Pharmacogenetics & Vaccinations

What is the appropriate way to administer a medication to an infant?

Infant = birth to 12 months. First 28 days are called neonatal period. - Topical meds will be absorbed very quickly because infant have very porous skin! This is why we don't use sunscreen on a baby until they are 6 months old. Can lead to systemic absorption of meds that can be harmful to them. - Use a dropper and put in mouth towards inner cheek and give them time to swallow so they don't aspirate. - Don't put medication in a whole bottle! Could use a small nipple to administer med.

Is grapefruit juice an inhibitor or inducer?

Inhibitor

What are inactivated vaccines? Examples?

Killed vaccines! Microbes that have been inactivated by heat or chemicals and unable to replicate or cause disease. Boosters may be necessary to prolong immunity. Examples: Influenza, Human Papilloma Vaccine (HPV), and Hep A vaccines

What are attenuated vaccines? Examples?

Live vaccines! Microbes that are alive but weakened (attenuated). They are unable to produce disease unless the patient is immunocompromised. Examples: MMR or Flu shot but intra-nasally only!!!

What kind of cells do vaccines result in? How long does it take?

Memory B cells; About 10 days

Pharmacology of young and middle aged adults? *PP

Young adults (18 to 40): Typically in good health and don't need a lot of meds unless have diabetes or chronic disease or immune related condition. Med adherence usually pretty good b/c fully understand benefits. Middle-Aged (40 to 65): "Sandwhich generation" because caring for parents, their own kids and grandkids which can cause stress. Have more cardiovascular disease, anxiety, obesity, HTN, arthritis, cancer which they need to be treated for.

Reye syndrome is associated with _____?

Aspirin

A nurse is preparing to administer a Hep B vaccine to a patient. Which condition would cause the nurse to withhold the vaccines and check with the HCP? a. Patient smokes a pack of cigarettes per day b. Patient frightened of injections c. Patient allergic to yeast and yeast products d. Patient has HTN

C: Allergic to yeast and yeast products

Which statement is true regarding drug absorption in infants? a. Absorption is decreased for acid-labile drugs b. Absorption is increased when gastric emptying is decreased c. Absorption of drugs through IM is rapid d. Absorption of drugs through transdermal route is faster in an infant but no more than that in a child

C: Blood flow through the muscle is fast during the infancy; therefore, intramuscular absorption is rapid, more so than in neonates and older children. Acid-labile drugs have increased absorption because infants have low gastric acidity until 2 years of age. Absorption of drugs is not dependent on gastric emptying. This is because delayed gastric emptying for the drugs absorbed through the stomach results in faster absorption, while that in the intestine results in delayed absorption. The stratum corneum of the skin in infants is very thin, and the blood flow is much faster through it than in older children and adults. Therefore, transdermal drug absorption is much faster in infants than in children.

With rapid metabolism, never has chance to get into system so it would have a ________ half life.

Shorter

What are cytochrome P450 (CYP-450) enzymes?

- Enzymes used to metabolize medication - Part of the liver-based metabolism system

Benefits of pharmacogenetics?

- Increased compliance with management - With conditions like cancer, genetic testing will personalize the treatment for the individual by pinpointing which drugs will work best - Some genetic tests will indicate a risk for a disease and that disease never occurs (benefit, but also may be a negative) - Decrease the cost of treatment and emotional strain in finding the best therapy

A 5 year old is due for her Pre-K immunizations. After interviewing her mother, which response may indicate a possible C/I for giving this preschooler a live vaccine (MMR) at this visit and would require further exploration by the nurse? A. Her cousin has the flu B. The mother just finished her series of Hep B vaccines C. Her arm became very sore after her last tetanus shot D. They are caring for her grandma who just finished her 2nd round of chemo

D: Caring for grandma who just finished 2nd round of chemo

What will a nurse teach the parents of a toddler with newly diagnosed cystic fibrosis about the administration of vitamin A, D, E and K? a. Offer them in a water-miscible form b. Give them during meals and snack times c. The dosage is based on the child's height and weight d. Present them to the child with fruit juice rather than milk

A: Because children with cystic fibrosis do not absorb fat-soluble vitamins effectively, they should be given in a water-miscible form. These vitamins may be given with other vitamins once a day; pancreatic enzymes are administered with meals and snacks. The nurse does not have to base the dosage of these vitamins on the child's height and weight. There is no reason to select juice over milk when administering these vitamins.

A patient who drinks alcohol on a daily basis is taking Grisofluvin (CYP-enzyme). What interactions will occur?

Alcohol is an inducer to the CYP-40 enzyme inducer, therefore will increase the metabolism of the Grisofulvin. An increased dose may be needed or the patient should limit or cease drinking alcohol while taking this medication.

What is a booster shot? Examples?

An additional dose of vaccination , increases effectiveness. Examples: MMR (requires two doses; one at 15 months and other before kindergarten); Tetanus (if you haven't within last 10 years) *Chicken Pox Booster is not required but highly recommended

Vaccines are contraindicated for patients who ____?

Have a weekend immune system or who are currently experiencing symptoms such a diarrhea, vomiting, or fever

How do inducers effect metabolism and would this result in a need to increase or decrease dosing?

Increases metabolism. Induces P450 - the enzyme that is used to metabolism. Will breakdown other drugs inappropriately and cause subtherapeutic results. A higher dose is needed!

Is alcohol an inhibitor or an inducer?

Inducer

What are different types of CYP-450 enzyme?

- Inducer - Inhibitors - Substrates

Pharmacology of older adults?

- Polypharmacy which dramatically increases risk for drug interactions and side effects. Urge patients to report all OTC meds and vitamins - More adverse effects than any other age group - Large font print and obtain feedback that they understand - As long as there are no small children present in household, older pts with arthritis should be encouraged to ask pharmacist for regular screw-cap med bottle to help with ease of opening - Alarmed pill containers, medicine management boxes, and clearly written instructions may be useful

Pharmacology of preschoolers and school-age children? *PP

- Preschoolers (3 to 5) can be a lot like toddlers but can be more cooperative with oral. Will need help with injections. Can use ventrogluteal for IM because causes less pain. Brief explanations not long detailed for explanation of medication. Demonstrate procedures on a doll or let child pretend they are doctor or nurse. Scan veins no longer used for IV access. - School age (age 6 to 12) pretty cooperative and starting to understand relationship between taking the medication and feeling better. Can still mix with things if taste bad. Let them make choices to feel more in control. Ex: which pill to take first or what liquid to take it with. Ventrogluteal site preferred although muscles of older children are developed enough for nurses to use other sites.

Medication Admin for Infants? *Textbook

- SHOULD be cuddled and held while meds are being administered - Pacifier should be offered if infant is on fluid restrictions caused by vomiting or diarrhea - Often administered via droppers into the eyes, ears, nose, or mouth - Oral meds should be directed towards the inner cheek and give time to swallow - If rectal suppositories, hold buttocks together for 5-10 mins to prevent expulsion of drug before absorption has occurred - For very young infants, med may be given via a nipple - Smallest needle possible for IV or IM. For volumes less than 1mL, a tuberculin syringe is appropriate - Vastus lateralis is preferred site; gluteal site is C/I due to potential for damaging sciatic nerve - Rotate legs to avoid overuse and prevent excessive pain/inflammation - For IV meds, the feet and scalp may provide more easily accessible and are the preferred venous access points

Education points for parents to protect this age group (toddlers) from poisoning? *PP

Toddler = 1 to 3 years old; *Poisoning major risks at this age - Will eat anything! Can chew a chewable tablet so keep meds in a child-proof bottle that they cannot open. If looks tasty or like candy they will try to eat it. - Keep any meds out of their reach - If med taste bad, mix with small amount of jam, syrup, or some type of fruit puree. - Vastus Lateralis also for Toddlers! *can give in gluteal site only after they have been walking for at least one year so muscle has had time to develop

Which strategies should be used to reduce pain during or after vaccination? SATA a. Applying topical anesthetic b. Providing tactile stimulation c. Holding the child upright during vaccination d. Preforming IM injections rapidly with prior aspiration e. Administering analgesics-antipyretics such as acetaminophen to reduce pain

a ,b, & c: Application of topical anesthetics on the skin before the injection numbs the skin and reduces the pain at the time of injection. Tactile stimulation at the injection site before and during injection results in reduced pain. Holding the child in an upright position provides a sense of control, can decrease fear, and help reduce pain. Avoiding aspiration prior to intramuscular injection, rather than encouraging it, reduces the pain. Administration of analgesics and antipyretics is avoided before and after vaccination because they reduce the immune response.

A patient with cirrhosis of the liver has liver impairment. This will require what possible changes? SATA a. A reduction in the dosage of drugs b. A change in the timing of medication administration c. An increased dose of prescribed drugs d. Giving all prescribed drugs via IM injection e. More frequent monitoring for adverse drug effects

a, b,& e: A reduction in the dosage of drugs-decreased metabolic activity. A change in the timing of medication administration lengthening time between doses may be needed for some drugs, not all. More frequent monitoring for adverse drug effects- due to impaired metabolism

Pharmacology of older adults related to absorption, distribution, metabolism, and excretion?

Absorption: Slower d/t diminished gastric motility and decreased blood flow to digestive organs. Gastric pH is decreased so meds that require a high level of acid to absorb may take longer Distribution: Aging cardiovascular system has decreased cardiac output and less efficient blood circulation which slows drug distribution. Why its important to initiate small doses and slowly/safety increase. Increased body fat provides larger storage compartment for lipid-solvable drugs and vitamins. Plasma levels reduced so therapeutic response is diminished. Have less water so effects of dehydration and dramatically and increase risk for drug toxicity. Increased risk for drug-drug interactions. Metabolism: Reduced hepatic drug metabolism b/c enzyme production in liver decreases and visceral blood flow decreases. This leads to an increase in the half-life of many drugs which prolongs and intensifies drug response. Relates to first pass metabolism so the change alters the standard dosage, the interval btwn doses, and the duration of side effects. Excretion: Reduced renal blood flow, GFR, and active tubular secretion and nephron function. This decreases excretion for drugs excerpted through the kidney. When excretion is reduced, serum drug levels and potential for toxicity markedly increase. Admin schedules and dosage amounts may need to be altered in many older adults d/t these changes in kidney function. Common for drug toxicity to be caused by accumulation of toxic amount of drugs secondary to impaired renal excretion.

Pharmacology of adolescents? *PP + Textbook

Adolescents (13 and 16) rapidly growing but not as mature as they think they are. Acne, menstrual symptoms, headaches, alcohol and tobacco use, contraception, sports-related injuries, and eating disorders common. Increased risk for STI when sexually active. If suspicious that they have an eating disorder, ask about OTC meds that could be used to decrease appetite or are laxatives. Experimentation common with drugs/alcohol/illicit drugs. Opioids often readily available in parents cabinet or after sport-related injury and can develop addiction. Normally appreciate a through explanation d/t need for privacy and control. Allow time for questions. Despite need to have independence and desire to self-medicate, teens have a very poor understanding to medication information so carefully explain important info like side effects.

Define pharmacogenetics?

Area of pharmacology that examines the role of heredity in drug response. Looks at our genetic makeup and helps us to decide which medication will work best for a specific individual

What are toxoid vaccines? Examples?

Contain bacterial toxins that have been chemically modified to be incapable of causing disease. When injected, toxoid vaccines induce the formation of antibodies that are capable of neutralizing the real toxins. Ex: Tetanus and diphtheria toxoids

What are recombinant technology vaccines? *pg 520

Contain partial viral subunits or bacterial proteins that have been generated in a lab Ex: Hep B vaccines

Medication admin for Toddlers? *Textbook

- Short concrete explanations followed by immediate drug administration best for this group - Physical comfort (hugs, touch, or verbal praise) following admin is important - Oral meds that taste bad should be mixed with a small amount of jam, syrup, or fruit puree - Can follow admin with a carbonated drink or their drink of choice - IM site preferred is vastus laterals. - IV injections may use scalp or feet veins; additional peripheral vein options become available in late toddlerhood - Firmly secure IV and educate parent about dangers of child trying to pull away from IV pump too quickly - Often helpful to put longer tubing on a toddlers to give child more room to play - Have parents in close proximity will usually reduce toddlers anxiety and increase cooperation

Medication Admin for Infants? *PP

- Smallest needle possible and use vastus laterals - Cannot use ventrogluteal site because of risk of injury to sciatic nerve d/t underdeveloped muscle - If giving multiple injections, need to rotate vastus lateralis site from one leg to the other - Acid liable drugs have increased absorption - IM absorption is rapid (more so than neonates and children)

Education points for parents to protect this age group (toddlers) from poisoning? *Textbook

- Store all drugs and harmful agents out of reach and in locked cabinets - Keep all household products and drugs in their original containers. Never put chemicals in empty drink containers (milk, OJ, or cereal) - Always ask the pharmacist to place the meds for everyone in family in child-resistant containers - Never tell children that medicine is candy - Keep poison control # near phones and call asap if suspected - Never leave medication unattended in a child's room or in areas where the child plays

What are vaccines?

Biological agent used to stimulate the immune system. Vaccination is the process of introducing foreign proteins or inactive cells into the body to trigger an immune response before the patient is exposed to the real pathogen.

A 10-year-old is prescribed Tetracycline. Which possible drug-related reactions are associated with this drug? a. Kernicterus b. Greys Syndrome c. Reye Syndrome d. Staining of the teeth

D: Tetracycline causes staining or discoloration of developing teeth in children. Sulfonamides may cause kernicterus in neonates. Chloramphenicol may cause Gray syndrome in infants. Aspirin may cause Reye syndrome in pediatric clients with a history of chickenpox or influenza. *Kernicterus - brain damage caused from too high of bilirubin levels which can cause visual difficulties, dental issues, and intellectual issues.

How do inhibitors effect metabolism and would this result in a need to increase or decrease dosing?

Decreases metabolism. Stops or inhibits the P450. Risk of toxicity! Lower dose will be needed.

A patient is taking Omeprazole (a substrate of the CYP- enzymes) and the physician adds Fluconazole (an inhibitor for the same CYP- enzyme) for a fungal infection, what will occur between these two medications?

Fluconazole will decrease the metabolism of the Omeprazole. Competeing because both are inhibitors.

DTaP vaccines are contraindicated when prior DTaP vaccination caused which of the following side effects? SATA a. Seizures within 3 days b. Encephalopathy within 7 days c. A shock-like state d. Severe febrile illness within 2 days e. Immediate anaphylactic reaction

b & e: DTaP vaccines are contraindicated if a prior DTaP vaccination has led to the development of encephalopathy within seven days of vaccination or an immediate anaphylactic reaction. If prior DTaP vaccinations potentially caused seizures within three days of administration, a shock-like state, and/or a severe fever within two days, the vaccine is not contraindicated but must be administered with caution.

A patient with acute kidney injury may have a diminished ability to excrete medications. The nurse must assess the patient more frequently for what development? a. Increased risk of allergy b. Decreased therapeutic drug effects c. Increased risk for drug toxicity d. Increased absorption of the drug from the intestines

c: Renal injury increases the drug action because it's not excreted as quickly. Therefore can become toxic if have kidney damage/injury.

An older adult patient has arthritis in her hands and takes several prescription drugs. Which statement by the patient requires further assessment by the nurse? a. "My pharmacists puts my pills in screw-top bottles to make it easier for me to take my medications." b. "I fill my prescriptions once per month." c. "I care for my 2-year-old grandson twice a week." d. "My arthritis medicine helps my stiff hands."

c: Toddlers are at risk of poisoning. Need to be stored in child-proof bottes and stored out of reach.