a people age.
Fat soluable drugs may be accumulated: weight loss will release these drugs.
Water soluable drugs are affected by dehydration
Biotransformation (Metabolism) : Drugs become more hydrophilic (water soluable) for excretion.
Also referred to as the P450 system or cytochrome P450 system. (a group of enzymes in the liver identified for their ability to breakdown drugs.)
Hepatic “First Pass Effect” (parenteral (IV or IM) meds bypass this enzymatic effect)
breaks PO meds down to some degree, some are protected with coating but they don’t always work
Metabolites
Usually less active, less toxic, easier
to excrete
Prodrugs – inactive in form given but metabolized to active drug (ex: enalapril)
Liver function determined by liver enzymes. NSG 6005 Advanced Pharmacology Midterm & Final Exam Study Guide.
Failing liver produces fewer enzymes, drugs available longer: caution
Excretion: Process by which medications are eliminated from the body unchanged or as metabolites
Kidneys are main organ of excretion
If poor renal function, drug may accumulate, may
wish to prescribe less of drug
Also eliminated via respiration, breast milk, defecation. Tears, sweat, saliva not as significant.
START LOW AND GO SLOW!!!!
PHARMOCODYNAMICS- “effect of drug on the body”
Receptors: Drugs must bind to for effect o Help a process happen: agonist
o Block a process from happening: antagonist o Know that:
All drugs have an effect
A drug’s ability to cause a response is
called its efficacy
If you give a bigger dose you will get a bigger effect up to a point, most drugs have a ceiling.
2) CRITERIA FOR CHOOSING AND EFFECTIVE DRUG?
) Effectiveness: elicits responses for which it is given – most important
Safety: Cannot produce harmful effects even at very high dosages and for long time
oNo such thing as completely safe drug
Selectivity: Only elicits response for which it is given, no side effects
No such thing as a selective drug, all have ADRs
Reversible action: most drugs should be reversible. NSG 6005 Advanced Pharmacology Midterm & Final Exam Study Guide.
Predictability: Know with certainty exactly how individual patient will respond – impossible, must individualize
Ease of administration: simple, convenient route – enhances compliance and decreases errors
Freedom from drug interactions: few drugs are without drug interaction
Low cost: easy to afford; significant factor in adherence, esp. with elderly
Chemical stability: drugs ability to be stored for long time without loss of effectiveness – variable between drugs
Possession of simple generic name: easier to remember and less confusion amongst drugs
3) SYNERGISTIC EFFECT: When two or more drugs are given
together they can react with each other: An effect arising between two or more agents, entities, factors, or substances that produces an effect greater than the sum of their individual effects. It is opposite of antagonism.
o Can be positive (synergistic) • Morphine and Motrin
o Can be negative (compete with each other) • Asa and Coumadin
4) Therapeutic drug levels: (not sure if this is correct)
Minimal Effective Concentration (MEC) – plasma drug level below which therapeutic effects will not occur.
Therapeutic Index or Range– margin of safety
The wider or bigger it is, the safer the drug. o Example 1: Drug A: normal dose is 1 mg, toxic dose is 10 mg
Acetaminophen’s therapeutic range is 30 times the MEC
o Example 2: Drug B: normal dose is 9 mg, toxic dose is 10 mg o Lithium’s therapeutic range is 3 times the MEC.
5) WHAT IS MEANT BY A SIGNIFICANT FIRST-PASS EFFECT?
Metabolism is the process of changing one chemical into another. The liver is a major organ for drug metabolism because it contains high amounts of drug-metabolizing enzymes and because it is the first organ encountered by drugs once they are absorbed from the GI tract. Metabolism by the liver following oral administration is called FIRST-PASS METABOLISM and is important in determining whether a drug can be orally administered. NSG 6005 Advanced Pharmacology Midterm & Final Exam Study Guide.
6) HOW DO YOU KNOW HOW OFTEN TO PRESCRIBE A MEDICATION-1/2 LIFE OF MEDICATIONS.
Half-life- amount of time it takes to reduce the plasma concentration by 50%.
In pharmacokinetics, steady state refers to the situation where the overall intake of a drug is fairly in dynamic equilibrium with its elimination. In practice, it is generally considered that steady state is reached when a time of 4 to 5 the half-life for a drug after regular dosing has started.
7) AGONISTS VERSUS ANTAGONISTS:
AGONISTS: Drugs that produces a physiological response when combined with a receptor.
ANTAGONISTS: a substance or drug that interferes with or inhibits the physiological action of another.
8) SUSTAINED RELEASE MEDICATION CONSIDERATIONS- implies slow release over time. It is defined as the type of dosage in which a portion of the drug is released immediately, and then the remaining/maintenance dose) is then released slowly by achieving a therapeutic level which is prolonged. NSG 6005 Advanced Pharmacology Midterm & Final Exam Study Guide.
9) SUBLINGUAL MEDICATION ADVANTAGES.
Sublingual medication administration (under the tongue) and buccal (between the cheek and gum) allow drugs to have a more rapid onset of action and to avoid liver metabolism as they enter the blood stream.
Nitroglycerin given under the tongue can act within minutes to treat an angina attack.
10) FIRST STEP IN THE PRESCRIBING PROCESS ACCORDING TO WHO?
The first step in the prescribing process is an accurate diagnosis and a determination of a therapeutic objective. (page 29)
WHO SIX-STEP MODEL OF RATIONAL PRESCRIBING:
STEP 1: DEFINE THE PATIENTS PROBLEM
STEP 2: SPECIFY THE THERAPEUTIC OBJECTIVE
STEP 3: CHOOSE THE TREATMENT
STEP 4: START THE TREATMENT
STEP 5: EDUCATE THE PATIENT
STEP 6: MONITOR EFFECTIVENESS
11) THERAPEUTIC GOALS OF PRESCRIBING:
Before deciding what medication to prescribe, it is important to clarify the therapeutic objective.
Is this goal to cure the disease
Relieve symptoms of the disease
Long term prevention
Is the goal treating the combination of 2 outcomes (pain and inflammation)
Palliative therapy
The provider should clarify whether the treatment goals are curative, symptom relieving or preventative.
Include patient in this stage as a partner of treatment. NSG 6005 Advanced Pharmacology Midterm & Final Exam Study Guide.
12.) Patients at risk for adverse drug reactions. (page 55)
Genetic abnormalities
Age
Sex
Polypharmacy
Concomitant medical conditons
Children- are at higher risk primarily because medication dosages must be tailored to their body weight, immature organ function.
Elderly- polypharmacy, decreased renal and hepatic function
13) FACTORS AFFECTING PATIENTS ADHERANCE TO A DRUG REGIMEN:
Highest risk is those patients with asymptomatic condition, chronic conditions. Cognitive impairment, psychiatric illness or disorders with significant lifestyle changes (smoker), and those with complex multiple daily dosing.
Adherance implies a voluntary act of negotiation and joint acceptance of a treatment regimen.
Patients harbor strong concerns about the need for their medication and the risk for taking it. NSG 6005 Advanced Pharmacology Midterm & Final Exam Study Guide.
Limited access to health care
Restricted formularies
High drug costs and co-payments
14) HOW DOES FOOD IN DIGESTIVE TRACT AFFECT ABSORPTION?
a) the presence of food in the GI tract can influence the rate and extent of absorption
b) alteration of PH- food tends to increase stomach PH by acting as a buffer.
c) gastric emptying –fats and some drugs tend to reduce gastric emptying and delay onset of action of drugs.
d) stimulation of GI secretions- GI secretions produced in response to food may result in degredation of drugs that are susceptible to enzymatic metabolism, reducing bioavailablity. Secretions may also increase bioavailability. NSG 6005 Advanced Pharmacology Midterm & Final Exam Study Guide.
e) fats stimulate bile secretion- bile salts dissolute poorly soluable drugs.
f) food induced changes in blood flow- blood flow to the GIT and liver increases blood flow after a meal. The faster the rate of drug presentation to the liver: the larger the fraction of the drug that escapes first-pass metabolism.
g)competition of food components and drugs: possibility of competitive inhibition of drug absorption, especially with drugs who have similar chemical structure of nutrients.
15) RECOMMENDATIONS REGARDING FIBER AND CV HEALTH.
A) Dietary fiber may lower cholesterol
b) provide feeling of fullness, thus causing weight loss.
c) increased soluable fiber intake has been associated with better glucose and improve blood lipid panels.
16) TETROGENIC VITAMINS-
a) vitamin A- can effect embryonic development
17)ANEMIAS- KNOW CHARACTERISTICS AND HOW TO TREAT. See # 27
18.Warfarin – This medication is used to treat blood clots (such as in deep vein thrombosis–DVT or pulmonary embolus-PE) and/or to prevent new clots from forming in your body. Preventing harmful blood clots helps to reduce the risk of a stroke or heart attack. Conditions that increase your risk of developing blood clots include a certain type of irregular heart rhythm (atrial fibrillation), heartvalve replacement, recent heart attack, and certain surgeries (such as hip/knee replacement).
Warfarin is commonly called a “blood thinner,” but the more correct term is “anticoagulant.” It helps to keep blood flowing smoothly in your body by decreasing the amount of certain substances (clotting proteins) in your blood. NSG 6005 Advanced Pharmacology Midterm & Final Exam Study Guide.
Pharmacotherapeutics
Warfarin
Pharmacokinetics
Well-absorbed when taken orally
Metabolized by CYP 1A2 and 2C9
Half-life of 3 to 4 days
Precautions and contraindications§
Pregnancy category X
Use cautiously in patients with fall risk, dementia, or
uncontrolled hypertension.
Avoid in hypermetabolic state.
Adverse drug reactions
Bleeding
Antidote is vitamin K
Allergic reactions
Many drug-drug interactions
Antiplatelet drugs
Thrombolytic drugs
Anticoagulant effect may be decreased by
Oral contraceptives, carbamazepine, etc.
Vitamin K-containing foods
Clinical use and dosing
Drug of choice for deep vein thrombosis (DVT) and pulmonary embolism (PE)
Start at 5 mg per day (7.5 mg/d if weight greater than 80 kg).
Consider lower dose if
Older than 75 years
NSG 6005 Advanced Pharmacology Midterm & Final Exam Study Guide.
Multiple comorbid conditions
Elevated liver enzymes
Changing thyroid status
Dose to maintain international normalized ratio (INR) between 2 and 3.
Monitoring
INR daily until in therapeutic range for 2
consecutive days
Then two or three times weekly for 1 to 2 weeks
Then less frequently but at least every 6 week
19.VITAMIN K
Vitamin K, is a critical component of blood clotting, is found in many foods and is synthesized by intestinal bacteria. Newborns are at risk for early vitamin K–deficiency bleeding
American Academy of Pediatrics(AAP) recommends that all newborns receive
vitamin K within the first 2 weeks of life .
The dose of vitamin K (phytonadione) recommended 0.5 mg to 1.0 mg IM, ideally given within the first hour of life (AAP Committee on Fetus and Newborn, 2003).
Oral vitamin K is used by some countries and by some providers in the United States. The AAP notes that vitamin K–deficiency bleeding in newborns who received oral vitamin K. The AAP recommends IM administration until further study of oral administration is conducted. NSG 6005 Advanced Pharmacology Midterm & Final Exam Study Guide.
Warfarin interferes with the vitamin K–dependent clotting factors (II, VII, IX, and X), leading to decreased formation of clots.
Vitamin K(phytonadione) is prescribed for patients who develop critically high INRs while on warfarin. Patients with an INR greater than 10 with no evidence of bleeding can be administered oral vitamin K (5–10 mg): if high INR with bleeding occurs, vitamin K (5–10 mg IV) is administered along with prothrombin complex (Guyatt et al, 2012).
Foods high in vitamin K compete with warfarin. Therefore, drug–nutrient interactions must be considered to utilize drugs effectively in the prevention and treatment of disease. Patient education must be provided about drug–food interactions, especially if there is a potential for adverse patient outcomes. NSG 6005 Advanced Pharmacology Midterm & Final Exam Study Guide.
Patients who are taking warfarin should not ingest foods high in vitamin K, as the combination may lead to therapeutic failure.
Vitamin K Content in Common Foods
Food
Serving Size
Daily Value (%)
Foods High in Vitamin K (more than or equal to 200% DV)
Eat No More Than 1 Serving per Day
Kale, fresh, boiled
1/2 cup
660
Spinach, fresh, boiled
1/2 cup
560
Turnip greens, frozen, boiled
1/2 cup
530
Collards, fresh, boiled
1/2 cup
520
Swiss chard, fresh, boiled
1/2 cup
360
Parsley, raw
1/2 cup
300
Mustard greens, fresh, boiled
1/2 cup
260
Foods Moderately High in Vitamin K (60% to 199% DV)
Eat No More Than 2 Servings per Day
Brussels sprouts, frozen, boiled
1/2 cup
190
Spinach, raw
1 cup
180
Turnip greens, raw, chopped
1 cup
170
Green leaf lettuce, chopped
1 cup
125
Broccoli, raw, chopped
1 cup
110
Endive lettuce, raw
1 cup
70
Romaine lettuce, raw
1 cup
70
Power point information (short and sweet..)
Vitamin K
A critical component of blood clotting
Found in many foods
Synthesized by intestinal bacteria
Newborns need 0.5 mg to 1.0 mg, ideally within the first hour of life, to prevent vitamin K-deficiency bleeding. NSG 6005 Advanced Pharmacology Midterm & Final Exam Study Guide.
Vitamin K is used as an antidote to critically high international normalized ratio in patients taking warfarin.
20.Vitamin C (ASCORBIC ACID)
Vitamin C, also known as ascorbic acid, is a water-soluble vitamin that humans do not have the ability to synthesize so they must get adequate amounts of it in their diet. Patients with inadequate vitamin C intake may develop scurvy, with symptoms of fatigue, malaise, and gum inflammation or bleeding. Smokers and persons who are heavily exposed to secondary smoke have decreased vitamin C levels; therefore, it is recommended they take 35 mg more vitamin C per day than nonsmokers. Other groups at risk of vitamin C deficiency are infants fed evaporated milk or boiled milk without additional supplementation of vitamin C, patients with malabsorption disorders, and patients with end-stage renal disease who are on hemodialysis (ODS, 2013b).
Vitamin C therapy has been studied for its effects on health because of its antioxidant and immune function action. It has been touted as prevention or treatment of the common cold since the 1970s, when Linus Pauling published his landmark study. A Cochrane Review in 2007 of 30 trials did not find that vitamin C decreases the incidence of colds in the general population (Douglas, Hemiliä, Chalker, & Treacy, 2007). NSG 6005 Advanced Pharmacology Midterm & Final Exam Study Guide.
The role of antioxidants in reducing the risk of cardiovascular disease . The Nurses’ Health Study found an inverse relationship between coronary heart disease and vitamin C intake (Myint et al, 2008). A meta-analysis of 16 studies examining vitamin C intake, circulating vitamin C levels, and risk of stroke suggests lower stroke risk with higher vitamin C intake and levels (Chen, Lu, Pang, & Liu, 2013).
Powerpoint
Humans do not have the ability to synthesize vitamin C.
Inadequate vitamin C intake may cause scurvy.
Smokers have decreased vitamin C levels (+35 mg/day).
Vitamin C does not decrease incidence of URIs.
Mixed results in decreasing cardiovascular disease ,stroke and cancer
Vitamin C
Children:
1–3 yr
4–8 yr
Adolescents aged 9–13 yr
14–18 yr male
14–18 yr female
Adult males
Adult females
Pregnancy
15 mg/d
25 mg/d
45 mg/d
75 mg/d
65 mg/d
90 mg/d
75 mg/d
85 mg/d
Citrus fruits, tomatoes, tomato juice, potatoes, Brussels sprouts, cauliflower, broccoli, strawberries, cabbage, and spinach
IRON
Iron is an essential mineral required for the regulation of cell growth and differentiation, as well as a component of oxygen transport. Patients with irondeficiency will develop microcytic-hypochromic anemia and have red blood cells that are small in size, pale, and low in hemoglobin. Iron-deficiency anemia (IDA) reduces the oxygen-carrying capacity of the blood, leading to fatigue and decreased immunity. Too much iron can lead to iron toxicity; therefore, patients should be advised to take only the recommended amount for their age and condition.
POWERPOINT
Needed for oxygen transport
Patients with iron deficiency will develop microcytic-hypochromic anemia.
Adequate intake is determined by age.
All infants should be assessed for adequate iron in diet. NSG 6005 Advanced Pharmacology Midterm & Final Exam Study Guide.
Iron
0–6 mo 0.27 mg/d
7–12 mo 11mg/d
1–3 yr
4–8 yr
9–13 yr
14–18 yr male
14–18 yr female
19–50 yr male 8mg/d
19–50 yr female 18mg/d
19 to 50 yr pregnant 27mg/d
50+ yr 8mg/d
Chicken liver, oysters, beef, clams, turkey dark meat. Legumes, dark green vegetables. Fortified breads and cereals. Iron-fortified infant formula.
22.VITAMIN A
Vitamin A plays a critical role in vision, bone growth, reproduction, immune function, cell division and differentiation . There are two types of vitamin A: preformed vitamin A, which is derived from animal sources, and provitamin A carotenoid, which is derived from plant sources. Ahealthy diet should contain a variety of carotenoid-rich fruits and vegetables. NSG 6005 Advanced Pharmacology Midterm & Final Exam Study Guide.
Vitamin A deficiency can lead to night blindness and decreased immune function. Vitamin A may reduce the severity and duration of diarrheal episodes in malnourished children in developing countries but not in well-nourished children (Imdad et al, 2011; ODS, 2013a). NSG 6005 Advanced Pharmacology Midterm & Final Exam Study Guide. Vitamin A supplementation has also been found to decrease bronchopulmonary dysplasia in extremely low-birth-weight infants with no increase in mortality or neurodevelopmental disorder. Chronic alcoholism may lower vitamin A levels, and patients with chronic alcoholism may require supplementation. Patients with cystic fibrosis (CF) are predisposed to malabsorption and fat-soluble vitamin deficiency, with 10% to 40% of CF patients being vitamin deficient and requiring supplementation .
Caution should be used to avoid excessive vitamin A supplementation, as toxicity may occur. Levels above recommended amounts may be teratogenic in pregnant women; vitamin A is labeled Pregnancy Category X if intake is greater than recommended amounts.
Vitamin A(POWERPOINT)
Critical role in vision, bone growth, reproduction, immune function, cell division and differentiation
Vitamin A
Children:
1–3 yr
4–8 yr
Adolescents aged 9–13 yr
Adult males
Adult females
Pregnancy
300 mcg/d
400 mcg/d
600 mcg/d
900 mcg/d
700 mcg/d
770 mg/d
Liver, dairy products, fish, darkly colored fruits and leafy vegetables
Vitamin B6
Vitamin B6, also known as pyridoxine, is a water-soluble vitamin needed for protein and red blood cell metabolism, as well as glucose regulation. Vitamin B deficiency may lead to microcytic anemia, dermatitis with mouth sores and cracked lips, and glossitis (ODS, 2011a). Vitamin B6 deficiency may be drug-induced by use of isoniazid (INH), cycloserine, or hydrazine, or caused by a diet that is deficient in vitamin B6–containing foods (fortified cereals, potatoes, bananas, meat). Pyridoxine (vitamin B6) 25 mg/day should be added to the regimen for pregnant patients to decrease the incidence of peripheral neuropathy associated with INH (American Thoracic Society, 2003). Pyridoxine (adults 100 to 200 mg/d in divided doses) may also be given prophylactically to patients on isoniazid, cycloserine, or hydrazine to prevent drug-induced neuritis. Vitamin B6 supplements may reduce the symptoms of premenstrual syndrome, and nausea and vomiting associated with pregnancy (10 to 25 mg TID). NSG 6005 Advanced Pharmacology Midterm & Final Exam Study Guide.
Vitamin B6 (pyridoxine)
Deficiency may be drug-induced
Pyridoxine given prophylactically to patients on isoniazid, cycloserine, or hydrazine to prevent peripheral neuropathy
Vitamin B12(RIBOFLAVIN)
Vitamin B12 is a water-soluble vitamin that is essential for red blood cell formation and neurological function. Older adults and patients with reduced stomach acid levels, gastric bypass surgery, or intestinal disorders (celiac disease or Crohn’s disease) may not absorb vitamin B12 well and are at risk for deficiency . Also, women who follow strict vegetarian diets without supplementation place their breastfed infant at risk for vitaminB12 deficiency. Acid suppression medications (proton pump inhibitors or H2 receptor antagonists) and metformin reduce the absorption of vitaminB12. vitamin B12 deficiency will lead to megaloblastic anemia, fatigue, loss of appetite, and neurological changes (numbness and tingling in hands and feet). NSG 6005 Advanced Pharmacology Midterm & Final Exam Study Guide.
Deficiency will lead to megaloblastic anemia
PROTON PUMB INHIBITORS causes Risk for significant nutrient deficiencies: iron, vitamin B12, and calcium.
Antacid therapy or potassium therapy can reduce absorption of folic acid, iron, and vitamin B12.
Pregnant women need 600 mcg/day of folic acid, a multivitamin/mineral supplement, 27 mg/day of iron (60 mg/day if patient is anemic), and vitamin B12 if the patient is vegan or lacto-ovo-vegetarian.
Older adults over age 50 need 2.4 mcg/day of vitamin B12 and need to ensure adequate intake of vitamin D and calcium.
24.FOLIC ACID
Folate
Folate is a water-soluble vitamin that is critical to the production and maintenance of new cells. Folate is found in foods such as green leafy vegetables, citrus fruits, and dried legumes. Folic acid, the synthetic form of folate, is added to breads, flours, pastas, rice, and other grain products (ODS, 2012a). Folate deficiency occurs in times of increased demand, such as occurs in pregnancy and lactation, or when loss increases (malabsorption, alcohol abuse, dialysis, liver disease). Medications may interfere with folate utilization, leading to deficit. Folic acid supplementation is recommended for all women of childbearing age (400 mcg/d), with extra given when a woman is pregnant (600 mcg/d) to prevent neural tube defects in the fetus . NSG 6005 Advanced Pharmacology Midterm & Final Exam Study Guide. Lactating women should take 500 mcg/day.
BOX 9–1 MEDICATIONS INTERFERING WITH FOLATE UTILIZATION
Antiepileptic drugs (phenytoin, primidone)
Metformin
Sulfasalazine
Triamterene
Methotrexate
Barbiturates
Trimethoprim
Pyrimethamine
Isoniazid
Oral contraceptives
Folate is necessary for the normal maturation and functioning of red blood cells. Folate deficiency produces a macrocytic-normochromic anemia. Patients with folic acid–deficiency anemia commonly complain of glossitis, stomatitis, nausea and anorexia, and diarrhea, and a systolic ejection murmur may be heard. Oral folic acid is well absorbed, and doses of 1 to 2 mg/day result in correction of the deficiency in 4 to 5 weeks. Hemoglobin (Hgb) levels begin to rise within the first week, and anemia is completely corrected in 1 to 2 months. NSG 6005 Advanced Pharmacology Midterm & Final Exam Study Guide.
POWERPOINT
Folate
Critical to the production and maintenance of new cells
Found in foods such as green leafy vegetables, citrus fruits, and dried legumes
Folic acid is the synthetic form of folate.
Folate deficiency occurs during pregnancy and with increased losses.
Folic acid supplementation is recommended for
Childbearing age teens and women: 400 mcg/day
Pregnant women: 600 mcg/day
Lactating women: 500 mcg/day
Antacid therapy or potassium therapy can reduce absorption of folic acid, iron, and vitamin B12.Phenytoin reduces the level of folic acid.
25.THIAMINE
Vitamin B1 (thiamine) is a water-soluble vitamin critical for many body functions and is widely available in fortified breads and cereals. Deficiency of thiamine can lead to beriberi or Wernicke’s encephalopathy. Alcoholic patients develop thiamine deficiency at 8 to 10 times the rate of the nonalcoholic population . Wernicke’s encephalopathy is a serious neurological illness in alcoholic patients and requires immediate high-dose levels of thiamine (500 mg IV TID for 2 days, then 500 mg/d IV or IM for 5 days). Patients should be given a daily 100 mg dose of oral thiamine until no longer considered at risk. Treatment for beriberi in children is IV thiamine 10 to 25 mg or 10 to 50 mg daily for 2 weeks, and in adults 50 mg IM/IV for several days or 5 to 30 mg/day for a month. NSG 6005 Advanced Pharmacology Midterm & Final Exam Study Guide.
POWERPOINT
Vitamin B1 (thiamine)
Deficiency can lead to beriberi or Wernicke’s encephalopathy
Alcoholics at high risk
26.Symptoms of Folate and Vitamin B12 Deficiency.
vitamin B12 deficiency will lead to megaloblastic anemia, fatigue, loss of appetite, and neurological changes (numbness and tingling in hands and feet). Deficiency will lead to megaloblastic anemia
Folate is necessary for the normal maturation and functioning of red blood cells. Folate deficiency produces a macrocytic-normochromic anemia. Patients with folic acid–deficiency anemia commonly complain of glossitis, stomatitis, nausea and anorexia, and diarrhea, and a systolic ejection murmur may be heard. NSG 6005 Advanced Pharmacology Midterm & Final Exam Study Guide. Oral folic acid is well absorbed, and doses of 1 to 2 mg/day result in correction of the deficiency in 4 to 5 weeks. Hemoglobin (Hgb) levels begin to rise within the first week, and anemia is completely corrected in 1 to 2 months.
27.Characterstics of each Anemia and treatment
ANEMIA: Decreased iron-carrying capacity of the blood
Iron deficiency anemia
Caused by poor intake or blood loss (acute or chronic)
Treated with iron replacement
Folic acid deficiency anemia
Seen in alcoholics, chronic malnutrition, fad diets, and diets low in vegetables
Drugs: dilantin, sulfamethoxazole/trimethoprim, oral contraceptives, methotrexate
Pernicious anemia
Vitamin B12 deficiency leads to macrocytic-normochromic anemia.
Vegetarians, vegans, genetic predisposition, autoimmune disease
GOAL:Restore hemoglobin (Hgb) and red blood count to normal levels to maintain oxygen-carrying capacity of blood.
IRON DEFICIENCY ANEMIA
Prevention
Adequate intake via iron-rich diet
Monitor in periods of rapid growth (infancy, adolescence, pregnancy).
Replacement in infants 1 mg/kg/day starting at 4 months (2 mg/kg/day in preterm infants)
Treatment
Iron replacement based on age
Divide dose in three doses per day.
Monitoring
Reticulocyte count 5 to 10 days after starting therapy
Hgb, hematocrit (Hct), ferritin at 4 weeks, then at 3 months and annually
Outcome evaluation
Return to normal Hgb, Hct, and ferritin levels
If Hgb, Hct, and ferritin do not return to normal levels the patient should be evaluated for a source of blood loss of other pathology.
Patient education NSG 6005 Advanced Pharmacology Midterm & Final Exam Study Guide.
Importance of prevention with adequate iron intake in diet
Administration
Empty stomach if tolerated
Three times per day is best
Constipation (may need a stool softener)
FOLIC ACID DEFICENCY ANEMIA
Risk groups
Infants fed goat’s milk or powdered milk formula
Vegetarians and vegans
Pregnancy increases daily requirement need.
Patients with sprue, Crohn’s disease, giardial infections, and short bowel syndrome
Patients taking drugs that affect folic acid absorption
Prevention
Adequate dietary intake
Folic acid supplementation in pregnancy
Drug therapy for deficiency
Oral folic acid 1 to 2 mg/day for 4 to 5 weeks
Hgb levels start to rise in a week
Women of childbearing age and pregnant women should consume 0.4 to 0.8 mg/day.
Monitoring
Follow Hgb/Hct in 4 weeks and then regularly
Education
Need for folic acid
Administration
PERNICIUS ANEMIA
Pernicious anemia is caused by inadequate vitamin B12.
Defective secretion of gastric intrinsic factor, which is necessary for vitamin B12 absorption
Vitamin B12 malabsorption occurs in 10% to 30% of adults over age 50 due to reduced pepsin activity and gastric acid secretion.
Prevention
Eat foods high vitamin B12, such as mollusks (e.g., clams), fortified breakfast cereals, liver, trout, salmon, milk, and eggs.
Drug therapy
Oral, intramuscular (IM), and intranasal vitamin B12 replacement
Nutritional deficit: 1,000 mcg/day of cobalamin is given until normal B12 levels
Pernicious anemia: vitamin B12 therapy 1,000 mcg IM daily for 1 week followed by 100 to 1,000 mcg IM weekly for a month
Parental, nasal, or oral therapy may be used once a patient’s B12 levels return to normal. NSG 6005 Advanced Pharmacology Midterm & Final Exam Study Guide.
Parenteral: 1,000 mcg of vitamin B12 IM monthly
Nasal: 500 mcg of cyanocobalamin weekly
Oral: 1,000 mcg daily (least expensive)
Monitoring
Reticulocyte counts, Hgb and Hct, iron, folic acid, and vitamin B12 serum levels prior to treatment, at 5 to 7 days of therapy, then frequently until the Hgb and Hct are normal. NSG 6005 Advanced Pharmacology Midterm & Final Exam Study Guide.
Monitor potassium levels.
Liver function tests every 2 to 4 weeks to monitor for hepatotoxicity
Patient education
Disease process and need for lifelong therapy
Vitamin B12 therapy regimen
Monitoring
Anemia of chronic disease
Occurs due to a disease process
Older adults
Patients with renal failure, osteomyelitis, tuberculosis, rheumatoid diseases, hepatitis, carcinoma, myeloma, lymphoma, and leukemia at risk
28.Powerpoint: Children with autism or attention deficit hyperactivity disorder may respond to omega-3 supplements.
Omega-3 fatty acids have received attention as a possible treatment for autism and attention deficit-hyperactivity disorder (ADHD). The theory is that either deficiency in omega-3 or an imbalance in the omega-3 to omega-6 fatty acid ratio is affecting neurocognitive development in children. It is clear that sufficient amounts of the essential fatty acids are crucial in central nervous development, with deficiency or imbalance found in multiple observational studies of children with neurocognitive issues . NSG 6005 Advanced Pharmacology Midterm & Final Exam Study Guide. This has led to the addition of DHA and ARA to commercial infant formulas (Enfamil LIPIL) to meet the need in the key developmental period of infancy.
In an extensive review
