Chapter 2: Prescription Review Flashcards Preview

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Flashcards in Chapter 2: Prescription Review Deck (16):
1

Safe routine for Pescribing 

PReSCRIBER

  • Patient details
  • Reactions (+allergies)
  • Sign, front of chart
  • Contrainidcations 
  • Route
  • IV fluids
  • Blood clot prophylaxis
  • (anti)Emetic 
  • Relief of pain

2

What to check for P in PReSCRIBER

Patient details

3 pieces of information needed: name  + DOB + Hosp #

3

What to check for Re in PReSCRIBER

Reactions i.e. allergy + the reaction.

Complete or check allergy box before prescribing.

NB: Co-amoxiclav + Tazocin both contain penicillin.

4

What to check for S in PReSCRIBER

Sign : Front of chart + individual pescription

5

What to check for C in PReSCRIBER

Contraindications: 

 

BANS: consider 4 groups of drugs.

  • Bleeding risk:
    • Do not give if patient bleeding or suspected or at risk of bleeding e.g. prolonged PT in CLD.
    • Prophylactic heparin CI in acute ischaemic stroke as may bleed into stroke.
    • Enzyme inhibitors (AO DEVICES) can increase warfarin’s effect, despite stable dose e.g Erythromycin
  • Antihypertensives:
    • Hypotension – including postural hypotension, from ALL groups of antihypertensives.
    • Bradycardia – B-blockers + CCBs.
    • Electrolyte disturbances – ACE-i + diuretics.
    • Specific side-effects: ACE-i = dry cough; B-blockers = wheeze in asthmatics + worsening of ACUTE heart failure; CCBs = peripheral oedema + flushing; diuretics = renal failure → loop diuretics = gout, K+-sparing diuretics (e.g. spironolactone) = gynaecomastia.
  • NSAIDs:
    • Cautions/CIs = NSAID = No urine (renal failure), Systolic dysfunction (HF), Asthma, Indigestion (any cause) + Dyscrasias (clotting abnormality).
    • NB: Although aspirin an NSAID, it is NOT CI in renal or HF, or asthma.
  • Steroids:
    • S/Es (+ loosely the Cis) = STEROIDS = stomach ulcers, thin skin, edema, R+L HF, osteoporosis, infection, diabetes (mainly hyperglycaemia, rarely progresses to diabetes), syndrome (Cushing’s).

6

Contraindications: B

Bleeding risk:

  • Do not give if patient bleeding or suspected or at risk of bleeding e.g. prolonged PT in CLD.
  • Prophylactic heparin CI in acute ischaemic stroke as may bleed into stroke.
  • Enzyme inhibitors (AO DEVICES) can increase warfarin’s effect, despite stable dose.

7

Contraindications: A

Antihypertensives:

  • Hypotension – including postural hypotension, from ALL groups of antihypertensives.
  • Bradycardia – B-blockers + CCBs.
  • Electrolyte disturbances – ACE-i + diuretics.
  • Specific side-effects:
    • ACE-i = dry cough;
    • B-blockers = wheeze in asthmatics + worsening of ACUTE heart failure;
    • CCBs = peripheral oedema + flushing;
    • Diuretics = renal failure + loop diuretics = gout, K+-sparing diuretics (e.g. spironolactone) = gynaecomastia

8

Contraindications: N

NSAIDs:

  • Cautions/CIs = NSAID = No urine (renal failure), Systolic dysfunction (HF), Asthma, Indigestion (any cause) + Dyscrasias (clotting abnormality).
    • NB: Although aspirin an NSAID, it is NOT CI in renal or HF, or asthma.

9

Contraindications: S

Steroids: S/Es (+ loosely the Cis) = STEROIDS

  • stomach ulcers
  • thin skin
  • edema
  • R+L HF
  • osteoporosis
  • infection
  • diabetes (mainly hyperglycaemia, rarely progresses to diabetes)
  • syndrome (Cushing’s)

10

What to check for R in PReSCRIBER

Route for each drug.

  • Vomiting = give via IV/IM/SC.
  • If short-lasting vomiting (which it usually is) = no need to change route of other prescribed medicines.
  • Doses of anti-emetics all SAME regardless of route e.g. cyclizine 50mg 8-hourly, metoclopramide 10mg 8-hourly.
  • NBM still need their oral medication, including prior to surgery.

11

What to check for I in PReSCRIBER

IV fluids.

Prescribed in 2 situations: (1) Replacement = if dehydrated/acutely unwell; (2) Maintenance = if NBM.

 

12

What to check in replacement fluids?

Replacement: Which fluid? All 0.9% saline unless:

  • Hypernatraemic or hypoglycaemia = give 5% dextrose.
  • Ascites = give human-albumin solution (HAS) – maintains oncotic pressure, 0.9% saline worsens ascites.
  • Shocked with SBP < 90mmHg = 500 ml 0.9% Sodium Chloride over 15 minutes (250 ml in elderly). (x3->inotropes)
  • Shocked with bleeding = 500 ml 0.9% Sodium Chloride over 15 minutes (250 ml in elderly), then like with like (senior decision)

Replacement: How much + how fast? Assess HR, BP + UO first.

  • Tachycardic + hypotensive = 500ml IV STAT (250ml if HF) → reassess.
  • Only oliguric (not obstruction) = 1L over 2-4h → reassess.
    • ↓UO (oliguric <30mL/h, anuric <0ml/h) = 500ml depleted.
    • ↓UO + tachycardia = 1L depleted.
    • ↓UO + tachycardia + hypotension (i.e. shocked) = >2L depleted.
  • General rule – never prescribe >2L IV fluid, as should review rate regularly.
  • 0.9% saline 1L 2⁰ = give over 2h – should write “2 hours” or “2-hourly” instead.

13

What to check in maintenance fluids?

Which fluids + how much?

  • Adults need 3L/day of IV fluid OR 25-30ML/KG/DAY. Elderly need 2L/day.
  • Adequate electrolytes = 1 salty + 2 sweet = 1L 0.9% saline + 2L 5% dextrose.
  • Provide K+ by adding KCl to bags, guided by U&Es. If N K+, need 1mmol of KCl/kg/day. (c.40mmol/day) 
  • Do NOT give IV K+ at rate of >10mmol/hour.

How fast?

  • If giving 3L/day = 8 hourly bags.
  • If giving 2L/day = 12 hourly bags.
  • Before prescribing, always check: U&Es, not fluid overloaded, bladder not palpable.

14

What to check for B in PReSCRIBER

Blood clot prophylaxis.

  • To prevent VTE, majority get LMWH (e.g. dalteparin 5000U daily SC) + compression stockings.
  • Drug charts provide assessment tool.
  • Note if bleeding/suspected/at risk (including ischaemic stroke), don’t give warfarin or heparin.
  • If peripheral arterial disease, don’t give compression stockings (may cause acute limb ischaemia)

15

What to check for E in PReSCRIBER

Emesis relief.

  • Nauseated = regular anti-emetic vs Not nauseated = as-required anti-emetic:
  • Cyclizine 50mg 8-hourly IM/IV/oral → but fluid retention
  • Metoclopramide 10mg 8-hourly IM/IV if HF.

 

  • Avoid cyclizine (anti-histamine) if HF, otherwise good 1st-line for almost all cases except cardiac.
  • Avoid metocloporamide (dopamine antagonist) if Parkinson’s disease (exacerbates) + young women (dyskinesia, especially acute dystonia).

16

What to check for R in PReSCRIBER

Relief of Pain

  • No pain = nil regular & PRN paracetamol 1g up to 6-hourly oral.
  • Mild pain = paracetamol 1g 6-hourly oral & PRN codeine 30mg up to 6-hourly oral (or tramadol).
  • Severe pain = co-codamol 30/500 2 tablets 6-hourly oral & PRN morphine sulphate 10mg up to 6-hourly oral.
    • ​co-codamol 30/500 = codeine 30mg+Paracetamol 500mg

  • In order of increasing effectiveness, morphine sulphate may be given orally (oramorph), SC or IV.
  • Oramorph comes in 2 strengths (more concentrated rarely used) – so must specify, usually 10mg/5ml.
  • NSAIDs can be introduced at any stage (e.g. ibuprofen 400mg 8-hourly) regularly or ‘as required’ if no CI.
  • Neuropathic pain (arises from nerve damage or disease, usually shooting/stabbing/burning): amitriptyline 10mg oral night (1st line) → pregabalin 75mg oral 12-hourly.
    • Duloxetine 60mg oral nightly given if diabetic neuropathy.
  • Check paracetamol + co-codamol e.g. 2 co-codamol 30/500 6-hourly = 500 x 2 x 4 = 4000mg = 4g = maximum paracetamol level reached. Stop either of the drugs (paracetamol or co-codamol), dictated by patient’s pain.