EXTRA LEARNING

1. The majority of cytochrome P450 (CYP) enzymes are located where, also the
primary site for drug metabolism: a. stomach b. small intestine c. kidney d. muscle
e. liver
2. Valium (diazepam) acts through this receptor system: a. aspartate b. GABA c.
acetylcholine d. glutamate e. serotonin
3. Typically, the magnitude of drug effects are thought proportional to the number
of occupied receptors: a. true b. false
4. The nurse is reviewing factors that influence pharmacokinetics in the neonatal
patient. Which factor puts the neonatal patient at risk with regard to drug therapy?
a. immature renal system b. hyperperistalsis in the GI tract c. irregular temperature
regulation d. smaller circulatory capacity
5. While teaching a 76-year-old patient about the adverse effect of his medications,
the nurse encourages him to keep a journal of the adverse effects he experiences.
This intervention is important for the elderly patient because of which alterations in
pharmacokinetics? a. increased renal excretion of protein-bound drugs b. more
alkaline gastric pH, resulting in more adverse effects c. decreased blood flow to the
liver, resulting in altered metabolism d. less adipose tissue to store fat-soluble drugs
6. Arrange the following drug forms in order of speed of dissolution and absorption,
with (1) being the fastest and (4) being the slowest: 1. Capsules 2. Enteric-coated
tablets 3. Elixirs 4. Powders
7. When a healthcare provider is writing a prescription for a drug, he or she is not
permitted to mark a refill on a prescription if the drug falls into which category? a.
C-I b. C-II c. C-III d. C-IV e. C-V
8. The nurse is administering medications. Examples of high-alert medications
include: (Select all that apply.) a. Insulins b. Antibiotics c. Opiates d. Anticoagulants
e. Potassium chloride for
injection
9. In which of the following patients would a nurse expect to experience alterations
in drug metabolism? a. A 35-year-old woman with cervical cancer b. A 62-year old
woman with acute renal failure c. A 19-year-old woman with type 1 diabetes d. A 50-
year-old man with cirrhosis of the liver e. A 41-year-old man with kidney stones
10. Which medication dosage form avoids the first-pass effect? a. Suspension b.
Troche c. Elixir d. Sublingual tablet
Dosing questions
11. Solumedrol 1.5 mg/kg is ordered for a child weighing 74.8 lb. Solumedrol is
available as 125/2mL. How many mL must the nurse administer?
12. Solumedrol 1.5 mg/kg is ordered for a child weighing 48 lb. Solumedrol is
available as 75/1mL. How many mL must the nurse administer?
13. Ordered 2 g of amoxicillin. Amoxicillin is available as 400 mg per 5 mL. How
much will the nurse draw up?
14. Administer tobramycin 1 mg/kg/day divided into two doses. Available as
tobramycin 10 mg/mL. The patient weighs 110 lbs. How many mL will you
administer in each dose (twice/day)?
15. Administer ampicillin 0.2 g/kg/day q 6 hours in even doses. Available as
ampicillin powder when reconstituted it will deliver 1 gram per mL. The patient
weighs 60 kg. How many mL will you administer at 0800?
Half-life questions
16. If a diphenhydramine 25 mg tablet has a typical half-life of 8.5 hours, how long
will it take until the blood concentration of this dosage falls to 25% of its initial
strength?
17. Zolpidem has a half-life of 3 hours. If a patient takes 10 mg at 9 pm, what will
the blood level be at 6 am?
18. A drug’s half-life is known to be 2 hours. What percentage will be left in the body
after six hours?
ANSWERS
1) e 2) b 3) a 4) a 5) c 6) Elixirs, Powders, Capsules, Enteric-coated tablets 7) b 8) a,
c, d, e 9) d
10) d 11) 0.82 mL 12) 0.44 mL 13) 25 mL 14) 2.5 mL 15) 3 mL 16) 17 hours 17) 1.25
mg 18) 12.5%
What is the study of how the body acts upon drugs – how the body absorbs,
distributes, metabolizes, and excretes medications (ADME)?
• pharmacodynamics
• pharmaceutics
• pharmacokinetics
• pharmacology
ANSWER: pharmacokinetics
Lifespan Considerations for the Elderly Patient
Pharmacokinetic Changes (ADME)
Absorption
Gastric pH is less acidic because of a gradual reduction in the production of
hydrochloric acid in the stomach.
Gastric emptying is slowed because of a decline in smooth muscle tone and motor
activity.
Movement throughout the gastrointestinal tract is slower because of decreased
muscle tone and motor activity.
Blood flow to the gastrointestinal tract is reduced by 40% to 50% because of
decreased cardiac output and decreased perfusion.
The absorptive surface area is decreased because the aging process blunts and
flattens villi.
Distribution
In adults 40 to 60 years of age, total body water is 55% in males and 47% in
females; in those older than 60 years of age, total body water is 52% in males and
46% in females.
Fat content is increased because of decreased lean body mass.
Protein (albumin) binding sites are reduced because of decreased production of
proteins by the aging liver and reduced protein intake.
Metabolism
The levels of microsomal enzymes are decreased because the capacity of the aging
liver to produce them is reduced.
Liver blood flow is reduced by approximately 1.5% per year after 25 years of age,
which decreases hepatic metabolism.
For elderly patients, dosage should be reduced for hepatically cleared drugs.
Excretion
Glomerular filtration rate is decreased by 40% to 50%, primarily because of
decreased blood flow.
The number of intact nephrons is decreased.
For elderly patients, drug accumulation will occur for renally cleared drugs.
Ten Medications Older Adults Should Avoid or Use with Caution:
[Link]
should-avoid-or-use-with-caution/
Probenecid
Let's look at a drug such as probenecid, which is used to treat gout and gouty
arthritis. It is removed from the body via the kidneys. If the drug is eliminated
through the kidney, think about the effect of elimination if a kidney is
malfunctioning. Older patients usually have kidneys which are not optimally
functioning. Also patients with diseases affecting the kidneys (e.g. diabetes) don't
have optimally functioning kidneys.
So in these patients, if they are given probenecid, would drug remain in their
system longer or would the rate of elimination be the same as in adult patients with
normal kidneys?
ANSWER
The drug would remain in their system longer. There would be a decreased rate of
elimination and possibly a build up of the medication and toxic effects.
It is very important to take into consideration factors such as the age of the patient
and the state of health of the metabolizing/eliminating organs of the prescribed
drugs when determining the correct route of administration and dose of drugs.
In older patients and patients with kidney problems (e.g. diabetics), a smaller dose
of probenecid would be given. If the normal dose is given, it would build up in the
patient's body due to slower excretion by the kidneys. This could lead to toxicity.
Additionally, if a patient is on penicillin (or another drug excreted by the kidneys),
they may need to lower their dose of probenecid, or be put on a smaller dose of
penicillin to begin with.
Have you heard of latex-fruit syndrome?
Some foods have proteins that are like those in latex. Sometimes people with latex
allergies experience a reaction to “latex reactive foods.” Latex-fruit syndrome is
considered a cross reactivity immune response, where the structure of one antigen
is similar to another and it results in an allergic response.
My friend has a latex allergy and reacts to pineapple, banana, watermelon,
cantaloupe, and avocado. He remembers as a child never wanting to eat the
banana his mother gave him.
Less than 1% of people in the US have a latex allergy. Although latex allergy is rare,
the condition is more common in certain high-risk groups.
The highest risk is in children with spina bifida. Spina bifida is a condition in which
the spine fails to form completely before birth. More than three out of every five
children with spina bifida are allergic to latex.
Children who have frequent medical treatments or lengthy surgeries are also at high
risk. Many medical supplies use latex – from gloves to tubing to enema tips.
Between 8-17% of health care workers and others who regularly use latex gloves
are allergic to latex. Health care workers and children who have other allergies and
get contact dermatitis when they use latex gloves are more likely to develop a latex
allergy.
New cases of latex allergy are no longer common. However, in the 1980s and 1990s
they were much more frequent. Now, many health care facilities use non-latex
gloves and products.
What are the most common mistakes doctors make? What is the most common
medication error?
Patients want to hear an apology if a mistake is made. As practitioners, I think in
sharing our mistakes and the mistakes of others, we can prevent the same errors
from occurring in the future.
As a pharmacist, I make sure to thoroughly check prescriptions and technicians'
work. I am able to see a picture of the pill on the computer screen and check it with
what is in the bottle the patient will receive. The computer also uses software to see
if there are any drug-drug (prescription and OTC), drug-allergy, drug-food, or drug-
disease state interactions. The few mistakes I have caught were wrong dosages and
days supply. When counseling patients, it’s
important to remind them to follow up on lab work with certain medications as well.
The doctor and pharmacist should both have on file patients' current and past
medications, over-the-counter medications, disease states, and allergies. Also, a
prescription is only valid for 1 year from the date written. Even if there are refills
left, patients must see their doctor for a new prescription to keep up the patient-
physician relationship.
The following is a great example of a medication error that I show to all of my
pharmacy technician, nursing, and NP students:
Please watch the Dennis Quaid video - The Wrong Medicine
Dennis Quaid's newborn twins nearly died when they were mistakenly given a drug
overdose. The actor and his wife share their story to draw attention to hospital
mistakes that kill as many as 100,000 Americans a year. Steve Kroft reports.
[Link]
The 3 R’s for Medication Safety:
1) All medicines have RISKS as well as benefits. Weigh these risks and benefits
carefully for every medicine you take.
2) RESPECT the power of your medicine and the value of medicines properly used.
3) Take RESPONSIBILITY for learning about how to take your medication safely.
MUST - A National Education Campaign for Older Adults and Caregivers. (n.d.).
MUST - A National Education Campaign for Older Adults and Caregivers. Retrieved
June 11, 2014, from [Link]
Helpful Resources
[Link] has an excellent calculators tab, including heparin and warfarin
dosing protocols.
The following is a calculator for aminoglycoside and vancomycin dosing:
[Link]
Excellent chart of common drug levels: [Link]
First Pass Effect: [Link]
The following is a great overview of the 8 Rights of Medication Administration:
[Link]
administration
The following link shows the state-by-state level of NP Practice Environment:
[Link]
to an external site.

TOP 200 DRUGS OF 2022, based on number of prescriptions/year -

[Link]
TOP 200 DRUGS OF 2024 - [Link]
drugs/
TOP 200 DRUGS OF 2023 - Includes schedule number and medications can be
sorted by drug class [Link]