Introduction to Pharmacology in Nursing

Donna Penn RN MSN CNE.

 Nurses need to have knowledge about the actions and effects of medications To safely and accurately administer medications nurses need to have an understanding of pharmacologic principles

Pharmacologic Principles

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

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

Pharmacological Concepts: Classification

Classification- Nurses learn to categorize meds with similar characteristics by their class Medication classification indicates the effect of the med on the body system, the symptom the med relieves, or the meds desired effect (e.g. oral hypoglycemics)

Pharmacological Concepts: Classification

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

Pharmacological Concepts: Medication Forms

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 Many meds are available in several forms

Medication Forms

Tablet Capsule Elixir Enteric-coated Suppository Suspension Transdermal patch

Pharmacologic Principles

Pharmaceutics Pharmacokinetics Pharmacodynamics Pharmacotherapeutics Pharmacognosy

Pharmaceutics

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

Pharmacokinetics

The study of what the

body does to the drug

Absorption Distribution Metabolism Excretion

Pharmacodynamics The study of what the

drug does to the body

The mechanism of drug actions in living tissues

Figure 2-2 Phases of Drug Activity. (From McKenry LM, Salerno E: Mosbys pharmacology in nursingrevised and updated, ed 21, St. Louis, 2003, Mosby.)

Pharmacotherapeutics

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

Pharmacognosy

The study of natural (plant and animal) drug sources

Pharmacokinetics:

Absorption

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

Factors That Affect Absorption

Administration route of the drug Ability of Med 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 Med Status of GI motility

Routes of Administration

A drugs route of administration affects the rate and extent of absorption of that drug
Enteral (GI tract) Parenteral Topical

Enteral Route

Drug is absorbed into the systemic circulation through the oral or gastric mucosa, the small intestine, or rectum
Oral Sublingual Buccal Rectal

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 IV bypasses the liver, preventing the first-pass effect from taking place, and more drug reaches the circulation

Box 2-1 Drug Routes and First-Pass Effects

Parenteral Route

Intravenous (fastest delivery into the blood circulation) Intramuscular Subcutaneous Intradermal Intrathecal Intraarticular

Topical Route

Skin (including transdermal patches) Eyes Ears Nose Lungs (inhalation) Vagina

Distribution

The transport of a drug in the body by the bloodstream to its site of action
Protein-binding Water soluble vs. fat soluble Blood-brain barrier Areas of rapid distribution: heart, liver, kidneys, brain Areas of slow distribution: muscle, skin, fat

Metabolism (Also Known As Biotransformation)

The biologic transformation of a drug into an inactive metabolite, a more soluble compound, or a more potent metabolite
Liver (main organ) Kidneys Lungs Plasma Intestinal mucosa

Metabolism/Biotransformation (cont'd)

Delayed drug metabolism results in:

Accumulation of drugs Prolonged action of the drugs

Stimulating drug metabolism causes:

Diminished pharmacologic effects

Excretion

The elimination of drugs from the body

Kidneys (main organ) Liver Bowel
Biliary excretion Enterohepatic circulation

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. Absorption B. Biotransformation C. Distribution D. Excretion

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Pharmacodynamics

Study of the mechanism of drug actions in living tissue Drug-induced alterations to normal physiologic function Positive changeTherapeutic 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 enzymesenzyme 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.

A patient is complaining of severe pain and has orders for morphine sulfate. The nurse knows that the route that would give the slowest pain relief would be which route?

1. IV 2. IM 3. SC 4. PO

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 effectsoverreacts 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 reactionAnaphylactic reaction Mild reaction-hives, rash, pruritis

 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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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 Warfarin and Amiodarone

Iatrogenic Responses

Unintentional adverse effects that occur during therapy Treatment-Induced Dermatologic-rash, hives, acne Renal DamageAminoglycoside antibiotics, NSAIDS, contrast medium Blood DyscrasiasDestruction of blood cells (Chemotherapy) Hepatic Toxicity-Elevated liver enzymes (hepatitislike 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 Empiric 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 benefits and its toxic effects

Monitoring (cont'd)

Tolerance
A decreasing response to repetitive drug doses

Monitoring (cont'd)

Dependence
A physiologic or psychological need for a drug

Monitoring (cont'd)

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

Monitoring (cont'd)

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

The Nursing Process (cont'd)

Assessment Nursing diagnosis Planning (with outcome criteria) Implementation Evaluation

The Nursing Process

An organizational framework for the practice of nursing Orderly, systematic Central to all nursing care Encompasses all steps taken by the nurse in caring for a patient Flexibility is important

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 Nursing Process (cont'd)

Nursing diagnosis Judgment or conclusion about the need/problem (actual or at risk for) of the patient Based upon an accurate assessment NANDA format

The Nursing Process (cont'd)

Planning Identification of goals and outcome criteria Prioritization Time frame

The Nursing Process (cont'd)

Goals Objective, measurable, realistic Time frame specified Outcome criteria Specific standard(s) of measure Patient oriented

The Nursing Process (cont'd)

Implementation Initiation and completion of the nursing care plan as defined by the nursing diagnoses and outcome criteria Follow the five rights of medication administration

The Five Rights

Right drug Right dose Right time Right route Right patient

Another RightConstant 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

Life Span Considerations

Pregnancy Breast-feeding Neonatal Pediatric Geriatric

Pregnancy

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

Table 3-1 Pregnancy safety categories

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 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

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 patient

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

Legal, Ethical, and Cultural Considerations

U.S. Drug Legislation

1906: Federal Food and Drug Act 1912: Sherley Amendment (to the Federal Food and Drug Act of 1906) 1914: Harrison Narcotic Act 1938: Federal Food, Drug, and Cosmetic Act (revision of 1906 Act)

U.S. Drug Legislation (cont'd)

1951: DurhamHumphrey Amendment (to the 1938 act) 1962: Kefauver-Harris Amendment (to the 1938 act) 1970: Controlled Substance Act

U.S. Drug Legislation (cont'd)

1983: Orphan Drug Act 1991: Accelerated drug approval

New Drug Development

Investigational new drug (IND) application Informed consent Investigational drug studies Expedited drug approval

U.S. FDA Drug Approval Process

Preclinical investigational drug studies Clinical phases of investigational drug studies

Phase I Phase II Phase III Phase IV

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 Errors: Preventing and Responding

Medication Misadventures

Medication errors (MEs) Adverse drug events (ADEs) Adverse drug reactions (ADRs)

Medication Misadventures (cont'd)

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

Medication Errors

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

Box 5-1 Common classes of medications involved in serious errors

Preventing Medication Errors

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

Preventing Medication Errors (cont'd)

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

Preventing Medication Errors (cont'd)

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

Preventing Medication Errors (cont'd)

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

Preventing Medication Errors (cont'd)

Check medication order and what is available while using the 5 rights

Take time to learn special administration techniques of certain dosage forms

Preventing Medication Errors (cont'd)

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

Medication Reconciliation

Medication Errors Possible consequences to nurses Reporting and responding to MEs

ADE monitoring programs USPMERP (United States Pharmacopeia Medication Errors Reporting Program) MedWatch, sponsored by the FDA Institute for Safe Medication Practices (ISMP)

Notification of patient regarding MEs

 3. 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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 4. 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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Medication Administration

Preparing for Drug Administration

Check the 5 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

Preparing for Drug Administration (cont'd)

Check expiration dates Check the patients identification 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 RoutesAural, 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

Parenteral Drugs (cont'd)

Removing medications from ampules

Removing medications from vials Disposal of used needles and syringes

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 Heparin administration

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