OER Legal Ethical Pharmacology Cases and Critical Thinking Chapter 2
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In this chapter, we take a deep dive into some of the legal and ethical issues surrounding pharmacology. You can find all the episodes here at https://www.memorizingpharm.com/oer
Here is the Link to my Pharmacy Residency Courses: residency.teachable.com
Auto Generated Transcript:
Hey, welcome to the Memorizing Pharmacology podcast. We’re going to be starting the critical thinking activities in Chapter 2 of Nursing Pharmacology and what I wanted to do is show you where all of these videos and audio are going to be. So here is the Nursing Pharmacology book and what I’ve done is I’ve put it at memorizingfarm.com. And if you go to the front page, I know that this is a little bit small because this is what it would look like on a mobile and it’s just click here for the OER Nursing Textbook videos and audio which will take you to this page and here we have all of the links that you need to Memorizing Pharmacology, Memorizing Pharmacology Mnemonics and the Nursing Pharmacology Textbook and here are the kinetics and Dynamics. This is where you would find all of those videos so this Kinetics and Dynamics Chapter 1 button here will take you to the videos so we had video One video two and video three or part one part two and part three.
Alright, and the nice thing is that it’s not really hard to figure out where this is because it’s memorizingfarm.com OER one and then Chapter two will be OER2. And so eventually I’ll record the entire chapter readings again this will take some time so that will all be here for you so but right now we’re kind of going one chapter at a time and now we’re gonna hit Chapter two okay.
Alright, our first critical thinking activity is here at 2.2 a. I’ll read it to you and then I will give you a detailed response so critical thinking activity 2.2 a a nurse is preparing to administer medications to a patient while reviewing the chart the nurse notices two medications with similar mechanisms of action have been prescribed by two different providers what is the nurse’s best response well first I’m going to give you my answer and then I’ll show you another resource on the memorizing Farm web page that can really help you here.
So when you look at two similar medications with mechanisms of action for example maybe both of them reduce heart rate well we could make the patient bradycardic or both increase heart rate and they can tachycardic. And so the first thing is to clarify both with both providers that you know letting them know that we have this duplicate because they may not know that the other person is doing it and this is not uncommon for someone to go to their primary care physician I’d get a prescription and then go to maybe their cardiologist and get another prescription and only to find out that the cardiologist and primary care physician are not really communicating and that we have some kind of duplicate or something like that.
So I want to do is take you to Two web pages on the website. The first one is memorizingfarm.com forward slash drug hyphen prefixes hyphen and hyphen suffixes. This suffix and prefix list allows you to find a number of the medications and their suffixes. And these are the suffixes from Memorizing Pharmacology, The First Edition Just 200 medications. And for example, we can look in here and we can see that prizol isn’t anti-ulcer agent but when we go to immune okay there’s a connazole okay that is a systemic anti-fungal okay and in neuro we see piprazole which is a psychotropic.
"Searchable documents make it a lot easier for you to find it much more comprehensive. But in terms of usability, I might use the one before it. But when we’re talking about the same mechanism of action, if we see the same endings, then we’re going to have the same mechanism of action likely. Okay, but you have to kind of go a little bit into the weeds because if you have, for example, esomeprazole and omeprazole, well you actually have two proton pump inhibitors and both of the physicians were thinking, ‘Hey, you know I want to reduce this patient’s gastric acid.’ One gave them one medication and the other one gave him the other and they both didn’t mean to give the same type of medication. But if a patient is on let’s say Omeprazole and fluconazole and aripiprazole for a GI issue, an immune issue, well it’s an antifungal and then we’re also talking about an antipsychotic then well we may have physicians that all three want to write those medications and those are not duplicates but that again is what the memorizing pharmacology books are all about making sure that you can not only understand memorize the medications but also increase your patient’s safety. Okay so that was 2.2a maybe I went a little bit too deep into that one but the bottom line is same mechanism of action you want to clarify with both prescribers here is critical thinking activity 2.
2 B okay a nurse is preparing to administer metoprolol, a cardiac medication to a patient and implement the nursing process assess the vital signs prior to administration and discovers the heart rate is 48 so patient is bradycardic diagnosis that the heart rate is too low to safely administer the medication for the parameters provided establishes the outcome to keep the patient’s heart rate within the normal range of 60 to 100 so again below 60s bradycardic above 100s tachycardic plans to call the physician as well as report this incident in the shift handoff report implements interventions by withholding metoprolol at this time documenting the incident that the medication is withheld and notifying the provider continuous to evaluate the patient’s status throughout the shift after not receiving the metoprolol. The nurse is providing patient teaching to a patient about the medication before discharge. The nurse provides a handout with instructions as well as a list of current medications what other information should be provided to the patient? Well here what we’re going to do is uh we’re gonna make sure to let them know hey when are you need to take the medication what kind of side effects you’re going to watch out for uh and adverse effects and then maybe there’s diet over-the-counter restrictions herbal supplement restrictions as well but let’s just give one so with beta blockers one of the things that is maybe a little bit of a surprise to something called exercise intolerance where all of a sudden patient goes home goes tries to exercise like whoa what is going on I just did not feel "Like myself, that’s something they should know before they go home with the medication that okay that’s gonna happen with a beta blocker that will reduce you know heart rate very sometimes significantly and that’s kind of one of the things that should be in there. The other thing is to make sure that you’re looking at the patient so if the patient is diabetic okay beta blockers mask this signs and symptoms of hypoglycemia because normally a hypoglycemic patient would get a rapid heart rate and kind of get tremors and those types of things and if that’s not the case then the patient might not realize that they’re hypoglycemic so that’s another one of the counseling points to put in there. So that kind of tiredness that a patient might feel is going to be somewhat normal with a beta blocker especially at first and then if a patient’s diabetic want to make sure that they know that the signs and symptoms of hypoglycemia might be covered up. All right critical thinking activity 2.
3 A Levofloxacin is an antibiotic that received FDA approval however the drug was on the market it was discovered that some patients who took levofloxacin developed serious irreversal adverse effects such as tendon rupture. The FDA issued a black box warning with recommendations to reserve levofloxacin for use in patients who have no alternative treatment options for certain indications uncomplicated UTI acute exacerbation of chronic bronchitis acute bacterial sinusitis. A nurse is preparing to administer medications to a patient notices that levofloxacin has been prescribed for the indication of pneumonia there’s no other documentation in the provider’s notes related to the use of the medication what’s the nurse’s best response? So we’ll give you a second since this is not one of the normal indications we’re going to want to first clarify that the prescriber whether a nurse practitioner or physician whatever really meant to give levofloxacin for this patient that’s the first thing we’re going to do um and then we want to make sure that we document that then if it is a go ahead then we want to make sure we tell the patient okay take the levofloxacin with water make sure you take it at the same time each day you can take it with or without food but the patient should be told that they need to avoid dairy products like you know milk yogurt things like that at least two hours before or after because it will chelate or bind with um those types of things and make it much less effective it’ll also bind with things like antacids calcium carbonate and magnesium hydroxide aluminum hydroxide and and I didn’t want to go into the weeds with that but the idea is that multivalent cations multivalent again this is why chemistry is so important so multivalent means it’s plus two or plus three multi meaning many and so if you look in group two of the periodic table group theory of the period three of the periodic table in group two you see calcium and magnesium and in group three you see aluminum and so if you see those those are going to bind with the levofloxacin or fluoroquinolones more generally and they’re going to make them ineffective so that’s if you get the go ahead from the prescribed okay let’s go on to critical thinking activity 2.
3 B A nurse is providing discharge education to a patient who has recently had surgery and has been prescribed hydrocodone with acetaminophen tablets to take every four hours as needed at home. The nurse explains that when medication is no longer needed when the post-op pain subsides should be dropped off at a local pharmacy for disposal in a collectible receptacle."
In a collection receptacle, the patient states, ‘I don’t like to throw anything away. I usually keep unused medications in case another family member needs it.’ What is the nurse’s best response?
'Alright, well the first thing is we really don’t want to share medications. It is illegal, especially with controlled substances like hydrocodone with acetaminophen, which is Vicodin or Lortab. Not only does the other patient, we don’t know what other issues they might have. For example, let’s say that a patient has trouble breathing or just something like that. You can have respiratory depression if you take too many of these. So what we want to do is talk about the dangers of potential drug interactions, dietary interactions, other side effects of the medication for themselves where the prescriber and the nurse have already looked at their record. But to give a medication to someone and you haven’t even evaluated the other medications, that would be irresponsible and in this case also illegal.
Let’s do number two or part two here. A nurse begins a job on a medical surgical unit. One of the charge nurses on this unit is highly regarded by her colleagues and appears to provide excellent care to her patients. The new nurse cares for a patient that the charge nurse cared for on the previous shift. The new nurse asks the patient about the effectiveness of the pain medication documented as provided by the charge nurse during the previous shift. The patient states, ‘I didn’t receive any pain medication during the last shift.’ The nurse mentions this incident and the preceptor states, ‘I’ve noticed the same types of incidents have occurred with previous patients but didn’t want to say anything.’ What’s the new nurse’s best response?
‘Well this is an issue where we may have an impaired nurse and this could obviously endanger the patient and themselves to be honest. So it’s their obligation to report suspected drug use to the nurse manager and supervisor and then in maybe in some cases to the board of nursing. But if that happens and certainly if it happens on a consistent basis then it’s not to take it on your own. It’s to talk to the right people about this and kind of go from there.’
Alright, critical thinking activity 2.3 C: A nurse is preparing to administer morphine, an opioid, to a patient who recently had surgery.
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Explain the five rights that the nurse will check prior to administering this medication to the patient.
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Outline three methods the nurse can confirm patient identification.
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What should the nurse assess prior to administering this medication to this patient?
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Which should be monitored after administering the medication?
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Which should the nurse teach the patient and/or family member about the medication?
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What information should be included in the shift handoff report about this medication?
Alright, let me re-read each question each time I do this just because there are a lot of pieces to this.
So number one: Explain the five rights that the nurse will check prior to administering this medication to the patient.
The five rights are: right patient, right medication, right dose, right route, right time. And then of course we’re going to want to make sure that we check the expiration date and check allergies although it’s not on here. A sixth right is correct or right documentation as well.
The second question said: Outline three methods that a nurse can confirm patient identification.
Let’s kind of break this up: You could scan a barcode on both medication and patient’s armband if they have it; you can ask their name and date of birth; you could just check their armband or identification band itself.
But sometimes you’re going to be in settings like long-term care where there might not be an armband and also if you’re talking about dementia patients they may not know their name or date of birth so what we want to do is maybe if their medication record has an image of them that would be one way to do it but probably the best way is to get somebody who is working there as well Here is the corrected version of your text:
"And say, ‘You know, I think this is such and such,’ or just say, ‘Look, I know who I think this person is. I just want you to identify them to match it so that you don’t already say, hey, this is this person.’ The person says, ‘Yeah, that’s that person.’ What we do in the pharmacy is we’ll generally ask for somebody’s address and that’s just an innocuous way of saying, ‘Okay, we have the same person.’ So Tom Smith, we’re just hoping that Tom Smith and Tom Smith don’t both live in the same place or in the same address. And even if they do live in the same building like we’re in some place like New York where you could have many people living in the same building, making sure to pay attention to the apartment number or something like that.
Alright, what should the nurse assess prior to administering this medication to the patient? So we weren’t really that specific. We just said it was some kind of opioid so we know that there’s going to be some issue with pain. So what’s the patient’s pain level? Are they conscious and alert? What’s their respiratory rate? Again, we know that an overdose of opioids can reduce the respiratory rate cause respiratory depression. And then are they oxygenating? So what do we do then if there is a respiratory rate that’s decreased or an oxidation level that’s decreased or sedation is too high? We want to make sure that we contact the prescriber, talk about withholding the medication things like that. And then of course if there’s some kind of overdose.
I definitely want to start talking about interventions. Number four: What should be monitored after administering this medication? Well again, we’re monitoring respiratory rate, that oxygenation level, the sedation status. And then you know, is it effective in treating the pain? You know, is it doing its job?
Okay number five: Which should the nurse teach the patient and/or family member about the medication? So this would be the common side effects and we’re not talking about toxicity. We’re talking about patient’s probably going to be constipated and this would be a good time to check the medication record to make sure that maybe there’s some docusate sodium on board or something like that. Some degree of laxative that’s going to help them or a stool softener. And then let them know that drowsiness is going to be something that does happen but also to maybe let them know okay well what are the signs of toxicity where we would be going kind of a little bit further than the common side effects.
And then the sixth one was: What information should be included in the shift handoff report about this medication? So again we’re talking about the pain. Where is that pain coming from? What’s the pain level? What medications were given and what times during the shift? And then how did the patient respond? Is the patient comfortable? Is the patient doing well?
Alright let’s go on to 2.3 D: Okay a nurse is disciplined by the Wisconsin Board of Nursing for an incident reported by her employer that she arrived to her shift intoxicated. Then our shares with a nursing colleague: ‘I love taking care of patients. I work so hard to obtain my nursing license. I don’t want to lose it. I know my drinking has gotten out of control but I don’t know where to turn.’ What is the best advice by a nursing colleague for this patient with a drinking problem?
Well most boards are going to have some level of assistance so in Wisconsin you’d have a professional assistance procedure where a patient committed to recovery is able to get treatment and support. And what we want to do is prioritize patient safety but also acknowledge that a nurse has rights as well to get help especially if she’s committed to recovery.
Alright, question 2.4: A nurse is providing education to a mother regarding a liquid antibiotic prescribed for her child to take at home. The prescription states amoxicillin 250 milligrams one teaspoonful (5 mL) every eight hours for seven days. After talking with the mother, the nurse realizes the family does not have measuring spoons in their home. What is the nurse’s best response?
So this is a really common thing that happens especially when maybe you have a spoon that gets lost or someone just forgot their medication itself. If you go to any pharmacy, they’ll give you a syringe. You don’t have to ask, ‘Do I need to pay for a syringe?’ I mean, you could buy one, but just go up to the counter and say, ‘Hey, can I just get a measuring spoon or a syringe?’ Now to be fair, the syringe is actually a bit more accurate. I don’t want to say it’s necessarily more accurate, but the data show that patients do better with the syringe than they do with the measuring spoon in terms of giving the appropriate dose. So going to a pharmacy to get this, don’t try to use the spoons at home. The tablespoons, the teaspoons, that is not the way that you want to do it to make sure that the patient, especially a child, gets the right medication.
Alright, we’re in our last section. We’re going to do two more critical thinking activities.
Activity 2.5 A: The nurse is performing medication reconciliation for an elderly patient admitted from home. The patient does not have a medication list and cannot report the names, dosages, and frequency of the medication taken at home. What other sources can the nurse use to obtain medication information?
In this case, what we’re going to do is we’re going to try to compile everything for them. Often in the pharmacy world, we’ll have brown bag events where the patient just kind of brings all their medications including over-the-counter stuff. We don’t want to exclude that. We don’t want them to just bring prescribed medications and what we want to do is make sure that we compile them into a list that we can print out for the patient so that when they go to their next provider they can provide this list to them. Again, the medications will change and things like that but making sure that all the medications are correct and appropriate. That we don’t have medications they were using before they don’t need anymore and then making sure that they go home with the list.
Critical Thinking Activity 2.5 B: A nurse is preparing to administer insulin to a patient. The nurse is aware that insulin is a medication on the ISMP list of high alert medications. Which strategy should the nurse implement to ensure safe administration of this medication to a patient?
So of course, we’re going to use the five rights. We’re going to want to make sure that the blood glucose level is where we want it to be. What type of insulin are they taking? Concentration? When was it opened? So we want to make sure that it’s good and then also what kind of storage was happening with the medication? The nurse should draw the dose; they can confirm the correct dose with another nurse prior to giving it; and then knowing the onset peak and duration of action to monitor for potential side effects like hypoglycemia which is quite common with insulin unfortunately.
But let me show you a page of memorizing pharmacology so that you can kind of see where memorizing some of these insulins would be really useful.
Okay when you’re looking at this and you’re working on memorizing these you want to memorize them in order some kind of order in this case with insulin you want to memorize the rapid acting those that start working in 15 minutes last about four hours those are going to work so quickly you’ve got to make sure that the patient has a meal so we’re talking about insulin lice Pro or Humalog something like that short acting Works in about 30 minutes and this lasts about six to eight hours and this is regular insulin Humulin R.
The intermediate NPH Humulin N about an hour or two last 14-24 hours and then that long duration insulin glargine Lantus and Tujeo those start working about an hour and last about 24 hours but when you memorize them you want to remember Humalog then Humulin R and Humulin N then Lantus or Tujeo.
We want to do that in order put them in your brain in order because then when you’re saying okay I’m giving insulin if you’re giving Humalog you know okay well I’ve got to talk to the patient about what they’re eating with R you know that there’s maybe some kind of "Know titration up or down where you know maybe we’re kind of looking at their blood glucose first and then giving our NPH should be given to you know kind of control insulin levels over a much longer period of time and then certainly insulin glargine you know are we giving it you know at night time or daytime uh which time are we kind of choosing uh to do that so my advice is when you get to that insulin and you know that insulin can be you know life-saving but it can also be very dangerous memorize them in order Humalog, Humulin R, Humulin N and then Lantus or Tujeo.
And just to be clear this is the book that I’m talking about it’s right here: Memorizing Pharmacology Relaxed Approach Second Edition. And this was the Kindle version. The audiobook obviously is gonna you know narrate those types of things but I just want to make clear this is where this is coming from.
Alright well let’s kind of go back to the beginning here so again this was a nursing pharmacology lesson this was chapter two legal and ethical and the next thing you do is go into antimicrobials which is chapter three and I’ll talk a little bit about the way that I teach and the way that I put them in order.
I always put my classes and then I ask the patient, the patients I ask the students to always put their groups in order so they would put um gastrointestinal musculoskeletal respiratory immune neurocardio endocrine. I asked them to always put the medications on the patient’s med list in that order so that they can look for duplicates and things like that and then when they’re studying for and collect snat applex whatever it is they’re studying for to also continue to study in that order so that in your brain you kind of have these partitions and you know okay the first partition is GI the second partitions musculoskeletal the third partition is respiratory because I think it gets confusing when you use multiple books or multiple resources and you’re in a different order but so if you need my help or want to get in touch with me Tony the pharmacist gmail.com. I hope you’ve enjoyed this episode and hope it’s been helpful.
Like to learn more?
Find my book here: https://geni.us/iA22iZ
or here: https://www.audible.com/pd/B01FSR7HLE/?source_code=AUDFPWS0223189MWT-BK-ACX0-059486&ref=acx_bty_BK_ACX0_059486_rh_us
and subscribe to YouTube Channel TonyPharmD here: https://www.youtube.com/c/tonypharmd
Here is the Link to my Pharmacy Residency Courses: residency.teachable.com
