NURS 6521 Week 1 Discussion Pharmacokinetics and Pharmacodynamics
A Sample Answer For the Assignment: NURS 6521 Week 1 Discussion Pharmacokinetics and Pharmacodynamics
Title: NURS 6521 Week 1 Discussion Pharmacokinetics and Pharmacodynamics
NURS 6521 Week 1 Discussion Pharmacokinetics and Pharmacodynamics
NURS 6521 Week 1 Discussion Pharmacokinetics and Pharmacodynamics
Introduction
The processes that a medicine goes through in the body after administration are referred to as pharmacokinetics. Absorption, distribution, metabolism, and excretion are all included in this. Pharmacodynamics, on the other hand, deals with the effects that drugs have on the body, such as adverse effects. Variables like a patient’s genetics, gender, ethnicity, age, behavioral factors, medical history, and concurrent drugs all have an impact on pharmacokinetics and pharmacodynamics. According to the case study, these variables especially age do indeed change the drugs pharmacokinetics and pharmacodynamics (Rosenthal. & Burchum, 2018).
Age influencing pharmacodynamics and pharmacokinetics
The patient is of advanced age whereby it has been stated that they are 74 years old this is indeed can affect the pharmacodynamics and pharmacokinetics related to the drug. In advanced age you find the boy’s physiology has changed thus affecting the pharmacokinetics and elements such as absorption, distribution, metabolism and excretion. One of the most significant impacts in old age is whereby you’ll have a decreased glomeruli filtration rate which determines the level of drug elimination. Since it is decreased it could lead to the drug being retained in the system and leading to toxicity (Sieder et al., 2016).
In old age there is also decreased gastrointestinal motility thus leading to delayed absorption rate. This leads to delayed onset of pharmacological effects of drugs thus making them less effective. The peak drug concentrations are also affected hence the drug doesn’t reach its maximum capacity for effect (Mangoni & Jarmuzewska, 2019).
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Age also increases the body fat which could lead to increase the volume of distribution increases. Therefore if the drug has to be distributed to a wider area than affection it will affect its expected performance thus not delivering the desired therapeutic effect. Due to the increased body fat there is also decreased body water levels thus leading to the drug’s elimination half-lives also getting increased (Sieder et al., 2016).
Having an advanced age also affects metabolism which mostly occurs in the liver. This occurs in due to the decreased required enzymes that may no longer be available due to the physiological changes that occur because of age. This also leads to decreased clearance hence the already metabolised drug aren’t cleared from the system (Mangoni & Jarmuzewska, 2019).
Age impacting pharmacodynamics occurs through decrease in effect for beta-adrenergic agents. This is due to decrease in response in the vascular, cardiac, and pulmonary tissues due to a decline in some required proteins. There is also reduced sensitivity to drugs due to the body’s receptors undergoing physiological changes. Therefore if the response and sensitivity is inhibited the desired therapeutic effect isn’t achieved.
Homeostatic mechanisms are also seen to influence the pharmacodynamics in that in advanced age it is reduced. The mechanisms are seen to reduce in old age. Therefore in the case the drugs lead to adverse effects the body takes a longer period of time to return to the initial state (Sieder et al., 2016).
Changes in the Process that Impact the Patient’s Recommended Drug Therapy
Due to the old age the pharmacodynamics and pharmacokinetics has been impacted. The absorption has been delayed due to decreased gastric motility, on the distribution end the volume of distribution has increased due to the increased body fat and the metabolism due to decreased enzymes has also decreased. The physiological changes in the glomeruli has decreased the glomeruli filtration rate hence decreasing excretion and could lead to toxicity. The pharmacodynamics due to decrease in sensitivity, decrease in response and reduced homeostatic mechanisms negatively affect it (Mancia et al., 2014).
Therefore encompassing all this there is a definite change in the recommended drug therapy in order to benefit the patient. The changes are in medication such as atenolol will be used in place of the beta-blocker metoprolol, starting at 25 to 200 mg per day. However, fast response is attainable with longer release modules and can be delivered thrice daily, thus it’s advised to begin new medication, notably such as beta-blockers, with prolonged release formulae.
Instead of ibuprofen that is contraindicated with warfarin patients should be prescribed acetaminophen orally 500mg thrice daily to manage the pain. I would also advise using lipid-lowering drugs other than statins to lower the low-density lipoprotein cholesterol levels (Mangoni & Jarmuzewska, 2019).
How to Improve the Drug Therapy Plan
Patients with a high risk of cardiovascular disease, a heart attack, or is known diabetic, such as this patient, are advised to begin taking a moderate-intensity statin with the aim of reducing LDL-C levels by 30% or more. For this patient, it is advised to utilize Ezetimibe, administered orally at a dose of 10 mg each day. Cardiovascular diseases, diabetes mellitus, left ventricular dysfunction and diabetic neuropathy can receive treatment by use of angiotensin converting enzyme inhibitors.
They can also be used to prevent strokes. Starting doses of ramipril range from 1.25 mg to 2.5 mg orally every day. This medication is also recognized to lessen myocardial infarctions, strokes, and fatalities. Moreover aside from changes in medications can make other alterations such as diet change, smoking cessation, weight loss, provision of health education from medical professionals and physical activity is required (Mayor, 2017).
Conclusion
The majority of deaths globally are currently caused by cardiovascular disorders, and diabetes is frequently found in these people. It is thought that people with type diabetes are more likely than non-diabetics to die from cardiovascular illnesses. In order to get the best results in the management of cardiovascular diseases which aims to maximize the benefits of available treatments while minimizing patient harm clinicians must possess basic knowledge of pharmacokinetics and pharmacodynamics (Rosenthal. & Burchum, 2018).
References
Hoover, L. E. (2019). Cholesterol management: ACC/AHA Updates guideline. Https://eds-a- ebscohost-com-ezp.waldenulibrary.org/eds/pdfviwer/
Mayor, S. (2017). Pharmacokinetics: Optimizing safe and effective prescribing. Https://onlinelibrary.wiley.com/doi/pdf/10.1002/psb.1551
Rosenthal, L.D. & Burchum. J.R. (2018). Lehne’s pharmacotherapeutics for advanced practice providers. St. Louis, MO: Elsevier.
Sieder, S. T., Kalus, J. & Lanfear, D. E. (2016). Cardiovascular pharmacokinetics, Pharmacodynamics and Pharmacogenomics for the clinical practitioner. Https://eds-a- ebscohost-com.ezp.waldenulibrary.org/eds/delivery/
Mancia, G., Fagard, R., Narkiewicz, K., Redon, J., Zanchetti, A., Böhm, M., & Galderisi, M. (2014). 2013 ESH/ESC Practice guidelines for the management of arterial hypertension: ESH-ESC: The Task Force for the management of arterial hypertension of the European Society of Hypertension (ESH) and of the European Society of Cardiology (ESC). Blood Pressure, 23(1), 3-16.
Mangoni, A. A., & Jarmuzewska, E. A. (2019). The influence of heart failure on the pharmacokinetics of cardiovascular and non‐cardiovascular drugs: A critical appraisal of the evidence. British Journal of Clinical Pharmacology, 85(1), 20-36.
Misoprostol is a drug used for two different types of labor and delivery situations. It can be used to induce labor by softening the cervix and initiating contractions. It can also be used as a uterotonic during a postpartum hemorrhage. I worked as a labor and delivery nurse at a Trauma 1 center in Irvine, California, for many years. During that time, I witnessed many high-risk patients hemorrhage after delivering. In this event, it is crucial that the healthcare team acts fast and provides the patient with the necessary drugs to contract the uterus and stop the bleeding. However, it is essential to consider the patient’s vitals and medical history when deciding which uterotonic to use.
Some uterotonics are contraindicated in patients with asthma or hypertension. Although other uterotonics have a faster absorption rate and longer duration, Misoprostol is safe for hypertensive or asthma patients. Misoprostol can be given vaginally, rectally, sub-lingual, or buccal. One study compared the effects of the drug when given rectally versus sub-lingual and found that intra-operative bleeding and postpartum hemorrhaging during a cesarian delivery were lower when given sub-lingual (Sweed et al., 2018). This is because the administration route affects the absorption and distribution rate.
I was caring for a woman who had complications during the placenta delivery. I was working at a teaching hospital where residents worked as physicians on the unit. The resident decided to administer Misoprostol vaginally. The woman continued to hemorrhage despite the residents’ efforts. This was because of the route of administration. The Misoprostol could not be absorbed and cross the cell membrane because of the amount of blood coming out of her vagina.
Therefore, the plasma drug concentration could not reach a level high enough to be therapeutic. Because the patient was only 25 and in good medical condition, age did not affect the effectiveness of the medication. Infants and the elderly are at risk because of decreased drug-metabolizing capacity and kidney function (Rosenthal et al., 2021). In this scenario, the baby was unaffected because the umbilical cord had been cut and no longer shared blood with its mother.
The patient’s personalized plan of care would be to change the route of administration to sub-lingual. The drug would be able to take full effect by absorbing into the blood, where it will stimulate uterine contractions, which will help stop the bleeding. Misoprostol acts as a prostaglandin that binds to the smooth muscle cells in the uterine lining and causes the uterus to contract. A common side effect of the drug is abdominal pain and diarrhea. This is due to the byproduct misoprostolic acid released during the drug’s metabolism at its peak plasma concentration (Krugh & Maani, 2022). Because diarrhea is a common side effect, I would increase the patient’s fluids to ensure she does not become dehydrated or hypovolemic.
References
Krugh, M., Maani, C. (2022). Misoprostol. In StatPearls. StatPearls Publishing.
Rosenthal, L. D., Burchum, J. R., & Rosenthal, L. D. (2021). Lehne’s pharmacotherapeutics for advanced practice nurses and physician assistants. Elsevier.
Sweed, M. S., El-Saied, M. M., Abou-Gamrah, A. E., El-Sabaa, H. A., Abdel-Hamid, M. M., Hemeda, H., Mansour, A. M., Shawky, M. E., El-Sayed, M. A., & Mohamed, R. M. (2018). Rectal vs. sublingual misoprostol before cesarean section: double-blind, three-arm, randomized clinical trial. Archives of Gynecology & Obstetrics, 298(6), 1115–1122. https://doi.org/10.1007/
Working in an intermediate care unit, I get to see patients from all races with different healthcare needs and conditions. One obvious thing observed from the so many patients that come into the facility is the prevalence of diabetes, hypertension and chronic obstructive pulmonary disease (COPD) in patients ages 20 years and above. Though the diseases are common, the types of medications used in treating them may differ in dose, brand, and pricing. When prescribing medications for an individual patient, the physician considers the effects of the drugs and the mechanism of their action on that particular patient.
Let us consider a 75-year-old male patient who is admitted for uncontrolled Diabetes. The patient has a past medical history of Diabetes type II and takes metformin to control his glucose but had not been able to afford the refills for his medication. On admission the patient presented with a blood glucose of 288 mg/dl and was ordered Lispro on a low dose sliding scale with blood glucose monitoring before meals and at bedtime. The patient was assigned to a young nurse who had recently just started working on the unit.
Just before the lunch trays came in, the nurse went to review the patients’ blood glucose levels the nurse tech had checked. Without paying much attention, the nurse drew up 8 units of lispro insulin and administered it to the patient for what she thought was a blood sugar of 288mg/dl. After about 20 minutes the nurse discovered that the patient was sweating a lot and had an increased heart rate with slight shivers. The young nurse called the attention of an older nurse and explained all the care she had provided to the patient prior to discovering his current state.
The two nurses reviewed the documentation on the computer and saw that the patients’ last blood glucose check was 98mg/dl and not 288mg/dl as the young nurse had thought it was. The older nurse immediately got a glucometer and checked the patients’ blood glucose which was now 52mg/dl, and also discovered that the patient had not eaten anything. The older nurse immediately followed the establishment’s protocol and administered 1 gram of glucagon to the patient, checked his blood glucose which had gone up slightly and then administered another gram, checked his blood glucose again, and then provided the patient with a small cup of orange juice and a cracker.
As nurse practitioners, it is important to know and understand the pharmacokinetics and pharmacodynamic processes. Pharmacokinetics is the process of a drug being absorbed, distributed, metabolized, and excreted from the body (Rosenthal and Burchum, 2021). Pharmacodynamics is the relationship between drug concentration at the site of action and the resulting effects which include the time and severity of therapeutic and adverse effects (DiPiro, 2008).
Lispro Insulin is a rapid-acting insulin that has a short duration of action which is used to improve blood glucose management in patients with diabetes (Rosenthal and Burchum, 2021). It is more effective than the normal human insulin in improving and helping to maintain blood glucose control (Campbell et al., 1996). Factors that might influence the pharmacokinetics and pharmacodynamics of insulin are the size of the dose, the injected volume and the insulin concentration, vigorously rubbing the site of the injection, increase in temperature which increases absorption rate, site of the injection (absorption is faster when administered in the abdomen), and exercising of extremity within an hour of injection can speed up absorption (Donner and Sarkar, 2019).
The patient received a large dose of insulin for an inaccurate blood glucose reading and presented with a hypoglycemic reaction due to the large amount of insulin that was administered.
A personalized care plan for the patient based on influencing factors and the patients history would be to set goals for the patient that include effective treatments to normalize and manage blood glucose levels, decrease the risk for hypoglycemic or hyperglycemic events using insulin medication, diet, and exercise, informing and educating the patient on the importance of compliance with medication regimen and importance of monitoring blood glucose, providing the patient with prescription savings or discount cards like Good Rx, and providing the patient with location to local community clinics that help with providing low-cost prescription medications.
Ensuring that the patient is properly educated and provided with the necessary resources to provide for his medication will promote his participation in self-care and ensure his compliance with monitoring and maintaining manageable blood glucose levels.
References:
Campbell, R. K., Campbell, L. K., & White, J. R. (1996, November). Insulin lispro: its role in the treatment of diabetes mellitus. The Annals of pharmacotherapy. https://pubmed.ncbi.nlm.nih.gov/8913409/.
Donner, T., & Sarkar, S. (2019). Insulin – Pharmacology, Therapeutic Regimens, and Principles of Intensive Insulin Therapy. Endotext [Internet]. https://www.ncbi.nlm.nih.gov/books/NBK278938/.
DiPiro, J. T. (2008). Pharmacotherapy: A pathophysiologic approach. McGraw-Hill Medical.
Rosenthal, L. D., & Burchum, J. R. (2021). Lehne’s pharmacotherapeutics for advanced practice nurses and physician assistants (2nd ed.) Elsevier.
Sample Answer for NURS 6521 Week 1 Discussion Pharmacokinetics and Pharmacodynamics Included
Discussion: Pharmacokinetics and Pharmacodynamics
As an advanced practice nurse assisting physicians in the diagnosis and treatment of disorders, it is important to not only understand the impact of disorders on the body, but also the impact of drug treatments on the body. The relationships between drugs and the body can be described by pharmacokinetics and pharmacodynamics.
Pharmacokinetics describes what the body does to the drug through absorption, distribution, metabolism, and excretion, whereas pharmacodynamics describes what the drug does to the body.
Photo Credit: Getty Images/Ingram Publishing
When selecting drugs and determining dosages for patients, it is essential to consider individual patient factors that might impact the patient’s pharmacokinetic and pharmacodynamic processes. These patient factors include genetics, gender, ethnicity, age, behavior (i.e., diet, nutrition, smoking, alcohol, illicit drug abuse), and/or pathophysiological changes due to disease.
For this Discussion, you reflect on a case from your past clinical experiences and consider how a patient’s pharmacokinetic and pharmacodynamic processes may alter his or her response to a drug.
To Prepare
- Review the Resources for this module and consider the principles of pharmacokinetics and pharmacodynamics.
- Reflect on your experiences, observations, and/or clinical practices from the last 5 years and think about how pharmacokinetic and pharmacodynamic factors altered his or her anticipated response to a drug.
- Consider factors that might have influenced the patient’s pharmacokinetic and pharmacodynamic processes, such as genetics (including pharmacogenetics), gender, ethnicity, age, behavior, and/or possible pathophysiological changes due to disease.
- Think about a personalized plan of care based on these influencing factors and patient history in your case study.
By Day 3 of Week 1
Post a description of the patient case from your experiences, observations, and/or clinical practice from the last 5 years. Then, describe factors that might have influenced pharmacokinetic and pharmacodynamic processes of the patient you identified. Finally, explain details of the personalized plan of care that you would develop based on influencing factors and patient history in your case. Be specific and provide examples.
Thank you for your post discussing malignant hyperthermia (MH). Bin et al. (2021) documented epidemiological findings such as MH patients are more often male (2:1- 4:1) and young (under 18 years old), with patients over 60 years old less common. Further, if a patient has a previous experience of rhabdomyolysis or significant heat intolerance, they may be at risk for MH. Sams et al. (2018) discussed that while MH typically presents near the initial exposure to the responsible substance, cases of delayed onset have been reported.
The case discussed by the authors described a 53-year-old male who underwent CABG with hypothermic cardiopulmonary bypass. The patient left the OR with a normal body temp, and once the paralytic was reversed in the ICU the patient immediately showed signs of MH. The patient was cooled, and dantrolene was administered. The patient survived the event. Zhao et al. (2020) discussed a case of a 55-year-old male with pneumonia who was taking trihexyphenidyl for Parkinson’s disease. The patient presented with MH and refractory hyponatremia determined to be an adverse reaction to the trihexyphenidyl. This patient survived as well.
References
Bin, X., Wang, B., & Tang, Z. (2022). Malignant hyperthermia: A killer if ignored. Journal of PeriAnesthesia Nursing, 37(4), 435–444. https://doi.org/10.1016/j.jopan.2021.08.018Links to an external site.
Sams, S. H., Revilla, S., & Stahl, D. L. (2018). Delayed development of malignant hyperthermia following cardiopulmonary bypass. Seminars in Cardiothoracic & Vascular Anesthesia, 22(1), 95–99. https://doi.org/10.1177/1089253217732128Links to an external site.
Zhao, J., Xu, G., Feng, C., Chen, Y., Kang, Y., Liu, F., & Ma, W. (2020). Trihexyphenidyl induced malignant hyperthermia in a patient with Parkinson’s disease complicated with pneumonia: A case report. Medicine, 99(20), e20129. https://doi.org/10.1097/MD.0000000000020129Links to an external site.
By Day 6 of Week 1
Read a selection of your colleagues’ responses and respond to at least two of your colleagues on two different days by suggesting additional patient factors that might have interfered with the pharmacokinetic and pharmacodynamic processes of the patients they described. In addition, suggest how the personalized plan of care might change if the age of the patient were different and/or if the patient had a comorbid condition, such as renal failure, heart failure, or liver failure.
Note: For this Discussion, you are required to complete your initial post before you will be able to view and respond to your colleagues’ postings. Begin by clicking on the “Post to Discussion Question” link, and then select “Create Thread” to complete your initial post. Remember, once you click on Submit, you cannot delete or edit your own posts, and you cannot post anonymously. Please check your post carefully before clicking on Submit!
As a psychiatric and mental health nurse for the past seven years, I have been involved in caring for and treating a 52-year-old male Caucasian patient at some point with schizophrenia, no known drug allergies who sometimes involves in self-mutilation. The said patient has not been consistent in following his treatment regimen and has many times endorsed suicide ideation with plans of running into traffic or jumping from the bridge. Pt sometimes exhibit violent behavior which had landed him into either four or six points restraints in the past. Most older adults are reluctant to seek help regarding mental illness, which leads to reasons behind the inadequate recognition and treatment of mental disorders among older adults (Tampi & Tampi,2020). The relationship between body, drug, and disease is impacted by age, gender, ethicality, and some pathophysiological changes that occur due to an illness. The purpose of this discussion is to reflect on a patient’s case from past clinical experiences and consider how a patient’s pharmacokinetic and pharmacodynamic processes may alter his or her response to a drug. Also, to develop a personalized plan of care based on influencing factors and patient history. For the last four months, he has been on various dosages of Clozaril to find the one that would work for him since it was a medication that has worked for him in the past. During the last two months, he has been complaining of drooling and chest discomfort. Each time he reports the discomfort, the doctor orders Atropine and EKG. For the last few days, he has stated that the pain is becoming worse.
Step by step explanation
Pharmacodynamics
Pharmacodynamics focuses on how drugs exert physiological effects on the body through factors like drug responses, dose-response relationships, interpatient variability, drug receptor interactions, and therapeutic index (Rosenthal & Burchum, 2021) Clozaril is a medication that binds loosely and transiently to dopamine D2 receptors, but the implications of these binding activities are unclear. Clozapine also binds to D1, D3, and DS receptors, and has a high affinity for the D4 receptor” Rosenthal & Burchum, 2021. Some research shows this to include the limbic system. From a pharmacodynamic perspective, clozapine primarily exerts antipsychotic effects through D2 receptor antagonism while also interacting with other neurotransmitter systems such as serotonin receptors. This multifaceted interaction contributes to its comprehensive efficacy in treating treatment-resistant schizophrenia. To effectively optimize patient outcomes necessitates understanding the intricate interplay between clozapine’s pharmacokinetics and pharmacodynamics. Personalized dosing schedules based on therapeutic drug monitoring can facilitate achieving appropriate plasma concentrations while minimizing adverse events. Additionally, genetic factors influencing drug metabolism pathways further contribute to individual variations in treatment response.
Pharmacokinetics
Pharmacokinetics encompasses the dynamic movement of drugs within the body, involving processes such as absorption, distribution, metabolism, and excretion. By understanding both aspects holistically, APNs can optimize patient outcome. Clozapine, the medication prescribed for the above-mentioned patient, is quickly absorbed. First-pass metabolism reduces its bioavailability to 60 to 70 percent of the administered dose; food has little effect on the bioavailability of clozapine. The elimination half-life of clozapine averages approximately 14 hours under steady state conditions, but there is substantial variability across individuals depending on that individual’s own metabolism and underlying factors. Clozapine possesses unique pharmacokinetic characteristics due to its extensive first-pass metabolism facilitated by cytochrome P450 enzymes. This metabolic pathway results in significant variability in plasma concentrations among patients. Moreover, cautious monitoring is crucial to mitigate adverse effects arising from both insufficient and excessive levels since it has a narrow therapeutic range.
Care plan
One important aspect of the care plan for patients on clozapine involves close monitoring of hematological parameters. As stated by Rosenthal and Burchum (2021), regular monitoring of absolute neutrophil count (ANC) is essential due to the risk of agranulocytosis associated with clozapine therapy. Agranulocytosis refers to a severe decrease in neutrophil count that can lead to life-threatening infections. Therefore, healthcare providers should be vigilant in assessing ANC levels throughout the course of treatment. Furthermore, it is imperative to monitor white blood cells (WBC) counts as part of the care plan for patients taking clozapine. According to Rosenthal and Burchum (2021), WBC counts may decrease significantly during clozapine therapy, which could increase susceptibility to infections. Regular monitoring allows healthcare providers to promptly detect any abnormalities and take appropriate measures if necessary.
Apart from hematological monitoring, weight management is another crucial component of the care plan for patients on clozapine. Weight gain has been consistently observed with long-term use of this medication (Rosenthal & Burchum, 2021). Excessive weight gain not only impacts physical health but can also have psychological implications for individuals already dealing with mental illness. Healthcare providers must prioritize regular assessments of body mass index (BMI) and collaborate with patients in implementing strategies such as lifestyle modifications or adjunctive interventions when needed. In addition to these specific considerations related directly to medication effects and side effects, the care plan for patients on clozapine should also address psychoeducation and support. As highlighted by Rosenthal and Burchum (2021), providing patients with comprehensive information about clozapine therapy promotes treatment adherence and empowers individuals to actively participate in their own care. Since clozapine has such a high incidence of clozapine-induced myocarditis as well as cardiomyopathy, patients on this medication will need to be monitored closely by a cardiologist.
Teaching of the risks must be reinforced to staff. “We need to understand that there should be standardized and mandatory plans of care which should include troponin levels as well as EKGs and echocardiograms at various times patient stays. Other factors to consider would be airway clearance due to excessive salvation and neutropenia.
Submission and Grading Information
Grading Criteria
To access your rubric:
Week 1 Discussion Rubric
Post by Day 3 of Week 1 and Respond by Day 6 of Week 1
To Participate in this Discussion:
Week 1 Discussion
Week 1: Basic Pharmacotherapeutic Concepts/Ethical and Legal Aspects of Prescribing
How do beta-blockers work? What exactly do antibiotics do to the bacteria they target? What effects does an anti-depressant have on blood flow?
Questions like these are related to the underlying pharmacokinetic and pharmacodynamic processes of pharmacotherapeutics. As an advanced practice nurse, understanding these fundamental pharmacotherapeutic concepts is important to ensure that the prescription drugs you recommend for your patients will be safe and effective to treat and/or manage their symptoms. Additionally, as the advanced practice nurse, it is your responsibility to ensure that when prescribing prescription drugs, you adhere to the ethical and legal principles set forth for prescribing drugs as an added layer of protection and safety for the patients you will treat.
This week, you will analyze factors that may influence pharmacokinetic and pharmacodynamics processes of a patient and assess the details of a personalized plan of care that you develop based on influencing factors and patient history. You will also evaluate and analyze ethical and legal implications and practices related to prescribing drugs, including disclosure and nondisclosure, and analyze the process of writing prescriptions to avoid medication errors.
Learning Objectives
Students will:
- Analyze factors that influence pharmacokinetic and pharmacodynamic processes in patients
- Assess patient factors and history to develop personalized plans of care
- Evaluate ethical and legal implications related to prescribing drugs
- Analyze ethical and legal practices of prescribing drugs
- Analyze strategies to address disclosure and nondisclosure
- Justify advanced practice nurse strategies to guide prescription drug decision-making
- Analyze the process of writing prescriptions to avoid medication errors
Learning Resources
Required Readings (click to expand/reduce)
Rosenthal, L. D., & Burchum, J. R. (2021). Lehne’s pharmacotherapeutics for advanced practice nurses and physician assistants (2nd ed.) St. Louis, MO: Elsevier.
- Chapter 1, “Prescriptive Authority” (pp. 1–3)
- Chapter 2, “Rational Drug Selection and Prescription Writing” (pp. 4–7)
- Chapter 3, “Promoting Positive Outcomes of Drug Therapy” (pp. 8–12)
- Chapter 4, “Pharmacokinetics, Pharmacodynamics, and Drug Interactions” (pp. 13–33)
- Chapter 5, “Adverse Drug Reactions and Medication Errors” (pp. 34–42)
- Chapter 6, “Individual Variation in Drug Response” (pp. 43–45)
This website outlines the code of federal regulations for prescription drugs.
This website details key aspects of drug registration.
This resource introduces the code of ethics for nurses and highlights critical aspects for ethical guideline development, interpretation, and application in practice.
This article provides NPs with information regarding state-based laws for NP prescribing.
The authors of this article assess the impact of a pharmacist‐led educational intervention on family nurse practitioner (FNP) students’ prescribing skills, perception of preparedness to prescribe, and perception of pharmacist as collaborator.
Required Media (click to expand/reduce)
NURS 6521 Week 1 Discussion Pharmacokinetics and Pharmacodynamics
Introduction to Advanced Pharmacology
Meet Dr. Terry Buttaro, associate professor of practice at Simmons College of Nursing and Health Sciences as she discusses the importance of pharmacology for the advanced practice nurse. (8m)
As a Med-Sure nurse for the past 2 1/2 years I’ve been a nurse, I’ve seen how medications can help or make a patient’s condition worse depending on how they react to it. There are medications that patient may be allergic to which can be deadly. “Absorption is the drug’s movement from its site of administration into the blood.” (Rosenthal & Burchum, 2021, p.13).
Pharmacokinetics and pharmacodynamics work hand in hand so we can understand how the drug work, how we can safely administer them, and their effects. Pharmacokinetics and pharmacodynamics work hand in hand together when administered in the body. It is the way we as providers can help understand the mechanism of how it works for us to write the proper correct prescriptions for patients. There are many variations in drug responses. A few to mention are race, age, gender, genetics and tolerance.
Reflecting on a past time encounter with a patient last month, he had numerous episodes of bloody stools, so many times that I’ve given him about 4 blood transfusions within three weeks span. He has been newly diagnosed with Parkinson’s disease and has had a spinal fusion which typically made him uncomfortable in bed, having to find the best position for him while resting in bed. For pain Oxycodone 5 mg has been ordered for him.
As the team who was following him talk talked to him by updating his condition and plan of care, he was told that maybe the oxycodone may be the cause or one of the cause for his bleeding. He did have a few colonoscopies done which showed ulcers. Now with any mediation taken long term can result in addiction, resistance, worsening responses, and death. According to Memorial Sloan Kettering Center, the drug may cause or worsen stomach ulcers and bleeding.
References
Rosenthal, L. D., & Burchum, J. R. (2021). Lehne’s pharmacotherapeutics for advanced practice nurses and physician assistants (2nd ed.) St. Louis, MO: Elsevier.
Oxycodone and Ibuprofen. Memorial Sloan Kettering Cancer Center. (n.d.). Retrieved November 27, 2022, from https://www.mskcc.org/cancer-care/patient-education/medications/oxycodone-and-ibuprofen
Understanding pharmacokinetics, pharmacodynamics, and pharmacogenomic relationships of a drug support a successful drug therapy to impact a disease across all ages optimally. Ideally, age is a continuum factor that complements adaptability of drugs impact and disposition (Van den Anker et al., 2018). The discussion seeks to reflect on the case of patients I observed in my clinical practice from the last five years. The discussion will elaborate on the factors that might influence the pharmacokinetics and pharmacodynamics process presented by the patient and explain the details of a personalized care plan that I would develop influencing factors and patient history.
The case study involves an 80-year-old male with diabetes mellitus with end-stage renal diseases complaining of loss of sensation, decreased endurance undertaking activities, and reduced balance. The past medical history includes hypertension, gout, and chronic lymphocytic leukemia. His son, who always accompanies him to the clinic, highlighted that he skipped his entire dose due to hypoglycemia, and his glucose was above 200 mg/dL, and 6.9% glycosylated hemoglobin (HbA1c).
As such, the patient was diagnosed with an average glycemic control, although he presented intolerable episodes of severe hypoglycemia. Besides, the patient’s renal function deteriorated despite showing tolerated glimepiride in the over the years. The current medications of the patient include atorvastatin 10 mg QD and glimepiride 4 mg BID.
According to Ponticelli et al. (2015), many organs’ function decreases with advancing age. The decline in functional reserve is associated with reduced lean body mass, a reduction in glomerular filtration rate, and reduced liver flow in aging patients. The associated presence of renal problems further impairs the deterioration of the condition. The presented patient is affected by comorbid development and should be administered multiple medications (Ponticelli et al., 2015).
Notably, the aging process alters interactions of some drugs such as the affinity of some medication receptors, the amount of receptor, and the response of cells upon activation of receptors (Ponticelli et al., 2015). Hence, elderly patients with renal problems are prone to risks of adverse drug interactions. Also, elderly patients suffer from unintentional poor compliance with drugs. Therefore, the prescription of medications for the patient is perplexed on the scarcity of information regarding the pharmacokinetics and pharmacodynamic profile of drugs (Segall et al., 2017).
In this case, the treatment goal is to maintain normal glucose levels with minimal or no hypoglycemia association. Therefore, the patient is recommended to take drugs that are not cleared renally excreted since he is diagnosed with moderate renal impairment or medicines that need adjustment based on the kidney or serum creatinine’s functioning. The risk factors associated with the patient’s condition are renal dysfunction and aging (Ponticelli et al., 2015). The personalized care plan will involve discontinuing insulin glargine and introduce dipeptidyl peptidase-4 inhibitor by oral administration at discharge, epitomized by a lower rate of hypoglycemia and ease of use (Scheen, 2015).
More importantly, the patient should be prescribed with Linagliptin 5 mg/day and recommend a follow-up visit scheduled after two weeks (Lutz, Jurk & Schinzel, 2017). The drug has a predominately nonrenal clearance route and low risk of hypoglycemia and does not need adjustments, hence minimizing glucose complexity lessening treatment with numerous comorbidities. The treatment plan is aimed to lower glucose treatments in the elderly patient by administering drugs that will prevent drug interaction, renal dysfunctions, and hypoglycemia based on the patient’s comorbidities.
References
Lutz, J., Jurk, K., & Schinzel, H. (2017). Direct oral anticoagulants in patients with chronic kidney disease: patient selection and special considerations. International journal of nephrology and renovascular disease, 10, 135.
Ponticelli, C., Sala, G., & Glassock, R. J. (2015, May). Drug management in elderly adult with chronic kidney disease: a review for the primary care physician. In Mayo Clinic Proceedings (Vol. 90, No. 5, pp. 633-645). Elsevier.
Scheen, A. J. (2015). Safety of dipeptidyl peptidase-4 inhibitors for treating type 2 diabetes. Expert opinion on drug safety, 14(4), 505-524.
Segall, L., Nistor, I., Van Biesen, W., Brown, E. A., Heaf, J. G., Lindley, E., … & Covic, A. (2017). Dialysis modality choice in elderly patients with end-stage renal disease: a narrative review of the available evidence. Nephrology Dialysis Transplantation, 32(1), 41-49.
Van den Anker, J., Reed, M. D., Allegaert, K., & Kearns, G. L. (2018). Developmental changes in pharmacokinetics and pharmacodynamics. The Journal of Clinical Pharmacology, 58, S10-S25.
*week 1 – extra learning*
The following questions are here to provide extra practice and learning for this week’s material. They are not required. I will post the correct answers on Friday.
Multiple choice questions
- Primary site for drug metabolism: a. stomach b. small intestine c. kidney d. muscle e. liver
- Valium (diazepam) acts through this receptor system: a. aspartate b. GABA c. acetylcholine d. glutamate e. serotonin
- Typically, the magnitude of drug effects are thought proportional to the number of occupied receptors: a. true b. false
- 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
- 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
- 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
- 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
- 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
- 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
- Which medication dosage form avoids the first-pass effect? a. Suspension b. Troche c. Elixir d. Sublingual tablet
Dosing questions
- 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?
- 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?
- Ordered 2 g of amoxicillin. Amoxicillin is available as 400 mg per 5 mL. How much will the nurse draw up?
- 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)?
- 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?Bottom of FormBottom of Form
Half-life questions
- 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?
- Zolpidem has a half-life of 3 hours. If a patient takes 10 mg at 10 pm, what will the blood level be at 7 am?
- A drug’s half-life is known to be 2 hours. What percentage will be left in the body after six hours?
I agree that Pharmacokinetics plays a huge role on the effects of pain medication. I just have a recent experience where a patient was admitted to my floor and was later sent to surgery to receive split thickness graft to her BLE. The patient blood pressure began to slowly drop, and respirations became shallow after the administration of versed. The patient was 78 years old and was 78kg. The patient had to receive Narcan because of the medication. Later it was found that the patient had a Hydromorphone pump and was receiving Hydromorphone and sedatives while in surgery.
Sedates are usually given based off the patients age and weight. Pharmacokinetics and pharmacodynamics occur differently in older adults. Older adults typically have decreased gastric acid production and decreased gastric mobility which causes impaired drug dissolution (Rosenthal et al.,2021,p.60). This can cause decrease bioavailability of drugs. Decreased gastric mobility in adults increases the effects of medications (British Pharmacological Society, 2022, p.4).
British Pharmacological Society | Journals – Wiley Online Library. (n.d.). Retrieved December 4, 2022, from https://bpspubs.onlinelibrary.wiley.com/
Rosenthal, L. D., & Burchum, J. R. (2021). Lehne’s pharmacotherapeutics for advanced practice nurses and physician assistants (2nd ed.) St. Louis, MO: Elsevier.
Rubric Detail
Select Grid View or List View to change the rubric’s layout.
Content
Name: NURS_6521_Week1_Discussion_Rubric
| Excellent | Good | Fair | Poor | ||
| Main Posting | Points Range: 45 (45%) – 50 (50%) Answers all parts of the discussion question(s) expectations with reflective critical analysis and synthesis of knowledge gained from the course readings for the module and current credible sources. Supported by at least three current, credible sources. Written clearly and concisely with no grammatical or spelling errors and fully adheres to current APA manual writing rules and style. | Points Range: 40 (40%) – 44 (44%) Responds to the discussion question(s) and is reflective with critical analysis and synthesis of knowledge gained from the course readings for the module. At least 75% of post has exceptional depth and breadth. Supported by at least three credible sources. Written clearly and concisely with one or no grammatical or spelling errors and fully adheres to current APA manual writing rules and style. | Points Range: 35 (35%) – 39 (39%) Responds to some of the discussion question(s). One or two criteria are not addressed or are superficially addressed. Is somewhat lacking reflection and critical analysis and synthesis. Somewhat represents knowledge gained from the course readings for the module. Post is cited with two credible sources. Written somewhat concisely; may contain more than two spelling or grammatical errors. Contains some APA formatting errors. | Points Range: 0 (0%) – 34 (34%) Does not respond to the discussion question(s) adequately. Lacks depth or superficially addresses criteria. Lacks reflection and critical analysis and synthesis. Does not represent knowledge gained from the course readings for the module. Contains only one or no credible sources. Not written clearly or concisely. Contains more than two spelling or grammatical errors. Does not adhere to current APA manual writing rules and style. | |
| Main Post: Timeliness | Points Range: 10 (10%) – 10 (10%) Posts main post by day 3 | Points Range: 0 (0%) – 0 (0%) | Points Range: 0 (0%) – 0 (0%) | Points Range: 0 (0%) – 0 (0%) Does not post by day 3 | |
| First Response | Points Range: 17 (17%) – 18 (18%) Response exhibits synthesis, critical thinking, and application to practice settings. Responds fully to questions posed by faculty. Provides clear, concise opinions and ideas that are supported by at least two scholarly sources. Demonstrates synthesis and understanding of learning objectives. Communication is professional and respectful to colleagues. . Responses to faculty questions are fully answered, if posed. Response is effectively written in standard, edited English. | Points Range: 15 (15%) – 16 (16%) Response exhibits synthesis, critical thinking, and application to practice settings. Responds fully to questions posed by faculty. Provides clear, concise opinions and ideas that are supported by at least two scholarly sources. Demonstrates synthesis and understanding of learning objectives. Communication is professional and respectful to colleagues. . Responses to faculty questions are fully answered, if posed. Response is effectively written in standard, edited English. | Points Range: 13 (13%) – 14 (14%) Response is on topic and may have some depth. Responses posted in the discussion may lack effective professional communication. Responses to faculty questions are somewhat answered, if posed. Response may lack clear, concise opinions and ideas, and a few or no credible sources are cited. | Points Range: 0 (0%) – 12 (12%) Response may not be on topic and lacks depth. Responses posted in the discussion lack effective professional communication. Responses to faculty questions are missing. No credible sources are cited. | |
| NURS 6521 Week 1 Discussion Pharmacokinetics and Pharmacodynamics Second Response | Points Range: 16 (16%) – 17 (17%) Response exhibits synthesis, critical thinking, and application to practice settings. Responds fully to questions posed by faculty. Provides clear, concise opinions and ideas that are supported by at least two scholarly sources. Demonstrates synthesis and understanding of learning objectives. Communication is professional and respectful to colleagues. . Responses to faculty questions are fully answered, if posed. Response is effectively written in standard, edited English. | Points Range: 14 (14%) – 15 (15%) Response exhibits critical thinking and application to practice settings. Communication is professional and respectful to colleagues. Responses to faculty questions are answered, if posed. Provides clear, concise opinions and ideas that are supported by two or more credible sources. Response is effectively written in standard, edited English. | Points Range: 12 (12%) – 13 (13%) Response is on topic and may have some depth. Responses posted in the discussion may lack effective professional communication. Responses to faculty questions are somewhat answered, if posed. . Response may lack clear, concise opinions and ideas, and a few or no credible sources are cited. | Points Range: 0 (0%) – 11 (11%) Response may not be on topic and lacks depth. Responses posted in the discussion lack effective professional communication. Responses to faculty questions are missing. No credible sources are cited. | |
| Participation | Points Range: 5 (5%) – 5 (5%) Meets requirements for participation by posting on three different days. | Points Range: 0 (0%) – 0 (0%) | Points Range: 0 (0%) – 0 (0%) | Points Range: 0 (0%) – 0 (0%) Does not meet requirements for participation by posting on 3 different days | |
| Total Points: 100 | |||||
Name: NURS_6521_Week1_Discussion_Rubric
Pharmacokinetics and Pharmacodynamics
When prescribing medication, it is crucial to consider several individual patient factors that might affect the pharmacokinetic and pharmacodynamic process (Reeve et al., 2017). For instance, while working with the geriatric population, I encountered an 85-year-old female patient with a history of atrial fibrillation and serum creatine of 1.8mg/dl. The patient was prescribed digoxin to help manage the rapid heart rate. A maintenance dose of 125mcg tabs once a day was decided based on the patient’s pharmacodynamic and pharmacokinetic processes.
Advanced age is characterized by reduced functionality of several regular body processes responsible for functional integration between different cells and organs. The 85-year-old patient displayed several pharmacokinetic changes, with the main ones being a reduction in hepatic and renal clearance and decreased distribution volume of water-soluble drugs leading to higher serum levels (Drenth‐van Maanen et al., 2019). Consequently, some of the pharmacokinetic changes associated with the patient’s advanced age include increased sensitivity to drugs like digoxin.
Serum creatine of 1.8mg/dl is quite high indicating that the patient’s kidneys are not functioning properly. However, since approximately 67% of digoxin undergoes renal clearance, it was necessary to calculate the standard renal clearance of the drug, which is 6 liters per hour per 70 kg body weight, with a creatinine clearance of 100 mL/min (Holford, 2017). The patient’s creatinine clearance is however reduced hence the need to administer a lower dose of the drug. A once-daily dosing frequency is thus recommended with a bioavailability of 0.7 that requires 127 mcg/day as the daily maintenance dose. The dose should however be monitored closely for further changes.
References
Drenth‐van Maanen, A. C., Wilting, I., & Jansen, P. A. F. (2019). Prescribing medicines to older people—How to consider the impact of aging on human organ and body functions. British Journal of Clinical Pharmacology, 86(10), 1921–1930. https://doi.org/10.1111/bcp.14094
Holford N.G. (2017). Pharmacokinetics & pharmacodynamics: rational dosing & the time course of drug action. Katzung B.G.(Ed.), Basic & Clinical Pharmacology, 14e. McGraw Hill. https://accessmedicine.mhmedical.com/content.aspx?bookid=2249§ionid=175215748
Reeve, E., Trenaman, S. C., Rockwood, K., & Hilmer, S. N. (2017). Pharmacokinetic and pharmacodynamic alterations in older people with dementia. Expert Opinion on Drug Metabolism & Toxicology, 13(6), 651–668. https://doi.org/10.1080/17425255.2017.1325873
PHARMACOKINETICS AND PHARMACODYNAMICS
As an advanced practice nurse assisting physicians in the diagnosis and treatment of disorders, it is important to not only understand the impact of disorders on the body, but also the impact of drug treatments on the body. The relationships between drugs and the body can be described by pharmacokinetics and pharmacodynamics.
Pharmacokinetics describes what the body does to the drug through absorption, distribution, metabolism, and excretion, whereas pharmacodynamics describes what the drug does to the body.
When selecting drugs and determining dosages for patients, it is essential to consider individual patient factors that might impact the patient’s pharmacokinetic and pharmacodynamic processes. These patient factors include genetics, gender, ethnicity, age, behavior (i.e., diet, nutrition, smoking, alcohol, illicit drug abuse), and/or pathophysiological changes due to disease.
For this Discussion, you reflect on a case from your past clinical experiences and consider how a patient’s pharmacokinetic and pharmacodynamic processes may alter his or her response to a drug.
RESOURCES
Be sure to review the Learning Resources before completing this activity.
Click the weekly resources link to access the resources.
WEEKLY RESOURCES
To prepare:
- Review the Resources for this module and consider the principles of pharmacokinetics and pharmacodynamics.
- Reflect on your experiences, observations, and/or clinical practices from the last 5 years and think about how pharmacokinetic and pharmacodynamic factors altered his or her anticipated response to a drug.
- Consider factors that might have influenced the patient’s pharmacokinetic and pharmacodynamic processes, such as genetics (including pharmacogenetics), gender, ethnicity, age, behavior, and/or possible pathophysiological changes due to disease.
- Think about a personalized plan of care based on these influencing factors and patient history in your case study.
BY DAY 3 OF WEEK 1
Post a description of the patient case from your experiences, observations, and/or clinical practice from the last 5 years. Then, describe factors that might have influenced pharmacokinetic and pharmacodynamic processes of the patient you identified. Finally, explain details of the personalized plan of care that you would develop based on influencing factors and patient history in your case. Be specific and provide examples.
BY DAY 6 OF WEEK 1
Read a selection of your colleagues’ responses and respond to at least two of your colleagues on two different days by suggesting additional patient factors that might have interfered with the pharmacokinetic and pharmacodynamic processes of the patients they described. In addition, suggest how the personalized plan of care might change if the age of the patient were different and/or if the patient had a comorbid condition, such as renal failure, heart failure, or liver failure.
Note: For this Discussion, you are required to complete your initial post before you will be able to view and respond to your colleagues’ postings. Begin by clicking on the Reply button to complete your initial post. Remember, once you click on Post Reply, you cannot delete or edit your own posts and you cannot post anonymously. Please check your post carefully before clicking on Post Reply!
As a Med-Sure nurse for the past 2 1/2 years I’ve been a nurse, I’ve seen how medications can help or make a patient’s condition worse depending on how they react to it. There are medications that patient may be allergic to which can be deadly. “Absorption is the drug’s movement from its site of administration into the blood.” (Rosenthal & Burchum, 2021, p.13).
Pharmacokinetics and pharmacodynamics work hand in hand so we can understand how the drug work, how we can safely administer them, and their effects. Pharmacokinetics and pharmacodynamics work hand in hand together when administered in the body. It is the way we as providers can help understand the mechanism of how it works for us to write the proper correct prescriptions for patients. There are many variations in drug responses. A few to mention are race, age, gender, genetics and tolerance.
Reflecting on a past time encounter with a patient last month, he had numerous episodes of bloody stools, so many times that I’ve given him about 4 blood transfusions within three weeks span. He has been newly diagnosed with Parkinson’s disease and has had a spinal fusion which typically made him uncomfortable in bed, having to find the best position for him while resting in bed. For pain Oxycodone 5 mg has been ordered for him.
As the team who was following him talk talked to him by updating his condition and plan of care, he was told that maybe the oxycodone may be the cause or one of the cause for his bleeding. He did have a few colonoscopies done which showed ulcers. Now with any mediation taken long term can result in addiction, resistance, worsening responses, and death. According to Memorial Sloan Kettering Center, the drug may cause or worsen stomach ulcers and bleeding.
References
Rosenthal, L. D., & Burchum, J. R. (2021). Lehne’s pharmacotherapeutics for advanced practice nurses and physician assistants (2nd ed.) St. Louis, MO: Elsevier.
Oxycodone and Ibuprofen. Memorial Sloan Kettering Cancer Center. (n.d.). Retrieved November 27, 2022, from https://www.mskcc.org/cancer-care/patient-education/medications/oxycodone-and-ibuprofen
JINKLE
As a nurse for 3 years, I have taken care of patients with a variety of disorders and illnesses. When determining the best treatment for patients, pharmacokinetics, or how the body processes the drug as well as how it interacts within the body is critical. “That is, when two drugs are taken together, one may alter the absorption, distribution, metabolism, or excretion of the other.” (Rosenthal & Burchum, 2021). When I used to work as a bedside Med/Surg Nurse I remember taking care of a patient with Post-op Knee Arthroplasty, with Chronic Kidney Disease (CKD) who was on hemodialysis.
It was crucial to make sure what medicines you are giving patients when their kidneys are not functioning properly and may cause further damage due to lack of systemic clearance, build-up of toxins, and lack of metabolism. For a post-op surgical patient pain medications were very important to control the patient’s pain. Blood pressure monitoring is important with CKD patients as pain also increases blood pressure. Hemodialysis also tends to cause cramping and pain. The patient was in excruciating pain post-op surgery and was scheduled for hemodialysis the next day, morphine 1mg was ordered as needed and oxycodone 5mg.
Morphine 1mg was given as per the pain scale. “Morphine and codeine are not recommended, because the accumulation of their metabolites may cause neurotoxic symptoms” (Coluzzi et al., 2020) Moreover, elder patients have pharmacodynamic sensitivity compared with younger adults. Hence, constant monitoring was needed to make sure the patient blood pressure, respiration, and other vitals are stable.
I educated the patient as his pain subsided a bit on tramadol that was ordered because getting morphine every time is not good for him or his kidneys. Controlling pain with Opioids post-op can heavily affect patients with chronic kidney disease as the metabolites accumulate and increase the risk of toxicity. The glomerular filtration rate (GFR) needs careful monitoring.
Due to the patient’s history and recent surgery, it was crucial to not only control the pain but also anticipate it. It was also important to prescribe medications that would be less harmful to the kidneys and also take the age into the consideration. Tylenol IV around the clock would have been slightly beneficial so the patient would not have been in excruciating pain post-surgery. Tylenol tends to be less harmful to the kidneys and is the choice of drug for CKD patients. IV route would have enhanced the relief a lot faster.
Taking morphine, not only negatively affects the kidney but also causes drowsiness and respiratory distress. It is also only effective for a short amount of time. Oxycodone 5mg would have helped but a higher dose would have helped with such unbearable pain. Older patients tend to excrete and metabolize a lot slower than younger patients, hence having oxycodone 10mg and Tylenol 1000mg around the clock for the first day after surgery would have been more beneficial than morphine as a needed dose. I would also add non-pharmacological interventions Tylenol IV would be beneficial for the patient.
Rosenthal, L. D., & Burchum, J. R. (2021). Lehne’s pharmacotherapeutics for advanced practice nurses and physician assistants (2nd ed.) St. Louis, MO: Elsevier.
Coluzzi, F., Caputi, F. F., Billeci, D., Pastore, A. L., Candeletti, S., Rocco, M., & Romualdi, P. (2020, September 9). Safe use of opioids in chronic kidney disease and hemodialysis patients: Tips and tricks for non-pain specialists. Therapeutics and clinical risk management. Retrieved November 28, 2022, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7490082/
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