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Wear prescribed uniform and ID all the time.

No book, no notebook, no paper, no blue/black and red ball-pens means, NO ENTRY! Seating arrangement must be done alphabetically During quiz, DONT DO ANYTHING THAT I MAY INTERPRET AS CHEATING During group activities, make sure you participate. If absent, please secure excuse slip or else , NO ENTRY! Once inside, no going out until your break time. 15 minutes break only. You may bring finger-foods.

Why its usually okay to give children Tylenol but not aspirin? Why a lot of middle-aged and older people take an aspirin a day? Why people with high blood pressure, heart failure, or diabetes take ACE inhibitors and what ACE inhibitors are? When an antibiotic should NOT be prescribed for an infection?

A. To pass the requirement. B. You will be able to use fancy terms like Pharmacodynamics. C. My instructor likes to torture people. D. A competent nurse must understand why his/her patient is getting a medication, and HOW IT WORKS.

The purpose of studying PHARMACOLOGY is to help you learn about medicines and the WHY, WHAT, HOW, WHEN, and WHERE they are used in daily life.

BEFORE Drugs were mainly derived from


Plants (eg, morphine) animals (eg, insulin) and minerals (eg, iron)

2700 BB earliest recorded drug use found in Middle East & China 1550 BC Egyptians created Ebers Medical Papyrus

Galen (131-201 AD) Roman physician; initiated common use of prescriptions 1240 AD introduction of apothecary system (Arab doctors) 1st set of drug standards & measurements (grains, drams, minims), currently being phased out

15th century apothecary shops owned by barber, surgeons, physicians, independent merchants 18th century small pox vaccine (by Jenner) Digitalis from foxglove plant for strengthening & slowing of heartbeat Vitamin C from fruits

19th century morphine & codeine extract from opium Introduction of atropine & iodine Amyl nitrite used to relieve anginal pain Discovery of anesthetics (ether, nitrous oxide) Early 20th century aspirin from salicylic acid Introduction of Phenobarbital, insulin, sulforamides

Mid 20th century 1940 Discovery antibiotics (penicilline, tetracycline, streptomycin), antihistamines, cortisone 1950 discovery antipsychotic drug, antihypertensives, oral contraceptives, polio vaccine Dr Albert Sabin, b. 1906, developer of the oral live polio vaccine.

NOW Synthetic Semi-synthetic Biotechnology

Pharmacology
pharmacon - meaning drug logos - meaning science
is the study of drugs (chemicals) that alter functions of living organisms.

Drug therapy
also called pharmacotherapy, is the use of drugs to prevent, diagnose, or treat signs, symptoms, and disease processes.

Medication
Drugs given for therapeutic purposes.

Pharmacoeconomics involves the costs of drug therapy, including those of purchasing, dispensing, storage, administration, laboratory and other tests used to monitor client responses, and losses from expiration. Drug
Any chemical that affects the physiologic processes of a living organism

Chemical name
Describes the drugs chemical composition and molecular structure Generic name (non-proprietary name) Name given by the country or 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)

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

Generic name
Ibuprofen

Trade name
Alaxan, Advil

Classification: Functional Class vs. Chemical Class Medication classification indicates: effect of the medicine symptom the medicine relieves medicine desired effect (e.g. oral hypoglycemics)

A medication may also be part of more than one class Aspirin is an analgesic, antipyretic, antiinflammatory, and anti-platelet

Medications are available in a variety of forms and preparations The form of the med will determine its route of administration Composition of med is designed to enhance its absorption & metabolism

Tablet Capsule Caplet Elixir Enteric-coated Suppository Suspension

Transdermal patch Drops Injections Ointment Tincture Liniment Aerosol

Pharmaceutics Pharmacokinetics Pharmacodynamics Pharmacotherapeutics Pharmacognosy

Dose of Formulated Drug

PHASES OF DRUG ACTIVITY


(source: Mosbys Pharmacology for Nursing (2003))

Administration

Disintegration of dosage from dissolution of drug

PHARMACEUTICAL PHASE

Drug available for absorption

Absorption, distribution, metabolism, excretion

PHARMACOKINETIC PHASE

Drug available for action

Drug-receptor interaction
PHARMACODYNAMIC PHASE

The study of how various drug forms influence pharmacokinetic and pharmacodynamic activities

Figure 2-1 The chemical, generic, and trade names for the common analgesic ibuprofen are listed next to the chemical structure of the drug.

What does this have to do with drug administration? Drugs must reach and interact with or cross the cell membrane to stimulate or inhibit cellular function

The study of what the body does to the drug Absorption Distribution Metabolism Excretion Remember:

ADME

The rate at which a drug leaves its site of administration, and the extent to which absorption occurs Bioavailability Bioequivalent

Administration route of the drug Ability of Medicine to Dissolve Food or fluids administered with the drug Body Surface Area Status of the absorptive surface Rate of blood flow to the small intestine Lipid Solubility of Medicine Status of GI motility

Age Diseases Individual Differences Psychological Factors Type & Amount of Drug Prescribed Social Factors

Pills, capsules, tablets, liquids SL, Buccal, NG, Gastrostomy, Duodenostomy tubes

NOTE: Assess clients ability to take oral medications

Dosage is determined by how much of the drug is required to be taken by mouth to given the desired affect. Time in the stomach is the stomach empty full does it make a difference on how drug is absorbed Small intestine large surface area for absorption of nutrients and minerals

Food in stomach Certain juices grapefruit juice Milk binds with molecules of some drugs so that the drug is never absorbed Orange juice enhances absorption of iron taken orally The coating on the tablet: chewable, enteric coated (breakdown occurs in small intestine), slow release capsules

Ventral forearm Upper chest Shoulder

Outer aspects of the arms & thighs Hip & lower abdomen Above the iliac crest

Ventrogluteal
for 1 year and above

Vastus lateralis
below 1 year old

Dorsogluteal - clients w/ well-developed gluteal


muscles

Deltoid

(IV) is the installation of fluid and/or electrolytes, or nutrient, medication substances into a vein.

skin, ophthalmic, otic, nasal, vaginal, rectal

Transportation of drug molecules within the body Drug needs to be carried to the site of the action
Need blood to circulate the drug Heart, liver, kidneys

Protein binding drug molecules need to get from the blood plasma into the cell Protein binding allows part of the drug to be stored and released as needed Some of the drug is stored in muscle, fat and other body tissues and is gradually released into the plasma

Drug must pass though the capillary wall Blood brain barrier very effective in keeping drugs from getting into the central nervous system or CNS limits movement of drug molecules into brain tissue

This is especially important when treating infections of the brain such as meningitis, encephalitis, or brain abscess Medications must be able to penetrate the blood brain barrier Medications usually given intravenous

Direct penetration of the membrane Protein channels Carrier proteins

Lipid soluble drugs are able to dissolve in the lipid layer of the cell membrane No energy expended by the cell Passive diffusion Oral tablets or capsules must be water soluble to dissolve in fluids of the stomach and small intestine

Most drug molecules are to big to pass in to the cell via the channels small ions such as sodium and potassium use the protein channels but their movement is regulated by gating mechanisms only small amounts allowed

Molecule needs to bind with a protein that will transport it from one side of the cell membrane to another a drugs structure determines which carrier will transfer it.

Method by which the drugs are inactivated or biotransformed by the body Active drugs contain metabolites that are excreted skin, urine, stool Most drugs metabolized in the liver by cytochrome P450 (CYP)

Enzyme inhibition Other drugs Combination drugs Liver disease Impaired blood circulation in person with heart disease Infant with immature livers Malnourished people or those on low-protein diets

First-pass effect some drugs are extensively metabolized or broken down in the liver and only a part of the drug is released into the systemic circulation This is why dosage is important how much drug needs to be taken in to give the desired effect and how often does it need to be taken

Refers to the elimination of the drug from the body Requires adequate functioning of the circulatory system and organs of excretion
Kidneys Bowels Lungs Skin

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

Laboratory values reflecting function of liver and kidneys need to be looked at. BUN and Creatinine kidney function Liver function tests: ALT alamine aminotransferase (elevated in hepatitis) AST or SGOT aspartate aminotransferase elevated in liver disease Bilirubin levels infants gallstones in adults

Laboratory measurement of the amount of drug in the blood at a particular time A minimum effective concentration (MEC) must be present before a drug exerts its action on a cell.

Excessive level of a drug in the body Single large dose Repeated small doses Slow metabolism which allows drug to accumulate in the body Slow excretion from the body by the kidneys or gastrointestinal tract

Serum drug levels indicate the onset, peak and duration of the drug action

No When do we need them? Drugs with narrow margin of safety (digoxin, aminoglycoside antibiotics, lithium) To check to see if the drug is at therapeutic levels seizure medications When drug overdose is suspected

Serum half-life or elimination half-life is the time it takes the serum concentration of the drug to reach 50% A drug with a short half-life requires more frequent administration A drug with a long half-life requires less frequent administration

Half-life determines how often a drug is given Daily in the morning At bedtime Q.I.D - four times a day T.I.D three times a day Q4 hours every four hours Q 12 hours 9 am and 9 pm

The study of what the drug does to the body the mechanism of drug actions in living tissues
WHAT THE DRUG DOES TO THE BODY

What does a cell do?


Exchange material Obtain energy from nutrients Synthesize hormones, neurotransmitters, enzymes, structural proteins and other complex molecules Duplicate themselves

Drugs can: 1. Inhibit 2. Activate 3. Replace

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)

Most drugs exert their effects by chemically biding with receptors at the cellular level. Receptors are proteins located
on the surfaces of cell membranes within the cells

The receptors are often described as the lock into which the drug molecule fits as a key. All body cells do not respond to all drugs even when all the cells are exposed to the drug.

Receptors are regulated in TWO WAYS: 1. Agonists (activators) bind to the receptor and act to produce a pharmacologic effect 2. Antagonists (blockers) bind to the receptor and prevent the cell from producing an effect

Number of receptors site available will effect drug action so giving a higher dose does not necessarily produce additional pharmacological effects.

Often the first dose is higher in an effort to bring the therapeutic blood serum levels up quicker

Food can slow absorption Food substances can react with certain drugs How to give medication is information provided in you drug manual

Some drugs taken together will enhance each other Tylenol with codeine Some drugs taken together will interfere with another drugs actions Some drugs are given to decrease or reverse the toxic effects of a drug Narcotic antidote is naloxone

Body becomes accustomed to drug over period of time

Undesired response Allergic reaction Drowsiness Nausea / vomiting / GI upset Liver or kidney damage Fevers Drug dependency Cancinogenicity ability to cause cancer Teratogenicity cause damage to fetus

The use of drugs and the clinical indications for drugs to prevent and treat diseases

The effectiveness of the drug therapy must be evaluated. One must be familiar with the drugs intended therapeutic action (beneficial) and the drugs unintended but potential side effects (predictable, adverse drug reactions).

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

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

The expected or predictable physiological response a medication causes A single med can have several therapeutic effects

A drug that does not cause sideeffects is a drug that does not work.

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/C People may stop taking medications because of the side effects

Medication misadventures Adverse drug events Adverse drug reactions Medication errors

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

Toxicology The study of poisons and unwanted responses to therapeutic agents

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

Table 2-9 Common Poisons and Antidotes

Unpredictable effectsoverreacts or under reacts to a medication or has a reaction different from normal Normal effect is produce by a small fraction of the standard dose.

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 medicine, chemical preservative or a metabolite

Medication acts as an antigen triggering the release of the bodys antibodies May be mild or severe

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

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

Interactions Additive effect Synergistic effect Antagonistic effect Incompatibility

Drugs are said to have an additive effect when they have similar actions. Lower doses are needed when the drugs are given together. Similar therapeutic activity can cause problems if administered together

Effect of 2 meds combined is greater than the meds given separately Alcohol & Antihistamines, antidepressants, barbiturates, narcotics

Combined effect is less than each of them alone. Drugs with opposite action to that of another drug or natural body chemical Examples: Beta-blockers the olol drugs

Drugs are incompatible when combining them causes chemical deterioration of one or both

NURSING RESPONSIBILITY

Assessment

Evaluation

Diagnosis

Implementation

Planning

Assessment Data collection

Assessment

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

Medication history Nursing assessment Physical assessment Data analysis

Evaluation

Diagnosis

Implementation

Planning

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

1. Right Patient 2. Right Medication 3. Right Dosage 4. Right Route 5. Right Time 6. Right Documentation 7. Right Client Education 8. Right to Refuse 9. Right Assessment 10. Right Evaluation

Proper drug storage Careful checking of transcription of orders Patient safety Close consideration of special situations Prevention and reporting of medication errors Monitoring for therapeutic effects, side effects, toxic effects

Assessment

Evaluation

Diagnosis

Implementation

Planning

Ongoing part of the nursing process Determining the status of the goals and outcomes of care Monitoring the patients response to drug therapy

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 sheet. 3. Call the pharmacy. 4. Review the nurses notes.

The patients Medication sheet 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.

Clients expect you to be knowledgeable You gain this knowledge be looking up medications Drug hand book PDA Pharmacist

The nurse is responsible for safe and accurate administration having sufficient drug knowledge to recognize and question erroneous orders actions delegated to other persons orderly cannot give medications monitor clients response to a medication following safe practices the ten rights

Each facility has a system for administering medication Be familiar with this process & need to learn at each new facility Basics of medication administration guidelines should always be observed

Full name of client Generic or trade name of drug Dose, route, frequency Date, time and signature of provider The nurse will need to look up the medication ordered to know its classification, safe dose, action, how to administer, and side effects The nurse should know why the medication is ordered

Pregnancy Breast-feeding Neonatal Pediatric Geriatric

First trimester is the period of greatest danger for druginduced developmental defects Drugs diffuse across the placenta FDA pregnancy safety categories

Class A
Studies failed to demonstrate fetal anomalies.

Class B
Animal studies have not demonstrated a fetal risk. Information in human is not available

Class C
Studies in animal have revealed an adverse effect

Class D
There is a positive evidence of fetal risk but in some cases may warrant the use of these drugs

Class X
Studies in animal and human have revealed abnormalities

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

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

Distribution
TBW 70% to 80% in fullterm 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

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

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

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

Body weight dosage calculations Body surface area method

Geriatric:
older than age 65

Healthy People 2010:


older than age 55

Use of OTC medications Polypharmacy

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

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

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

Excretion
Decreased glomerular filtration rate Decreased number of intact nephrons

Analgesics Anticoagulants Anticholinergics Antihypertensives Digoxin Sedatives and hypnotics Thiazide diuretics

By definition, all ADRs are also ADEs But all ADEs are not ADRs Two types of ADRs
Allergic reactions Idiosyncratic reactions

Preventable Common cause of adverse health care outcomes Effects can range from no significant effect to directly causing disability or death

Minimize verbal or telephone orders


Repeat order to prescriber Spell drug name aloud Speak slowly and clearly

List indication next to each order Avoid medical shorthand, including abbreviations and acronyms

Never assume anything about items not specified in a drug order (i.e., route) Do not hesitate to question a medication order for any reason when in doubt Do not try to decipher illegibly written orders; contact prescriber for clarification

NEVER use trailing zeros with medication orders Do not use 1.0 mg; use 1 mg 1.0 mg could be misread as 10 mg, resulting in a tenfold dose increase

ALWAYS use a leading zero for decimal dosages Do not use .25 mg; use 0.25 mg .25 mg may be misread as 25 mg .25 is sometimes called a naked decimal

Check medication order and what is available while using the 10 rights Take time to learn special administration techniques of certain dosage forms

Always listen to and honor any concerns expressed by patients regarding medications Check patient allergies and identification

Nurses are legally required to document medications that are administered to clients. The nurse is mandated to document: A. Medication before administering it B. Medication after administering it C. Rationale for administering the medication D. Prescribers rationale for prescribing the medication
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If a nurse experiences a problem reading a physicians medication order, the most appropriate action will be to: A. Call the physician to verify the order. B. Call the pharmacist to verify the order. C. Consult with other nursing staff to verify the order. D. Withhold the medication until the physician makes rounds.
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Meter is used for linear measure, gram for weight and liter for volume

Grains, minims, drams, ounces, pounds, pints, and quarts

Drops, teaspoons, tablespoons and cups Important since this is often how people take medications

mEq drugs ordered in number of units per dose


Insulin heparin

mL = milliliter. This is a VOLUME measurement. it is 1/1000 of a liter. when talking about water or similar liquids, it is equivalent to one cubic centimeter.

cc = cubic centimeter. This is also a VOLUME measurement. Most syringes measure their capacity in cc's. If you have a 5cc syringe, it will hold ~5mL of liquid in it.

1 mL = 1cc 1 cc = 15 to 16 minims 1 cc = 15 to 16 drops

Fluids are generally written in ccs to standardize the abbreviation you may see mLs written but this abbreviation is being eliminated

5 cc = 1 tsp (teaspoon) 15 cc = 1 tbs (tablespoon) 30 cc = 1 oz (ounce) = 2 tablespoons 240 cc = 8 oz or 1 cup

mg = milligram. This is a WEIGHT measurement. It is 1/1000 of a gram. the amount of chemical substance is often measured in milligrams. For injectable solutions, this will be reported as a concentration of weight to volume, such as mg/ml (milligrams per milliliter).

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