COURSE NAME: PHARMACOLOGY COURSE DESCRIPTION: This course deals with pharmacodynamics, pharmacokinetics, clinical therapeutic uses and

toxicology. Emphasis is given on how drugs works to anticipate when giving a drug to a patient are of paramount importance since nursing responsibilities include administering drugs, assessing drug effects, intervening to make drug tolerable and providing teaching about drugs and the drug regimen. COURSE CREDIT: 3 units lecture CONTACT HOURS/SEM: 54 lecture hours PREPREQUISITE: Math 1, Chemistry, Anatomy and Physiology, NCM 102 PLACEMENT: 2nd year, 2nd semester COURSE OBJECTIVES: At the end of the course and given relevant actual or simulated situations/conditions, the student will be able to: 1. Apply concept and principles of pharmacology to ensure safe and proper use of drugs 2. Explain the action, therapeutic use, preparation, dosage, mode of administration of selected drugs and medicinal plants 3. State precautionary measures to be observed in the administration of selected drugs 4. Discuss the role and responsibility of the nurse in pharmacology COURSE OUTLINE: A. Introduction to Nursing Pharmacology 1. Introduction to Drugs a. Drugs and the Body b. Toxic Effects of Drugs c. Dosage Calculations 2. Chemotherapeutic Agents a. Anti-infective agents b. Antibiotic agents c. Antiviral agents d. Antifungal agents e. Antiprotozoal agents f. Antihelmintic agents g. Antineoplastic agents 3. Drugs acting on the Immune System a. Anti-inflammatory agents b. Immune modulators c. Vaccines and Sera

4. Drugs on the CNS and PNS a. Anxioloytic and Hypnotic agents b. Antidepressant agents c. Psychotherapeutic d. Antiepileptic agent agents e. Muscle relaxants f. Narcotics and anti-migraine drugs g. General and Local anesthetics h. Neuromuscular blocking agents 5. Drugs acting on the ANS a. Adrenergic agents b. Adrenergic blocking agents c. Cholinergic agents d. Cholinergic blocking agents 6. Drugs acting on the Endocrine System a. Hypothalamic and pituitary agents b. Adrenocortical agents c. Thyroid and parathyroid agents d. Antidiabetic agents 7. Drugs acting on the Cardiovascular System a. Anti-hypertensive drugs b. Cardiotonic agents c. Anti-arrhythmic agents d. Anti-anginal agents e. Drugs affecting blood coagulations f. Drug used to treat anemias 8. Drugs acting on the Renal System a. Diuretics such as potassium-sparing, potassium-losing, osmotic diuretics, parenteral fluids (hypotonic, hypertonic, isotonic), electrolytes (sodium, potassium chloride) 9. Drugs acting on the Respiratory System a. Bronchodilators b. Expectorants c. Antitussive 10. Drugs acting on the Gastrointestinal System

Principles of Drug Administration

After reading this chapter, the student should be able to: 1. Discuss medication administration as a component of safe, effective nursing care, utilizing the nursing process. 2. Describe the roles and responsibilities of the nurse regarding medication administration. 3. Explain how the five rights of medication administration impact patient safety. 4. Give specific examples of how the nurse can increase patient compliance in taking medications. 5. Interpret medication orders that contain abbreviations. 6. Compare and contrast the three systems of measurement used in pharmacology. 7. Explain the proper methods to administer enteral, topical, and parenteral medications. 8. Compare and contrast the advantages and disadvantages of each route of drug administration.

Chapter Outline
Medication Knowledge, Understanding, and Responsibilities of the Nurse The Rights of Drug Administration Patient Compliance and Successful Pharmacotherapy Medication Orders and Time Schedules Systems of Measurement Enteral Drug Administration Tablets and Capsules Sublingual and Buccal Drug Administration Nasogastric and Gastrostomy Drug Administration Topical Drug Administration Transdermal Delivery System Ophthalmic Administration Otic Administration Nasal Administration Vaginal Administration Rectal Administration Parenteral Drug Administration Intradermal and Subcutaneous Administration Intramuscular Administration Intravenous Administration
Pharmacokinetics

Objectives
After reading this chapter, the student should be able to:

1. Explain the applications of pharmacokinetics to clinical practice.

2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. Identify the four components of pharmacokinetics. Explain how substances travel across plasma membranes. Discuss factors affecting drug absorption. Explain the metabolism of drugs and its applications to pharmacotherapy. Discuss how drugs are distributed throughout the body. Describe how plasma proteins affect drug distribution. Identify major processes by which drugs are excreted. Explain how enterohepatic recirculation might affect drug activity. Explain the applications of a drugs plasma half-life (t1/2) to pharmacotherapy. Explain how a drug reaches and maintains its therapeutic range in the plasma. Differentiate between loading and maintenance doses.

Pharmacokinetics

Chapter Outline
13.

14. Pharmacokinetics: How the Body Handles Medications

15. 16. 17. 18. 19. 20. 21. The Passage of Drugs through Plasma Membranes Absorption of Medications Distribution of Medications Metabolism of Medications Excretion of Medications Relationship between Drug Plasma Concentration and Therapeutic Response Plasma Half-life and Duration of Drug Action 22. Loading Doses and Maintenance Doses

Pharmacokinetics

Expanded Key Concepts

5.1 Pharmacokinetics focuses on the movement of drugs throughout the body after they are administered. Pharmacokinetics is an area of pharmacology dealing with how drugs are handled by the body. It describes the barriers that drugs must penetrate to achieve therapeutic success. The four components of pharmacokinetics are: absorption, distribution, metabolism, and excretion. 5.2 The physiological properties of plasma membranes determine movement of drugs throughout the body. To be distributed to body tissues, drugs use diffusion and active transport to cross biological membranes. Drugs that are small, uncharged, and lipid soluble are distributed more completely than those that are large, ionized, and water-soluble. 5.3 Absorption is the process of moving a drug from the site of administration to the bloodstream.

Many factors affect drug movement including the type of drug formulation, drug-drug and drug-food interaction, GI and bloodstream factors, and properties of cellular membranes. Lipid solubility, ionization characteristics, and the pH of the dissolving or transport medium will also affect drug absorption. 5.4 Distribution represents how drugs are transported throughout the body. A drugs distribution is affected by variables such as lipid solubility, degree of ionization, and plasma protein binding. The blood-brain and fetal-placental barriers represent areas in the body where drug distribution may be limited. Lipid-soluble and non- ionized drugs easily cross these barriers; water-soluble and ionized drugs do not. 5.5 Metabolism is a process that changes a drugs activity and makes it more likely to be excreted. Metabolism is the process of chemically converting a drug to a form that is usually more easily excreted by the body. The hepatic microsomal enzyme system performs much of drug metabolism. The first-pass effect is important to pharmacotherapy because many drugs absorbed across the intestinal tract are routed directly to the liver, which deactivates them before they can be distributed to body tissues. Metabolic enzymes in the liver are less active in infants and geriatric patients. 5.6 Excretion processes remove drugs from the body. The kidneys, lungs, sweat glands, mammary glands, and biliary system are the major tissues eliminating drugs from the body. The main organ involved with excretion is the kidney. Enterohepatic recirculation is responsible for circulating bile and certain drugs back into the bloodstream from the gastrointestinal tract. 5.7 The therapeutic response of most drugs depends on their concentration in the plasma. In order to produce a therapeutic effect, most drugs must reach a minimum effective concentration in the plasma. If the plasma drug level becomes too high, a toxic concentration may be reached. The therapeutic range of a drug lies between the minimum effective level and the toxic level. 5.8 Plasma half-life represents the duration of action for most drugs. The length of time the body takes to reduce the plasma level of a drug to 50% of its peak value is its plasma half-life. Drugs with short half-lives must be given more frequently than those with long half-lives. 5.9 Repeated dosing allows a plateau drug plasma level to be reached. After multiple doses, drugs will reach a plateau level in the plasma (an equilibrium state where the amount of drug administered is equal to the amount excreted.) The equilibrium state may be reached faster through the use of loading doses. Pharmacokinetics

Audio Glossary
absorption the process of moving a drug across body membranes affinity chemical attraction that impels certain molecules to unite with others to form complexes blood-brain barrier an anatomical structure that prevents some substances from gaining access into the brain conjugates

side chains that, during metabolism, make drugs more water-soluble and more easily excreted by the kidney distribution the process of transporting drugs through the body drug-protein complex a drug that has bound reversibly to plasma proteins, particularly albumin, and is too large to cross capillary membranes, thus making the drug unavailable for distribution to body tissues enterohepatic recirculation recycling of drugs and other substances by the circulation of bile through the intestine and liver enzyme induction a process in which a drug causes changes in the function of the hepatic microsomal enzymes and increases metabolic activity in the liver excretion the process of removing substances from the body fetal-placental barrier placenta possesses special anatomical barriers that inhibit many chemicals and drugs from entering first-pass effect a mechanism whereby drugs are absorbed across the intestinal wall and enter into the hepatic portal circulation hepatic microsomal enzyme system as it relates to pharmacotherapy, the primary actions are to inactivate drugs and accelerate their excretion; sometimes called the P-450 system loading dose comparatively large dose given at the beginning of treatment to rapidly obtain the effect of a drug maintenance dose a dose that keeps the plasma drug concentration in the therapeutic range metabolism the sum total of all biochemical reactions in the body minimum effective concentration the amount of drug required to produce a therapeutic effect pharmacokinetics the study of how drugs are handled by the body plasma half-life (t 1/2 ) the length of time required for a drug to decrease concentration in the plasma by one-half after administration prodrug drug that becomes more active after it is metabolized therapeutic range the dosage range or serum concentration that achieves the desired drug effects toxic concentration the level of drug that will result in serious adverse effects Pharmacodynamics

Objectives
After reading this chapter, the student should be able to:

1. Identify applications of pharmacodynamics to clinical practice.

2. Discuss how frequency response curves may be used to explain how patients respond differently to medications. 3. Explain the importance of the median effective dose (ED50) to clinical practice. 4. Compare and contrast median lethal dose (LD50) and median toxicity dose (TD50). 5. Discuss how a drug's therapeutic index is related to its margin of safety. 6. Identify the significance of the graded doseresponse relationship to clinical practice. 7. Compare and contrast the terms potency and efficacy.

8. Distinguish between an agonist, partial agonist, and antagonist. 9. Explain the relationship between receptors and drug action. 10. Explain possible future developments in the field of pharmacogenetics. Pharmacodynamics

Chapter Outline
11.

12. Pharmacodynamics and Interpatient Variability

13. 14. 15. 16. 17. Therapeutic Index and Drug Safety The Graded Dose-Response Relationship and Therapeutic Potency and efficacy Cellular Receptors and Drug Action Competition for Receptors: Drug-Drug Interactions 18. Pharmacology of the Future: Customizing Drug Therapy Pharmacodynamics

Expanded Key Concepts

19.

20. 6.1 Pharmacodynamics is the area of pharmacology concerned with how drugs
produce change in patients and the differences in patient responses to medications. 21. Pharmacodynamics explains how drugs produce changes in the body. Interpatient variability to drug actions in a population may be represented by a frequency distribution curve. The median of the frequency distribution curve represents a drugs median effective dose (ED50), which is the average or standard dose of a medication. 22. 6.2 The therapeutic index, expressed mathematically as TD50 ED50, is a value representing the margin of safety of a drug. 23. The median lethal dose (LD50) and median toxicity dose (TD50) represent two separate doses that can harm patients in a similar group. A medications therapeutic index is expressed mathematically as TD50 ED50. The larger a medications therapeutic index, the greater is its margin of safety. 24. 6.3 The dose-response relationship describes how the therapeutic response from a drug changes as the medication dose is increased. 25. The graded dose-response curve illustrates how drug action is related to dose. At low doses, little action is measured. As the dose is increased, the dose and response exhibit a direct, linear relationship until a plateau is reached. This plateau indicates the maximum effect that can be achieved from the medication. 26. 6.4 Potency (the dose of medication required to produce a particular response) and efficacy (the magnitude of maximal response to a drug) are means of comparing medications. 27. Potency relates to the dose of medication required to produce a particular response; the higher the potency, the less dose is needed to produce a response. Efficacy refers to the magnitude of maximal response: the higher the efficacy, the greater the response. In most cases, the efficacy of a drug is more important to the patient and nurse than is the potency. 28. 6.5 Drug receptor theory is used to explain the mechanism of action of many medications. 29. Most responses to medications are caused by drug-receptor interactions. The majority of receptors are proteins located on the plasma cell membrane. Drug-receptor binding may trigger second-messenger systems inside the cell. Some drug responses are nonspecific and do not involve direct receptor interaction. 30. 6.6 Agonists, partial agonists, and antagonists are substances that compete with drugs for receptor binding and can cause drug-drug and drug-food interactions. 31. Drugs compete with endogenous substances and other medications for cellular receptors. Agonists are drugs that bind to a receptor and cause effects that mimic normal cell activities. Antagonists are drugs that bind to a receptor and inhibit normal cell activities.

32. 6.7 In the future, pharmacotherapy will likely be customized to match the genetic make-up of each patient. 33. DNA technologies are being developed that will identify those patients who are responsive to specific types of drug therapy. Pharmacogenetics is the application of genetics to pharmacology with the objective of individualizing therapy. Pharmacodynamics

Audio Glossary
34. 35. 36. 37. 38. 39. 40. 41. 42. 43. 44. 45. 46. 47. 48. 49. 50. 51. 52. 53. 54. agonist a drug that is capable of binding with receptors in order to induce a cellular response antagonist a drug that blocks the response of another drug efficacy the effectiveness of a drug in producing a more intense response as its concentration is increased frequency response curve a graphical representation that illustrates interpatient variability in responses to drugs graded dose-response a relationship between and measurement of the patient's response obtained at different doses of a drug idiosyncratic response an unpredictable and unexplained drug reaction median effective dose (ED50) the dose required to produce a specific therapeutic response in 50% of a group of patients median lethal dose (LD50) often determined in pre-clinical trials, the dose of drug that will be lethal in 50% of a group of animals median toxicity dose (TD50) the dose that will produce a given toxicity in 50% of a group of patients nonspecific cellular responses a drug response that is independent of cellular receptors, and not associated with other mechanisms, such as changing the permeability of cellular membranes, depressing membrane excitability or altering the activity of cellular pumps partial agonist a medication that produces a weaker, or less efficacious, response than an agonist pharmacodynamics the study of how the body responds to drugs and natural substances pharmacogenetics the area of pharmacology that examines the role of genetics in drug response potency the power or strength of a drug at a specified concentration or dose receptor the structural component of a cell to which a drug binds in a dose-related manner in order to produce a response second messenger cascades of biochemical events that initiate the drug's action by either stimulating or inhibiting a normal activity of the cell therapeutic index (TI) the ratio of a drug's LD50 to its ED50

55. 56. 57. 58. 59. 60. 61. 62. 63. 64. 65. 66. 67. 68.

Drug Administration throughout the Lifespan

Objectives
After reading this chapter, the student should be able to:

1. Understand basic concepts of human growth and development.

2. Explain how physical, cognitive, and psychomotor development influences pharmacotherapeutics. 3. Match the five pregnancy categories with their definitions. 4. Identify the importance of teaching the breastfeeding mother about prescription and OTC drug use, as well as the use of herbal products. 5. Describe physiological and biochemical changes that occur in the older adult, and how these affect pharmacotherapy. 6. Discuss the nursing and pharmacologic implications associated with each of the following developmental age groups: prenatal period, infancy, toddlerhood, preschoolers, school-age children, adolescence, young adults, middle-age adults, and older adults.

Drug Administration throughout the Lifespan

Chapter Outline
Pharmacotherapy Across the Lifespan Drug Administration During Pregnancy and Lactation Drug Administration During Infancy Pharmacotherapy of Toddlers Pharmacotherapy of Preschoolers and School-Aged Children Pharmacotherapy of Adolescents Pharmacotherapy of Young and Middle-Aged Adults Pharmacotherapy of the Older Adult

Drug Administration throughout the Lifespan

Expanded Key Concepts

7.1 In order to contribute to safe and effective pharmacotherapy, it is essential for the nurse to comprehend and apply fundamental concepts of growth and development. Nurses must possess an understanding of what is considered normal, in terms of growth and

developmental patterns, so that deviations from the norm can be identified and health pattern impairments can be appropriately addressed. The very nature of pharmacology requires that the practitioner consider the specifics of age, growth, development, and weight in relation to pharmacokinetics and pharmacodynamics. 7.2 Pharmacotherapy during pregnancy should be conducted only when the benefits to the mother outweigh the potential risks to the fetus. Pregnancy Categories guide the practitioner in prescribing drugs for these patients. Breastfeeding patients must be aware that drugs and other substances can appear in milk and affect their infant. Chemicals derived from foods and drugs ingested by the mother may traverse the placental barrier and affect the developing baby. An in-depth nursing and pharmacologic history and prenatal assessment are vital so that drugs can be eliminated, substituted or dosages adjusted. Pregnancy Categories have been developed by the FDA to assess potential risk to the fetus. Breast-feeding patients must be aware that drugs and other substances can appear in milk and affect their infant. 7.3 During infancy, pharmacotherapy is directed toward the safety of the child and teaching the mother how to properly administer medications and care for the infant. Infants require special treatment due to their small size and their immature physiologic and biochemical processes. Mothers breastfeeding their infants must be counseled regarding the possibility of drugs entering their milk and affecting their baby. 7.4 Drug administration to toddlers can be challenging. Short, concrete explanations followed by immediate drug administration are usually best for the toddler. During the toddler stage, there is a tremendous sense of curiosity and this becomes a major concern for medication safety as well as household product safety. Toddlers can swallow liquids and usually chew tablets. Restraint may be required, particularly when administering parenteral medications. 7.5 Preschool and younger school age children can begin to assist with medication administration. During the early school years, children begin to realize the benefits of medications and the reasons why medications are needed. The nurse should give the child a sense of control over drug administration, while still being firm and giving the child praise for cooperation. 7.6 Pharmacologic compliance in the adolescent is dependent upon an understanding and respect for the uniqueness of the person in this stage of growth and development. Adolescents are very concerned with physical appearance and peer approval. Common indications for pharmacotherapy in this group includes: skin conditions, headaches, menstrual irregularities, and sports injuries. The use of tobacco and illicit drugs is a major concern. The nurse should respect a teens need for independence and privacy. 7.7 Young adults comprise the healthiest age group and generally need few prescription medications. Middle age adults begin to suffer from stress-related illness such as hypertension. Younger and middle-aged adults generally need little pharmacotherapy, relative to older adults. In females, contraception and complications associated with pregnancy are of major concern. In the middleaged adult, cardiovascular concerns such as hypertension become important. 7.8 Older adults take more medications and experience more adverse drug events than any other age group. For drug therapy to be successful, the nurse must make accommodations for age-related changes

in physiological and biochemical functions. The older adult is faced with numerous physical challenges, which become targets for pharmacotherapy. Changes in liver and kidney function make pharmacotherapy more risky. Cardiovascular disease becomes a major indication for pharmacotherapy.

Drug Administration throughout the Lifespan

Audio Glossary
adolescence person from 13 to 16 years of age infant child under the age of 1 year middle age adulthood person from 40 to 65 years of age older adulthood person over age 65 polypharmacy the taking of multiple drugs concurrently prenatal preceding birth preschool child child from 3 to 5 years of age school-age child child from 6 to 12 years of age teratogen drug or other agent that causes developmental birth defects toddlerhood child from 1 to 3 years of age young adulthood person from 18 to 40 years of age The Nursing Process in Pharmacology

Objectives
After reading this chapter, the student should be able to:

1. Describe the steps of the Nursing Process.

2. 3. 4. 5. 6. 7. Identify assessment data to be gathered pertinent to medication administration. Develop appropriate nursing diagnoses for patients receiving medications. Set realistic goals and outcomes during the planning stage for patients receiving medications. Discuss key intervention strategies to be carried out for patients receiving medications. Evaluate the outcomes of medication administration. When giving medications, apply the Nursing Process using the Nursing Process Focus flowcharts found in Chapters 13 through 48.

The Nursing Process in Pharmacology

Chapter Outline
8.

9. Review of the Nursing Process

10. Assessment of the Patient Related to Drug Administration 11. Nursing Diagnoses for the Patient Receiving Medications

12. Setting Goals and Outcomes to Plan for the Care of a Patient Receiving Medications 13. Key Interventions to be Accomplished for the Patient Receiving Medications 14. Evaluating the Effects of Drug Administration The Nursing Process in Pharmacology

Expanded Key Concepts

15.

16. 8.1 The Nursing Process is a systematic method of problem-solving and consists of clearly
17. defined steps: assessment, establishment of nursing diagnoses, planning care through the formulation of goals and outcomes, carrying out interventions, and evaluating the care provided. The steps of the nursing process include assessment, development of nursing diagnoses, identification of goals and outcomes, planning care, implementing interventions and evaluating the plan of care. Pharmacology requires the use of the Nursing Process to ensure the best possible outcomes for the patient. 8.2 Assessment of the patient related to medication administration includes health history information, physical assessment data, lab values and other measurable data. It also includes an assessment of medication effects: therapeutic, side or adverse effects. Assessment is the collection of objective and subjective data. This is acquired starting with the initial health history and continues on an ongoing basis during treatment. 8.3 Nursing diagnoses are written that address the patients responses related to medication administration. They are developed after an analysis of the assessment data. The diagnoses are focused on the patients problems or potential problems and are verified with the patient or caregiver. After analyzing the assessment data, the nurse formulates patient-specific nursing diagnoses appropriate for the medications used. These diagnoses will form the basis for the other steps in the Nursing Process. Two of the most common nursing diagnoses that may be established for medication administration are knowledge deficit and noncompliance. 8.4 Goals and outcomes are developed from the nursing diagnoses that will direct the interventions required by the plan of care. Goals focus on what the patient should be able to achieve and outcomes provide the specific, measurable criteria that nurses will use to measure goal attainment. After gathering patient assessment data and formulating nursing diagnoses, goals and outcomes are developed and priorities are established that will assist the nurse in planning care, carrying out interventions, and evaluating the effectiveness of that care. Goals and outcomes may be developed for the short-term or long-term, depending on the specific situation. 8.5 Interventions are aimed at returning the patient to an optimum level of wellness through the safe and effective administration of medications. Key interventions required of the nurse include monitoring drug effects, documenting medications, and patient education. Interventions are aimed at returning the patient to an optimum level of wellness and limiting adverse effects related to the patients condition. Key components of implementation include monitoring and documentation of drug effects, and patient education. 8.6 Evaluation begins a new cycle as new assessment data is gathered and analyzed, nursing diagnoses are reviewed or rewritten, goals and outcomes refined, and new interventions are implemented. Evaluation is the final step of the Nursing Process. It considers the effectiveness of the plan of care and interventions in meeting established goals and outcomes.

18.

19. 20.

21.

22.

23.

24.

25.

26.

27.

The Nursing Process in Pharmacology

Audio Glossary
assessment appraisal of a patient's condition that involves gathering and interpreting data

baseline data patient information that is gathered before pharmacotherapy is implemented evaluation systematic, objective assessment of the effectiveness and impact of interventions goal any object or objective that the patient or nurse seeks to attain or achieve interventions action that produces an effect or that is intended to alter the course of a disease or condition nursing diagnosis clinical-based judgments about the patient and their responses to health and illness nursing process a five-part systematic decision-making method that includes assessment, nursing diagnosis, planning, implementation, and evaluation objective data information gathered through physical assessment, laboratory tests, and other diagnostic sources outcome objective measures of goals planning links strategies, or interventions, to established goals and outcomes subjective data information gathered regarding what a patient states or perceives Legal and Ethical Issues Related to Medication Administration

Objectives
After reading this chapter, the student should be able to:

1. Explain how the ethical principles contained in the ANA Code of Ethics are used to guide nurses
2. 3. 4. 5. 6. 7. 8. in their practice. Apply general moral principles to the effective administration of medications. Describe how Nurse Practice Acts are designed to protect the public. Discuss the standards of care in the application of the nursing process. Explain the importance of documentation in the administration of medications. Discuss factors contributing to medication errors. Identify the process in reporting medication errors. Discuss strategies that the nurse may implement to prevent medication errors.

Legal and Ethical Issues Related to Medication Administration

Chapter Outline
9.

10. Medical ethics and nursing practice

11. 12. 13. 14. 15. Moral Principles Guiding Medication Administration Nurse Practice Acts and Standards of Care Documentation of Medication Administration Medication Errors Reporting Medication Errors Preventing Medication Errors

16. 17.

Legal and Ethical Issues Related to Medication Administration

Expanded Key Concepts

18.

19. 9.1 The American Nurses Association publishes a list of ethical principles that nurses can use to
guide their decision making. 20. Ethics (the moral principles guiding a persons conduct) are learned early in life through religious affiliations, family, role models, and peers. The ANA Code of Ethics provides guidance to nurses in their professional conduct and in decision- making. 21. 9.2 Moral principles such as beneficence, non-maleficent behavior, veracity, autonomy, justice, and fidelity are necessary for the nurse to apply in medication administration. 22. When making ethical decisions in clinical practice, the nurse uses fundamental moral principles. Three of the most important principles are: promote the most good for the patient (beneficence), do not harm the patient (non-maleficent behavior), and allowing the patient the informed right to choose the course of their care (autonomy). 23. 9.3 Nurse practice acts are enacted by every state to define the scope of practice of professional nursing and to protect the public. 24. The State nursing practice acts define the standard of care for practicing nurses. In essence, they define what a nurse can and cannot do. Standards of care state the minimum competency for proficiency in nursing and should be consulted frequently. 25. 9.4 Documentation of medication administration, including any errors, should be completed immediately after the patient takes the drug. 26. Medication use is documented in the MAR. Nurses frequently check the physicians orders against the MAR to be certain the correct drugs have been administered. 27. 9.5 A medication error is a preventable error that may cause or lead to an adverse reaction to the patient. Causes may include omission of one of the five rights or giving medications based on verbal, illegible or incomplete orders. 28. Medication errors can result in serious injury to the patient and litigation for the nurse and healthcare agency. The nurse must ensure that orders are carried out accurately and that every measure is taken to avoid errors. 29. 9.6 It is the ethical and legal responsibility of the nurse to report any medication errors that might have occurred. 30. Documentation of medication errors is necessary for patient safety. Several national organizations contain databases of medication errors that can assist nurses and healthcare agencies formulate better policies. 31. 9.7 Finding strategies to prevent of medication errors involves many different processes, including the nursing process. 32. Use of the nursing process can help reduce the number of medication errors. Nurses should work and collaborate with others on the healthcare team to develop agency policies for the storage and handling of medicines. Legal and Ethical Issues Related to Medication Administration

Audio Glossary
33. 34. 35. 36. 37. 38. 39. 40. 41. 42. 43. 44. 45. 46. 47. autonomy able to make decisions unaided by others beneficence the ethical principle of doing good ethics branch of philosophy that deals with distinguishing between right and wrong, and the moral consequences of human actions ethical dilemma a situation where two moral situations appear to be in conflict fidelity the obligation to be faithful to agreements and fulfill promises justice ethical principle that persons who have similar circumstances should be treated alike Medication Administration Record (MAR) documentation of all pharmacotherapies received by the patient

48. medication error 49. any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the health care professional, patient, or consumer 50. nonmaleficence 51. the ethical obligation to not harm the patient 52. Nurse Practice Act 53. legislation designed to protect the public by defining the legal scope of practice 54. standards of care 55. the skills and learning commonly possessed by members of a profession 56. veracity 57. the ethical obligation to tell the truth Drugs Affecting the Autonomic Nervous System

Objectives
After reading this chapter, the student should be able to:

1. Identify the two fundamental divisions of the nervous system.

2. Identify the three primary functions of the nervous system. 3. Compare and contrast the actions of the sympathetic and parasympathetic nervous systems. 4. Explain the process of synaptic transmission and the neurotransmitters important to the autonomic nervous system. 5. Compare and contrast the types of responses that occur when a drug activates alpha1, alpha2, beta1, or beta2adrenergic receptors. 6. Describe the nurses role in the pharmacological management of patients receiving medications affecting the autonomic nervous system. 7. For each of the drug classes listed in Drugs at a Glance, explain the mechanism of drug action, primary actions, and important adverse effects. 8. Use the nursing process to care for patients receiving parasympathomimetics, anticholinergics, sympathomimetics, and adrenergic-blockers.

Drugs Affecting the Autonomic Nervous System

Chapter Outline
The Peripheral Nervous System The Autonomic Nervous System: Sympathetic and Parasympathetic Branches Structure and Function of Synapses Acetylcholine and Cholinergic Transmission Norepinephrine and Adrenergic Transmission Classification and Naming of Autonomic Drugs Clinical Applications of Parasympathomimetics Clinical Applications of Anticholinergics

Clinical Applications of Sympathomimetics Clinical Applications of Adrenergic Antagonists Drugs Affecting the Autonomic Nervous System

Expanded Key Concepts

13.1 The peripheral nervous system is divided into a somatic portion, which is under voluntary control and an autonomic portion, which is involuntary and controls smooth muscle, cardiac muscle, and glandular secretion. The nervous system has two primary divisions: central and peripheral. The peripheral nervous system consists of all nerves lying outside the brain and spinal cord. It consists of a voluntary portion (somatic) and an involuntary portion (autonomic). The autonomic division controls smooth muscle, cardiac muscle and glandular secretion and is a frequent target for drug action. 13.2 Stimulation of the sympathetic division of the autonomic nervous system causes symptoms of the fight-or-flight response, whereas stimulation of the parasympathetic branch induces rest-and-digest responses. Symptoms of the fight-or-flight response, such as increased heart rate and blood pressure and decreased peristalsis, are produced by activation of the sympathetic nerves. Stimulation of the parasympathetic nerves induces the rest-and-relaxation response, with symptoms such as slowed heart rate and blood pressure and increased peristalsis. With few exceptions, the actions of the two divisions are opposite of each other. Homeostasis requires a proper balance of the two branches. 13.3 Drugs can affect nervous transmission across a synapse by preventing the storage or release of the neurotransmitter, binding receptors for the neurotransmitter or by preventing the destruction of the neurotransmitter. Synapses consist of a presynaptic neuron and a postsynaptic neuron separated by a physical space called the synaptic cleft. Neurotransmitters cross this synaptic cleft to regenerate nerve impulse. This nervous impulse is carried to a neuroeffector junction, where an action potential is initiated. Drugs may be used to affect the synthesis, storage, release, binding or destruction of the neurotransmitter. Altering neurotransmitter balance can have profound effects on the target tissue. 13.4 Acetylcholine is the primary neurotransmitter released at cholinergic receptors (nicotinic and muscarinic) in both the sympathetic and parasympathetic nervous systems. It is also the neurotransmitter at nicotinic receptors in skeletal muscle. Acetylcholine is the neurotransmitter released at the end of all the presynaptic nerves (ganglia) and the postganglionic nerves in the parasympathetic nervous system. It is also released by the sweat glands and is present in skeletal muscle. Cholinergic receptors are classified as nicotinic or muscarinic. Acetylcholine is synthesized from choline and acetyl coenzyme A and is destroyed by the enzyme acetylcholinesterase. 13.5 Norepinephrine is the primary neurotransmitter released by adrenergic receptors, which are divided into alpha and beta subtypes. Norepinephrine is the neurotransmitter released by muscarinic receptors in the sympathetic nervous system. Adrenergic receptors may be alpha or beta subtypes. Norepinephrine is synthesized from tyrosine. Its action is terminated through reuptake. Epinephrine and dopamine are two other neurotransmitters.

13.6 Autonomic drugs are classified by which receptors they stimulate or block. Sympathomimetics stimulate sympathetic nerves and parasympathomimetics stimulate parasympathetic nerves. Adrenergic antagonists inhibit the sympathetic division, whereas anticholinergics inhibit the parasympathetic branch. Sympathomimetics stimulate sympathetic nerves and parasympathomimetics primarily stimulate parasympathetic nerves. Adrenergic-blockers inhibit the sympathetic division, whereas cholinergicblockers mostly inhibit the parasympathetic branch. 13.7 Parasympathomimetics act directly by stimulating cholinergic receptors or indirectly by inhibiting acetylcholinesterase. They have few therapeutic uses because of their numerous side effects. A few parasympathomimetic agents in this class are used in ophthalmology or to stimulate the urinary or digestive tracts following general anesthesia. Some are used for their effects as acetylcholine receptors in skeletal muscle for the treatment of myasthenia gravis. 13.8 Anticholinergics act by blocking the effects of acetylcholine at muscarinic receptors and are used to dry secretions, treat asthma, and prevent motion sickness. The use of anticholinergics or cholinergic-blockers has declined due to their numerous side effects. They are occasionally prescribed to accelerate heart rate, dry secretions, dilate the bronchi, and dilate the pupil. 13.9 Sympathomimetics act by directly activating adrenergic receptors or indirectly by increasing the release of norepinephrine from nerve terminals. They are primarily used for their effects on the heart, bronchial tree, and nasal passages. Adrenergic receptors are divided into alpha and beta subtypes. The drug effects depend upon which subreceptor is activated. Uses include increasing the heart rate, raising blood pressure, dilating the bronchi, and drying excess secretions caused by the common cold. 13.10 Adrenergic antagonists are primarily used for hypertension and are the most widely prescribed class of autonomic drugs. Adrenergic-blockers comprise the most frequently prescribed autonomic medications. They may be selective for only one receptor subtype, such as the beta1-blockers or inhibit several subtypes. Hypertension is their primary indication. Drugs Affecting the Autonomic Nervous System

Audio Glossary
acetylcholine primary neurotransmitter of the parasympathetic nervous system; also present at somatic neuromuscular junctions and at sympathetic preganglionic nerves acetylcholinesterase (AchE) enzyme that degrades acetylcholine in the synaptic cleft adrenergic term relating to nerves that release norepinephrine or epinephrine alpha-receptor type of subreceptor found in the sympathetic nervous system anticholinergic drug that blocks the actions of the parasympathetic nervous system autonomic nervous system

portion of the peripheral nervous system that gives involuntary control over smooth muscle, cardiac muscle and glands beta-receptor type of subreceptor found in the sympathetic nervous system catecholamines a class of endogenous agents central nervous system (CNS) division of the nervous system consisting of the brain and spinal cord cholinergic term relating to nerves that release acetylcholine fight-or-flight response signs and symptoms produced when the sympathetic nervous system is activated ganglion a connection of neuron cell bodies located outside the CNS monoamine oxidase (MAO) enzyme that destroys norepinephrine in the nerve terminal muscarinic type of cholinergic receptor found in smooth muscle, cardiac muscle and glands myasthenia gravis disease characterized by a destruction of nicotinic receptors on skeletal muscles nicotinic type of cholinergic receptor found in ganglia of both the sympathetic and parasympathetic nervous systems norepinephrine (NE) primary neurotransmitter in the sympathetic nervous system parasympathetic nervous system portion of the autonomic system that is active during periods of rest and results in the rest or relaxation response parasympathomimetics drugs that mimic the actions of the parasympathetic nervous system peripheral nervous system division of the nervous system containing all nervous tissue outside the CNS, including the autonomic nervous system postsynaptic neuron nerve that has receptors for the neurotransmitter in the synapse presynaptic neuron nerve that releases the neurotransmitter into the synaptic cleft rest-and-digest response signs and symptoms produced when the parasympathetic nervous system is activated somatic nervous system nerves that provide voluntary control over skeletal muscle sympathetic nervous system portion of the autonomic system that is active during periods of stress and results in the fight or flight response sympathomimetic drug that stimulates or mimics the sympathetic nervous system synapse junction between two neurons consisting of a presynaptic nerve, a synaptic cleft and a postsynaptic nerve synaptic transmission