Concept of Medication Therapy

By Arif Muttaqin, S. Kep, Ns, MMRS

Drug Names
Chemical name
Describes the drugs chemical composition and molecular structure Generic name (nonproprietary name) Name given by the United States Adopted Name Council Trade name (proprietary name) The drug has a registered trademark; use of the name restricted by the drugs patent owner (usually the manufacturer)

Drug Names (cont'd)

Chemical name
(+/-)-2-(p-isobutylphenyl) propionic acid

Generic name
ibuprofen

Trade name
Motrin, Advil

Quality use of medicine

The quality use of medicines refers to the process of:
selecting patient management options wisely choosing suitable medicines if a medicine is considered necessary using medicines safely and effectively.

This definition of quality use of medicine not only applies to medicines in the general practice setting, but also to all medicines used by individual patients that can affect their health. This whole-health system view is necessary as general practice patients obtain their medications from a range of sources such as those initiated by themselves, other general practitioners, other medical specialists, pharmacists and complementary therapists.

Pharmacokinetics
Pharmacokinetics is the way the body acts on the drug once it is administered. It is the measure of the rate (kinetics) of absorption, distribution, metabolism and excretion (ADME).

Absorption
Absorption is the movement of a drug from its site of administration into the blood. Most drugs are absorbed by passive absorption but some drugs need carrier mediated transport. Small molecules diffuse more rapidly than large molecules. Lipid soluble non ionized drugs are absorbed faster. Absorption is affected by blood flow, pain stress etc.

Absorption
Acidic drugs such as asprin will be better absorbed in the stomach whereas basic drug ike morphine will be absorbed better in the intestine. Most of the absorption of the drug takes place in the small intestine. Since the surface area of the stomach is much smaller than that of the intestine. Most of the drugs are absorbed in the small intestine since the amount of time that the drugs spend in the stomach is less and also the surface area of the stomach is small. If a basic drug is taken after a meal then the activity of the drug can be reduced whereas if an acidic drug is taken after a meal then the action of the can be noticed much more quickly, owing to the gastric absorption. For a drug even though lipophilic to be absorbed in the intestine some portion of it needs to be dissolved in the intestinal juices which are aqueous. There are some substances that are partly soluble in water and it is these that will be absorbed and then an equivalent amount will be absorbed from the undissolved portion. Thus complete absorption will take place. There are bile salts present in the intestine which will aid in salvation of the drug and their resultant absorption. Drugs that are amphipathic have no problem in getting absorbed. There are some drugs that are completely insoluble in water such drugs float as globules in the intestine but the bile salts will emulsify these into small enough particles such that absorption can take place. E.g. vitamins. Some of the drugs are similar to compounds found in the body for e.g. thyroxine and such drugs can be absorbed into the system by active transport. When drugs are injected into the muscle, subcutaneous layer absorption still has to take place but it is less dependent on the chemical nature of the drugs since the drugs are absorbed into the circulatory system through the small pores in the capillary walls.

Distribution
Distribution is the movement of drugs throughout the body. Determined by the blood flow to the tissues, it is ability of the drug to enter the vasculature system and the ability of the drug to enter the cell if required.

Plasma Protein Binding

The blood stream has the ability to transport relatively insoluble substances. These substances are transferred by binding to the proteins which have a very amphipathic structure. The hydrophilic group renders the protein soluble in water and the lipophilic compounds are attracted to the lipophilic group and are loosely bound to the protein molecule hence protein bound. Most of the drugs travel in the plasma are partly in solution and partly bound to the plasma protein. The bound drug is inactive and the unbound drug is active. The ratio of bound to the unbound drug varies. Binding is reversible. Generally acidic drugs bind to albumin and basic drugs to 1 acid glycoprotein. Diseased state can cause a problem on the effectiveness of the drug. As globin levels increase with age this factor should be taken into account when treating an elderly person with a basic drug. The protein bound drug is in equilibrium with the free drug. That means that once the free drug enters the target tissue then the protein bound drug will be released to maintain equilibrium. If two drugs bind at the same site of the protein and are administered together then there can be problems. e.g. Warfarin and asprin.. asprin displaces warfarin from its bound protein as a result of which there are elevated levels of warfarin in the unbound state and this can lead to warfarin toxicity.

Tissue Distribution

After absorption most drugs are distributed in the blood to the body tissue where they have their effect. The degree to which the drug is likely to accumulate in the tissue is dependent on the lipophilicity and local blood flow to the tissue. Highly perfused organs receive most of the drugs.

The role of the liver in drug distribution

After the drug is absorbed by the GI tract, it is taken up by the part of the bloodstream called the hepatic portal system. Most of the drugs are absorbed into this system except for the lipids which are absorbed into the lymphatic system and then delivered into the blood by the thoracic duct into the superior vena cava. The hepatic portal system is designed to take digested foodstuff into the liver where it can be processed, in some cases it is stored before being distributed and it is possible that this may happen to the drug and the drug would be metabolized before reaching the rest of the body. Such drugs that metabolized by the liver are said to have a high hepatic first pass. Hence drugs with a very high hepatic first pass cannot be given orally.

The BloodBrain Barrier (BBB)

The capillaries in the CNS are different they have pores which are sealed by the connective tissue and hence only small molecules can cross the blood brain barrier and the substances that can cross over have to be very lipophilic in nature. The blood-brain barrier (BBB) is the protective mechanism of the CNS and is not present everywhere in the brain. This is sometimes useful as it avoids some drugs from crossing the CNS and causing deleterious effects. E.g. neuromuscular blocking agents. Sometimes the blood brain barrier allows the transport of drugs resulting in unwanted effect for e.g. antihistamines cross the bbb and result in drowsiness, now there are antihistamines that are made that are not so lipophilic in nature.

Metabolism or Biotransformation
It is the process of transformation of a drug within the body to make it more hydrophilic so that it can be excreted out from the body by the kidneys. This needs to be done since drugs and chemicals are foreign substances in our body. If the drug continues to be in the lipohilic state and is going to be filtered by the glomerulus then it will be reabsorbed and remain in the body for prolonged periods. Hence metabolism deals with making the drug more hydrophilic such that it can be excreted out from the body. In some cases the metabolites can be more active than the drug itself e.g. anxiolytic benzodiazepines. Some enzymes are highly specific and will breakdown only compounds that they recognize for e.g. glucose dehydrogenase. But there are some enzymes such as pepsin which are not specific and will breakdown most soluble proteins into smaller polypeptides or amino acids. This enzyme and many other proteolytic enzymes attack the peptide bond that joins the amino acids to make proteins, and in this way break the protein down.

Two types of enzymes are involved in metabolism:

Phase I Metabolism
These enzymes modify the drug chemically by processes such as oxidation, reduction and hydrolysis or by the removal and addition of an active group.

Phase II Metabolism
These include the conjugation of a drug or a phase I metabolite with a polar group to render it possible for excretion. e.g. sulphates and glucuronide

The deconjugation of the drug by bacterial enzymes is called the enterohepatic cycle. Sometimes this deconjugation can lead to increased levels of drugs in the body. But some times due to treatment with antibiotics there may be less or no deconjugation as a result of which there will be less drug in the body. Principal sites of metabolism are Liver and Kidney and once the drug is rendered hydrophilic they can be easily excreted out by the bile and urine without significant reabsorption.

Enzyme
Enzyme Induction
There are some drugs that can lead to an increase in the production of the enzyme and as a result speed up the metabolism of the drug and hence a higher dose of the drug is required to achieve the therapeutic effect.

Enzyme Inhibition
Some drugs result in the inhibition of certain enzymes and as a result there is an accumulation of the drug in the body and can lead to drug toxicity. This is also a form of drug drug interaction.

Excretion
Excretion is the removal of the substance from the body. Some drugs are either excreted out unchanged or some are excreted out as metabolites in urine or bile. Drugs may also leave the body by natural routes such as tears, sweat, breath and saliva. Patients with kidney or liver problem can have elevated levels of drug in the system and it may be necessary to monitor the dose of the drug appropriately since a high dose in the blood can lead to drug

1.

You are caring for a client who has diabetes complicated by kidney disease. You will need to make a detailed assessment when administering medications because this client may experience problems with:
A. B. C. D. Absorption Biotransformation Distribution Excretion

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Pharmacodynamics
Study of the mechanism of drug actions in living tissue Drug-induced alterations to normal physiologic function Positive change-Therapeutic effect-Goal of therapy

Mechanism of Action
Ways in which a drug can produce a therapeutic effect The effects that a particular drug has depends on the cells or organ targeted by the drug Once the drug hits its site of action it can modify the rate at which a cell or tissue functions

Mechanism of Action
Receptor Interaction Enzyme Interaction Non-Specific Interaction

Receptor Interaction
Drug structure is essential Involves the selective joining of drug molecule with a reactive site on the cell surface that elicits a biological effect Receptor is the reactive site on a cell or tissue Once the substance binds to and interacts with the receptor, a pharmacologic response is produced

Receptor Interaction
Affinity- degree to which a drug binds with a receptor The drug with the best fit or affinity will elicit the best response Drug can mimic bodys endogenous substances that normally bind to receptor site Drugs that bind to receptors interact with receptors in different ways to either block or elicit a response

Receptor Interaction
Agonist-Drug binds to receptor-there is a response (Adrenergic Agents) Antagonist-drug binds to receptor-no response-prevents binding of agonists (Alpha & Beta Blockers)

Enzyme Interaction
Enzymes are substances that catalyze nearly every biochemical reaction in a cell Drugs can interact with enzyme systems to alter a response Inhibits action of enzymes-enzyme is fooled into binding to drug instead of target cell Protects target cell from enzymes action (ACE Inhibitors)

Non-Specific Interaction
Not involving a receptor site or alteration in enzyme function Main site of action is cell membrane or cellular process Drugs will physically interfere or chemically alter cell process Final product is altered causing defect or cell death Cancer drugs, Antibiotics

The nurse is giving a medication that has a high first-pass effect. The physician has changed the route from IV to PO. The nurse expects the oral dose to be: 1. Higher because of the first-pass effect. 2. Lower because of the first-pass effect. 3. The same as the IV dose. 4. Unchanged.

Type of Medication Action

Therapeutic Effect Side Effects Adverse Effects Toxic Effect Idiosyncratic Reactions Allergic Reaction Medication Interactions Iatrogenic Response

Therapeutic Effect
The expected or predictable physiological response a medication causes A single med can have several therapeutic effects (Aspirin) It is important for the nurse to know why med is being prescribed

Side Effects
Unintended secondary effects a medication predictably will cause May be harmless or serious If side effects are serious enough to negate the beneficial effect of meds therapeutic action, it may be D/Cd People may stop taking medications because of the side effects

Adverse Effects
Undesirable response of a medication Unexpected effects of drug not related to therapeutic effect Must be reported to FDA Can be a side effect or a harmful effect Can be categorized as pharmacologic, idiosyncratic, hypersensitivity, or drug interaction

Adverse Effects
Adverse Drug Events Adverse Drug Reactions (ADR)

Toxic Effect
May develop after prolonged intake or when a med accumulates in the blood because of impaired metabolism or excretion, or excessive amount taken Toxic levels of opioids can cause resp.depression Antidotes available to reverse effects

Idiosyncratic Reactions
Unpredictable effects-overreacts or under reacts to a medication or has a reaction different from normal Genetically determined abnormal response Idiosyncratic drug reactions are usually caused by abnormal levels of drug-metabolizing enzymes (deficiency or overabundance)

Allergic Reaction
Unpredictable response to a medication Makes up greater than 10% of all medication reactions Client may become sensitized immunologically to the initial dose, repeated administration causes an allergic response to the med, chemical preservative or a metabolite

Allergic Reaction
Medication acts as an antigen triggering the release of the bodys antibodies May be mild or severe Among the different classes of meds, antibiotics cause the highest incidence of allergic reaction Severe reaction-Anaphylactic reaction Mild reaction-hives, rash, pruritis

Other Drug Reactions

Teratogenic-Structural effect in unborn fetus (thalidomide) Carcinogenic-Causes cancer Mutagenic- Changes genetic composition (radiation, chemicals)

Drug Interactions
Occurs when one med modifies the action of another Common in people taking several medications at once One med may potentiate or diminish the action of another or alter the way it is absorbed, metabolized or eliminated

Iatrogenic Responses
Unintentional adverse effects that occur during therapy Treatment-Induced Dermatologic-rash, hives, acne Renal Damage-Aminoglycoside antibiotics, NSAIDS, contrast medium Blood Dyscrasias- Destruction of blood cells (Chemotherapy) Hepatic Toxicity-Elevated liver enzymes (hepatitis-like symptoms)

Synergistic Effect
Effect of 2 meds combined is greater than the meds given separately Alcohol & Antihistamines, antidepressants, barbiturates, narcotics Not always undesirable, physician may combine meds to create an interaction that will have beneficial effects (Vasodilators & diuretics to control high BP)

Medication Dose Responses

Except when administered IV, meds take time to enter bloodstream The quantity & distribution of med in different body compartments change constantly Goal is to keep constant blood level within a safe therapeutic range Repeated doses are required to achieve a constant therapeutic concentration of a med because a portion of med is always being excreted

Medication Dose Responses

Serum Half-Life:Time it takes for excretion processes to lower the serum medication concentration by Regular fixed doses must be given to maintain therapeutic concentration Dosage schedules set by institutions (TID, q8h, HS, AC, STAT, PRN) Peak & Trough levels Therapeutic drug monitoring

Half-life
The time it takes for one half of the original amount of a drug in the body to be removed A measure of the rate at which drugs are removed from the body

Onset, Peak, and Duration

Onset
The time it takes for the drug to elicit a therapeutic response

Peak
The time it takes for a drug to reach its maximum therapeutic response

Duration
The time a drug concentration is sufficient to elicit a therapeutic response

Pharmacotherapeutics: Types of Therapies

Acute therapy Maintenance therapy Supplemental therapy Palliative therapy Supportive therapy Prophylactic therapy

Monitoring
The effectiveness of the drug therapy must be evaluated One must be familiar with the drugs:
Intended therapeutic action (beneficial) Unintended but potential side effects (predictable, adverse reactions)

Monitoring (cont'd)
Therapeutic index
The ratio between a drugs therapeutic effects Interactions may occur with other drugs or food
Drug interactions: the alteration of action of a drug by: Other prescribed drugs Over-the-counter medications Herbal therapies

benefits and its toxic

Drug interactions
Additive effect Synergistic effect Antagonistic effect Incompatibility

Monitoring (cont'd)
Medication misadventures
Adverse drug events Adverse drug reactions Medication errors

Monitoring (cont'd)
Some adverse drug reactions are classified as side effects
Expected, well-known reactions that result in little or no change in patient management Predictable frequency The effects intensity and occurrence are related to the size of the dose

Adverse Drug Reaction

An adverse outcome of drug therapy in which a patient is harmed in some way
Pharmacologic reactions Idiosyncratic reactions Hypersensitivity reactions Drug interactions

Other Drug-Related Effects

Teratogenic Mutagenic Carcinogenic

Toxicology
The study of poisons and unwanted responses to therapeutic agents

Table 2-9 Common Poisons and Antidotes

 2. A postoperative client is receiving morphine sulfate via a PCA. The nurse assesses that the clients respirations are depressed. The effects of the morphine sulfate can be classified as: A. Allergic B. Idiosyncratic C. Therapeutic D. Toxic

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First-Pass Effect
The metabolism of a drug and its passage from the liver into the circulation
A drug given via the oral route may be extensively metabolized by the liver before reaching the systemic circulation (high firstpass effect) The same druggiven IVbypasses the liver, preventing the firstpass effect from taking place, and more drug reaches the circulation

Routes of drug administration

Enteral route Parenteral route Inhalation Topical

Enteral Route:
Enteral route is through the alimentary canal. It might be:
Oral Sublingual Per rectum

Oral Route:

Oral route is the most common route of drug administration. It is mostly used for the neutral drugs. It may be in the form of tablets, capsules, syrup, emulsions or powders. Advantages:
It is convenient It is the cheapest available route It is easy to use It is safe and acceptable. Less amount of drug reaches the target tissue. Some of the drug is destroyed by gastric juices e.g. adrenaline, insulin, oxytocin Absorption has to take place which is slow, so is not preferred during emergency. It might cause gastric irritation It might be objectionable in taste. It might cause discoloration of teeth e.g. iron causes staining, tetracyclines below 14 cause brown discoloration so are not advisable during pregnancy.

Disadvantages:

First Pass Effect: First pass effect is the term used for hepatic metabolism of drug when absorbed and delivered through portal blood. Greater the first pass effect, less amounts of the drug reach the systemic circulation.

Sublingual Route:
Sublingual route involves tablets placed under the tongue or between cheeks or Gingiva. The drug should be lipid soluble and small. Advantages:
Rapid absorption takes place. Drug is dissolved easily Drug enters the blood directly Less first pass effect. Spitting out of the drug removes its effect This method is inconvenient. Irritation of the mucous membrane might occur Person may swallow the drug Might be unpleasant in taste.

Disadvantages:

Examples of drugs given by this route include nitroglycerin, isoprenaline and oxytocin. Nifedipine used for the treatment of hypertension in emergency is given by sublingual route.

Rectal Route:
Drugs in solid forms such as suppositories or in liquid forms such as enema are given by this route. This route is mostly used in old patients. Drugs may have local or systemic actions after absorption. Advantages:
This route is preferred in unconscious or uncooperative patients. This route avoids nausea or vomiting Drug cannot be destroyed by enzymes. This route is preferred if drug is irritant.

Disadvantages:
This route is generally not acceptable by the patients. Locally acting drugs include glycerin and Bisacodyl suppository Systemic acting drugs include Indomethacin (anti inflammatory) and aminophyllin (bronchodilator) Retention enema is diagnostic and is used for finding the pathology of lower intestines. Drugs given by rectal route have 50% first pass metabolism.

Parenteral Route:
Parenteral route includes: Injections:
Intra muscular Intra venous Intra-arterial Intra-cardiac Intra-thecal Intraosseous- into bone marrow Intrapleural Intraperitoneal Intra-articular Intradermal (Intracutaneous) Subcutaneous route (Hypodermic)

Classification:

Site of Release: Site of release may be intradermal, intraperitoneal, intrapleural, intracardiac, intraarterial, intrathecal (into meninges of spinal cord), intra-articular (into joint cavity). a. Subcutaneous:
Subcutaneous route might be used for the arm, forearm, thigh and subscapular space. The volume used is 2 ml. Insoluble suspensions like insulin and solids might be applied by this route. Advantages:
Absorption is slow and constant It is hygienic It might lead to abscess formation Absorption is limited by blood flow Examples of drugs given by subcutaneous route include insulin, adrenaline and norplant.

Disadvantages:

b. Intramuscular route:
Intramuscular route might be applied to the buttock, thigh and deltoid. The volume used is 3 ml. Advantages:
Absorption is rapid than subcutaneous route. Oily preparations can be used. Irritative substances might be given Slow releasing drugs can be given by this route. Using this route might cause nerve or vein damage.

Disadvantages

Classification:
c. Intravenous injections:
Intravenous injections might be applied to the cubital, basilic and cephalic veins. Advantages:
Immediate action takes place This route is preferred in emergency situations This route is preferred for unconscious patients. Titration of dose is possible. Large volume of fluids might be injected by this route Diluted irritant might be injected Absorption is not required No first pass effect takes place. Blood plasma or fluids might be injected. There is no retreat This method is more risky Sepsis-Infection might occur Phlebitis(Inflammation of the blood vessel) might occur Infiltration of surrounding tissues might result. This method is not suitable for oily preparations This method is not suitable for insoluble preparations

Disadvantages:

Classification:
d. Intraarterial route:
This method is used for chemotherapy in cases of malignant tumors and in angiography.

e. Intradermal route:
This route is mostly used for diagnostic purposes and is involved in: Schick test for Diphtheria Dick test for Scarlet fever Vaccines include DBT, BCG and polio Sensitivity is to penicillin
Injection can be applied to the left ventricle in case of cardiac arrest. Intrathecal route involves the subarachnoid space. Injection may be applied for the lumbar puncture, for spinal anesthesia and for diagnostic purposes. This technique requires special precautions. Intra-articular route involves injection into the joint cavity. Corticosteroids may be injected by this route in acute arthritis. Intraperitoneal route may be used for peritoneal dialysis. Penicillin may be injected in cases of lung empyma by intrapleural route. This route may be used for diagnostic or therapeutic purposes.

f. Intracardiac route

g. Intrathecal route:

h. Intra-articular route:

i. Intraperitoneal route: j. Intrapleural route: k. Injection into bone marrow

Inhalation
Inhalation may be the route of choice to avoid the systemic effects. In this way drugs can pass directly to the lungs.Drugs used involve volatile drugs and gases. Examples include aerosols like salbutamol; steam inhalations include tincture and Benzoin Advantages:
Rapid absorption takes place. Rapid onset of action takes place. This route has minimum side effects. No first pass effect takes place. This method is easy. Fewer doses is required. Special apparatus is required. Irritation of the respiratory tract may take place. Cooperation of the patient is required. Airway must be patent.

Disadvantages:

Topical route

Drugs may be applied to the external surfaces, the skin and the mucous membranes. Topical route includes: a. Enepidermic route
When the drug is applied to the outer skin, it is called enepidermic route of drug administration. Examples include poultices, plasters, creams and ointments.

b. Epidermic route (Innunition):

When the drug is rubbed into the skin, it is known as epidermic route. Examples include different oils.

c. Insufflations:
When drug in finely powdered form is blown into the body cavities or spaces with special nebulizer, the method is known as insufflations.

d. Instillation
Liquids may be poured into the body by a dropper into the conjunctival sac, ear, nose and wounds. Solids may also be administered.

e. Irrigation or Douching
This method is used for washing a cavity e.g. urinary bladder, uterus, vagina and urethra. It is also used for application of antiseptic drugs.

f. Painting/Swabbing
Drugs are simply applied in the form of lotion on cutaneous or mucosal surfaces of buccal, nasal cavity and other internal organs.

Time of Action using Different Routes of Administration

Drugs take different time durations after injection using different routes to perform their actions. This time delay is important, oral route has controlled release time, thus depot or reservoir preparation may be made e.g. penicillin for rheumatic fever. Usage of drug depends on its physical properties, chemical properties, speed of action, need and bypass effect.

Some of the approximate time intervals are given below: Route of Drug Administration
Intravenous route Intraosseous route Endotracheal inhalation

Delay time for Action

30-60 seconds 30-60 seconds 2-3 minutes

Sublingual route
Intramuscular route Rectal route Ingestion

3-5 minutes
10-20 minutes 5-30 minutes 30-90 minutes

System of medication measurements

Metric System Apothecary System Household System

Metric System
Basic unit of solid measurement is the gram, basic unit of liquid measurement is the liter, and basic unit of length measurement is the meter. Variations of these measurements will include the prefixes of kilo, centi, deci, milli, micro etc. Unit of measure follows the number Arabic numbers are used Fractions are expressed as decimals Example notations: 3 g; 0.25 mg; 500 mL

The Apothecary System

Basic unit of solid measurement is the grain and basic units of liquid measurement include minim, dram, and fluid ounce. Unit of measure precedes the number Roman numerals are used for smaller numbers. Arabic numbers are more commonly used if larger numbers. Fractions are expressed as numerical fractions. A small "ss" may be used to represent 1/2. Example notations: gr iiss; drams 3 (NOTE: There are symbols to represent dram and ounce which cannot be reproduced here. Refer to page 9 in the Drug Dosage Lab document to see these symbols.)

Household system
Basic units of solid measurement are pounds and ounces and units of liquid measurement include teaspoon, tablespoon, cups, etc. Unit of measure follows the number Arabic numbers are used Fractions are expressed as numerical fractions Example notations: 1/2 t; 125 lbs

The Nursing Process

Assessment Nursing diagnosis Planning (with outcome criteria) Implementation Evaluation

The Nursing Process (cont'd)

Assessment
Data collection
Subjective, objective Data collected on the patient, drug, environment

Medication history Nursing assessment Physical assessment Data analysis

The Seven Rights

Right drug Right dose Right time Right route Right patient Right to refuse Right documentation

Another Right Constant System Analysis

A double-check The entire system of medication administration Ordering, dispensing, preparing, administering, documenting Involves the physician, nurse, nursing unit, pharmacy department, and patient education

Other Rights
Proper drug storage Proper documentation Accurate dosage calculation Accurate dosage preparation Careful checking of transcription of orders Patient safety

Other Rights (cont'd)

Close consideration of special situations Prevention and reporting of medication errors Patient teaching Monitoring for therapeutic effects, side effects, toxic effects Refusal of medication

Evaluation
Ongoing part of the nursing process

Determining the status of the goals and outcomes of care Monitoring the patients response to drug therapy
Expected and unexpected responses

The day shift charge nurse is making rounds. A patient tells the nurse that the night shift nurse never gave him his medication, which was due at 11 PM. What should the nurse do first to determine whether the medication was given? 1. Call the night nurse at home. 2. Check the Medication Administration Record. 3. Call the pharmacy. 4. Review the nurses notes.

The patients Medication Administration Record lists two antiepileptic medications that are due at 0900, but the patient is NPO for a barium study. The nurses coworker suggests giving the medications via IV because the patient is NPO. What should the nurse do? 1. Give the medications PO with a small sip of water. 2. Give the medications via the IV route because the patient is NPO. 3. Hold the medications until after the test is completed. 4. Call the physician to clarify the instructions.

Life Span Considerations

Pregnancy Breast-feeding Neonatal Pediatric Geriatric

Pregnancy
First trimester is the period of greatest danger for drug-induced developmental defects Drugs diffuse across the placenta FDA pregnancy safety categories

Table 3-1 Pregnancy

Breast-feeding
Breast-fed infants are at risk for exposure to drugs consumed by the mother Consider risk-to-benefit ratio

Table 3-2 Classification of young patients

Pediatric Considerations: Pharmacokinetics

Absorption
Gastric pH less acidic Gastric emptying is slowed Topical absorption faster through the skin Intramuscular absorption faster and irregular

Pediatric Considerations: Pharmacokinetics (cont'd)

Distribution
TBW 70% to 80% in full-term infants, 85% in premature newborns, 64% in children 1 to 12 years of age Greater TBW means fat content is lower Decreased level of protein binding Immature blood-brain barrier

Pediatric Considerations: Pharmacokinetics (cont'd)

Metabolism
Liver immature, does not produce enough microsomal enzymes Older children may have increased metabolism, requiring higher doses Other factors

Pediatric Considerations: Pharmacokinetics (cont'd)

Excretion
Kidney immaturity affects glomerular filtration rate and tubular secretion Decreased perfusion rate of the kidneys

Summary of Pediatric Considerations

Skin is thin and permeable Stomach lacks acid to kill bacteria Lungs lack mucus barriers Body temperatures poorly regulated and dehydration occurs easily Liver and kidneys are immature, impairing drug metabolism and excretion

Methods of Dosage Calculation for Pediatric Patients

Body weight dosage calculations

Body surface area method

Geriatric Considerations
Geriatric: older than age 65
Healthy People 2010: older than age 55

Use of OTC medications Polypharmacy

Table 3-4 Physiologic changes in the

Geriatric Considerations: Pharmacokinetics

Absorption
Gastric pH less acidic Slowed gastric emptying Movement through GI tract slower Reduced blood flow to the GI tract Reduced absorptive surface area due to flattened intestinal villi

Geriatric Considerations: Pharmacokinetics (cont'd)

Distribution
TBW percentages lower Fat content increased Decreased production of proteins by the liver, resulting in decreased protein binding of drugs

Geriatric Considerations: Pharmacokinetics (cont'd)

Metabolism
Aging liver produces less microsomal enzymes, affecting drug metabolism Reduced blood flow to the liver

Geriatric Considerations: Pharmacokinetics (cont'd)

Excretion
Decreased glomerular filtration rate Decreased number of intact nephrons

Geriatric Considerations: Problematic Medications

Analgesics Anticoagulants Anticholinergics Antihypertensives Digoxin Sedatives and hypnotics Thiazide diuretics

Ethical Nursing Practice

American Nurses Association (ANA) Code of Ethics for Nurses

Cultural Considerations
Assess the influence of a patients cultural beliefs, values, and customs Drug polymorphism Compliance level with therapy Environmental considerations Genetic factors Varying responses to specific agents

Cultural Assessment
Health beliefs and practices Past uses of medicine Folk remedies Home remedies Use of nonprescription drugs and herbal remedies OTC treatments

Cultural Assessment (cont'd)

Usual response to treatment Responsiveness to medical treatment Religious practices and beliefs Dietary habits

Medication Administration

Preparing for Drug Administration

Check the 7 rights Standard Precautions: Wash your hands! Double-check if unsure about anything Check for drug allergies Prepare drugs for one patient at a time Check three times

Check expiration dates Check the patients identification (2 identifiers) Give medications on time Explain medications to the patient Open the medications at the bedside Document the medications given before going to the next patient

Drug Routes & First Pass Effects

First Pass Routes- Oral, Rectal Non-First Pass Routes- Aural, Buccal, Inhaled, Intraarterial, Intramuscular, Intranasal, Intraocular, Vaginal, Intravenous, Subcutaneous, Sublingual, Transdermal

Oral Route
Easiest, most commonly used Slower onset of action More prolonged effect Preferred by clients Sublingual Administration Buccal Administration

Enteral Drugs
Giving oral medications Giving sublingual or buccal medications Liquid medications Giving oral medications to infants Administering drugs through a nasogastric or gastrostomy tube Rectal administration

Parenteral Route
Injecting a medication into body tissues Subcutaneous (SQ) Intramuscular (IM) Intravenous (IV) Intradermal (ID) Advanced techniques

Parenteral Drugs
Never recap a used needle! May recap an unused needle with the scoop method Prevention of needlesticks Filter needles Removing medications from ampules Removing medications from vials Disposal of used needles and syringes Needle Selection

Injections
Needle angles for various injections
Intramuscular (IM) Subcutaneous (SC or SQ) Intradermal (ID)

Z-track method for IM injections Air-lock technique

Injection Techniques
Intradermal injections

Subcutaneous injections
Insulin administration Anticoagulant administration (Heparin/Lovenox)

Injection Techniques (cont'd) Intramuscular injections

Ventrogluteal site (preferred) Vastus lateralis site Dorsogluteal site Deltoid site

Preparing Intravenous Medications

Needleless systems Compatibility issues Expiration dates Mixing intravenous piggyback (IVPB) medications Labeling intravenous (IV) infusion bags when adding medications

Intravenous Medications
Adding medications to a primary infusion bag IVPB medications (secondary line) IV push medications (bolus)
Through an IV lock Through an existing IV infusion

Intravenous Medications (cont'd)

Volume-controlled administration set Using electronic infusion pumps Patient-controlled analgesia (PCA) pumps

Topical Drugs
Eye medications
Drops Ointments

Ear drops
Adults Infant or child younger than 3 years of age

Topical Drugs (cont'd)

Nasal drugs
Drops Spray

Inhaled drugs
Metered-dose inhalers Small-volume nebulizers

Topical Drugs (cont'd)

Administering medications to the skin
Lotions, creams, ointments, powders Transdermal patches

Vaginal medications
Creams, foams, gels Suppositories