Grouping of Drugs Names may reflect the conditions for which they are used (e.g. antidepressants) May reflect their chemical characteristics (benzodiazepines) May reflect the effects on body systems (central nervous system depressants) Prototype Drugs Individual drugs that represent groups of drugs are called Prototypes May be the first drugs of this group to be developed (e.g., penicillin for antibiotics, morphine for opioid analgesics) Pharmacokinetics Involves drug movement through the body to reach sites of action, metabolism, and excretion Specific processes are absorption, distribution, metabolism and excretion Pharmacokinetics-Drug Transport Pathways Three main pathways of drug movement across cell membrances 1. Most common is direct penetration by lipid soluble drugs 2. 2nd pathway involves passage through protein channels. Gates open and close either by voltage gating or by assist of chemical substances (Na+ and K+ ions affecting some cardiac drugs) Drug Transport Pathways cont. 3. 3rd is by carrier proteins that transport molecules from one side of the cell membrane to the other. An example would be oral drugs that carry hormones to their sites of action Pharmacokinetics Absorption-process that occurs from the time a drug enters the body to the time it enters the bloodstream to be circulated Factors affecting absorption include: dosage form, route of administration, blood flow to the site of administration, gastrointestinal function, presence of food or other drugs For many medications, food in the stomach slows absorption Bioavailability Is the portion of a dose that reaches the systemic circulation and is available to act on body cells IV administration is 100% bioavailable Subcutaneous administrations has more rapid absorption than does the oral route Mucous membranes allow for rapid and direct absorption into the bloodstream Distribution Involves the transport of drug molecules within the body After the drug is absorbed into the bloodstream, it is carried by the blood or tissue fluids to its sites of pharmacologic action, metabolism and excretion Protein binding is an important factor in drug distribution Distribution cont. Drug distribution into the CNS is limited because of the blood-brain barrier Blood-brain barrier is composed of capillaries with tight walls which limits movement of drug molecules into brain tissue Only drugs that are lipid soluble or have a transport system can cross the blood-brain barrier and reach therapeutic concentrations in brain tissue Distribution cont. Drug distribution during pregancy and lactation is unique as most drugs cross the placenta or in the case of lactation, pass into breastmilk Protein binding Most drugs form a compound with plasma proteins, mainly albumin, which act as carriers Only the free or unbound portion of a drug acts on body cells As unbound drug acts on cells, the decrease in plasma drug level causes some of the bound drug to be released Protein binding allows a part of a drug dose to be stored and released as needed Metabolism Method by which drugs are inactivated or biotransformed by the body Some drugs yield metabolites that are also active and exert effects on the body until they are excreted (normeperidine) Most drugs are lipid soluble which aids their passage across the cell membrane Metabolism cont. Excretion usually is by kidneys. Need to be water soluble for this to occur. Thus, one function of metabolism is to convert fat soluble medications to water soluble ones. Hepatic drug metabolism or clearance is a major mechanism for terminating drug action and eliminating drug molecules from the body Metabolism cont. Most drugs are metabolized by the cytochrome P450 enzymes in the liver Liver contains complex system of enzymes, three of which are key in the metabolism of medications/drugs Cytochrome p450 CYP enzymes catalyze the chemical reactions which ultimately metabolize the medications With chronic administration (greater than 1-3 weeks), some drugs stimulate hepatocytes to produce larger amounts of drug metabolizing enzymes (inducers). Enzyme induction accelerates drug metabolism. Result is that larger doses of the drug may be need for therapeutic effects. Cytochrome p450 Enzyme inhibition may occur with concurrent administration of two or more drugs that compete for the same metabolizing enzymes (e.g., Dilantin, EES, Tagamet) Oral meds are generally absorbed by the GI tract and carried to the liver. Drug may undergo extensive metabolism leaving little for systemic use. This is called the first pass effect. Excretion Refers to the elimination of a drug from the body Most are excreted by the kidneys although some are excreted in the bile then the feces Serum Drug Levels Lab measurement of the amount of a drug in the blood at a particular time Minimum effective concentration (MEC)- must be present before a drug exerts its pharmacologic action on body cells Duration of action-time during which serum drug levels are at or above the MEC (may measure serum drug levels when the drugs have a low therapeutic index) Pharmacodynamics--Receptors Involves drug actions on target cells and the resulting alterations in cellular biochemical reactions Most drugs chemically bind with receptors at the cellular level Drug-receptor complex initiates physiochemical reactions that stimulate or inhibit cellular functions Pharmacodynamics-receptors Receptors vary in type, location, number and functional capacity When drug molecules chemically bind with cell receptors, pharmacologic effects result from agonism or antagonism Pharmacodynamics-receptors Agonists-are drugs that produce effects similar to those produced by naturally occurring hormones, neurotransmitters and others. Agonists may accelerate or slow normal cellular processes depending on the type of receptor activated. Antagonists—drugs that inhibit cell function by occupying receptor sites. Not all drugs act on receptors. Examples include: antacids, osmotic diuretics, chelators. Variables that affect drug actions Dosage Route Drug-diet interactions. Food may slow absorption or foods may actually interact with certain medications (tyramine and MAO inhibitors; tetracycline and milk products; ingestion when taking certain antihypertensive medications) Variables affecting drug actions Drug-drug interations-additive effects such as seen with sedatives and ethanol. Synergism as seen with acetaminophen and codeine. Antidote—drug can be given to antagonize the toxic effects of another drug Variables that affect drug actions Age Pregnancy Body weight Gender-hormonal effects Pathologic conditions Placebo response Variables that affect drug actions Genetics-hepatic drug metabolizing enzymes===acetyltransferase. Rapid acetylators may need larger than usual dosages and conversely, smaller doses if slow acetylators Glucose-6-phosphate deficiency—develop hemolytic anemia if take antimalarials or sulfonamides Ethnicity—ACE inhibitors in African Americans Tolerance and cross tolerance Adverse effects of drugs CNS GI Hematologic-anticonvulsants Hepatic-acetaminophen, INH Nephrotoxicity-aminoglycosides, NSAIDS Hypersensitivity Drug fever-fever associated w/administration of some antimicrobials, atropine or TCAs Adverse Drug Effects Drug dependency Idiosyncrasy Carcinogenicity teratogenicity Pregnancy Categories Cat. A-studies in pregnant women failed to show risk to the fetus Cat. B- animal studies have failed to show a risk to the fetus but there are no adequate studies in women Cat. C-animal studies have shown an adverse effect on the fetus, no adequate human studies, benefits may outweigh risks Pregnancy Categories cont. Cat. D-positive evidence of human fetal risk Cat. X-animal or human studies have shown fetal abnormalities or toxicity Toxicology—Drug Overdosage General management 1. CPR 2. ETT 3. IV 4. Check blood sugar, drug screen, liver and kidney function 5. Charcoal 6. Narcan or possibly antidotes 7. May alkalinize the urine to prevent kidney damage Antidotes for Selected Therapeutic Drugs Acetaminophen- N acetyl cystiene Digoxin-Digi Fab Beta blockers-Glucagon (increases myocardial contractility) Coumadin-vitamin K Heparin-protamine sulfate Antidotes cont. Benzodiazepines—flumazenil Cholinergics-atropine Calcium channel blockers—calcium gluconate General Principles of accurate drug administration Six Rights 1. Right patient 2. Right drug 3. Right dose 4. Right route 5. Right time 6. Right documentation THANK YOU General Principles of accurate drug administration Six Rights 1. Right patient 2. Right drug 3. Right dose 4. Right route 5. Right time 6. Right documentation General Principles cont. Follow the ‘rights’ consistently Learn essential information about each drug Interpret prescriber’s orders correctly Read labels for right medication and concentration Drug Administration Minimize the use of abbreviations Calculate dosages correctly Measure doses accurately Use appropriate anatomic landmarks to identify sites of IM injections-follow manufacturers recommendations Verify client identity Drug Administration *****Seek information about the client’s medical diagnoses and condition in relation to drug administration Be especially vigilant with children to avoid errors Legal Responsibilities Nurse is legally responsible for safe and accurate administration of medications
Nurse is expected to have sufficient drug
knowledge to recognize and question erroneous orders
Unit dose wrappings of oral drugs should be left in
place until the nurse is in the presence of the client and ready to administer the medication Medication Orders Include the full name of the patient Generic or trade name of the drug The dose, the route and frequency of administration Date, time and signature of the prescriber Common abbreviations PO IM IV SL SOS OD BD TDS Times of Drug Administration AC Ad lib bid, tid, qid HS PC PRN Stat Drug Dosages cc g Gr gtt mL oz Tsp tbsp Routes of Administration Oral Via GI tube Parenteral-IM, IV and sub q Topical Rectal, ophthalmic Otic vaginal Sites for injections Sub q-abdomen, thighs, back and upper arms IM-deltoid, dorsogluteal, ventrogluteal and vastus lateralis muscles IV-antecubital, hands, arms, external jugular Others: intradermal, intra-articular, intra- arterial and intrathecal Equivalents Metric Apothecary Household (see p. 37) Drug administration cardinal rules Wash hands before giving meds Read MAR carefully. If ever in doubt, check the original order Never give medications you are uncertain of unless you have looked them up or have consulted with pharmacy Drug Administration Cardinal Rules Never give more than 3cc per IM injection Wear gloves with all injections For sub q injections, use 25G, 5/8” needles Do not give oral meds if patient is vomiting, sedated, NPO or is unconscious Follow narcotic protocol for signing out of narcotics Nursing Process in Drug Therapy Is a systematic way of gathering and using information to plan and provide individualized client care and to evaluate the outcomes of care Five steps of the nursing process are: assessment, nursing diagnosis, planning, interventions and evaluation General Principles of Drug Therapy Expected benefits should outweigh potential adverse effects Drug therapy should be individualized Drug effects on quality of life should be considered in designing a drug therapy regiment Drug selection and dosage Use as few drugs as possible Fixed dose combinations increase compliance Lowest dose with therapeutic effect Follow guidelines but dosages must be individualized Drugs with long half-lives may require loading doses then titrated lower maintenance doses Drug Therapy in special populations- pediatrics Pediatrics-all aspects must be guided by the child’s age, weight and level of growth and development Safe therapeutic ranges are less well- defined Choice of drug is restricted because many drugs used in adults have not been sufficiently investigated Pediatric physiologic characteristics affecting pharmacokinetics Thin, permeable skin –increased absorption of topicals Immature blood-brain barrier—increased distribution into the CNS until age 2 Altered protein binding until age 1 Decreased activity of metabolizing enzymes in infants, increased in children Pediatric physiologic effects Increased percentage of body water Decreased GFR until one year of age Pediatrics Oral route for meds is preferable For injections, may wish to use EMLA (eutectic mixture of lidocaine and prilocaine, local anesthetics) Site selection for injections—infants, use thigh muscles; older than 18 months of age, use deltoid; older than 3, use ventrogluteal muscle Drug Therapy in Older Adults Physiologic characteristics and pharmacokinetic impact Decreased GI motility—slower absorption Decreased cardiac output—slower absorption from site of administration, decreased distribution to sites of action in tissues Decreased blood flow to liver and kidneys- delayed metabolism and excretion Drug Therapy in Older Adults Decreased total body water and lean body mass-fat soluble meds stay with patient longer, water soluble drugs are distributed in smaller area, greater risk for toxicity Decreased blood flow to liver-slowed metabolism and detox of drugs Drug Therapy in Older Adults Decreased albumin-decreased availability of protein for binding and transporting. Will also have higher concentration of free active drug. Decreased blood flow to kidneys—impaired drug excretion, potential toxicity Older Adults Renal Impairment Know baseline renal function Tailor dosages Avoid nephrotoxic medications Be aware of need for additional dosing if patient is receiving renal replacement therapy Older Adults Hepatic Impairment Those with cirrhosis, hepatitis, receiving hepatotoxic drugs, have heart failure, are undergoing major surgery or have had trauma are at higher risk for toxicities r/t medications Know drug effects on hepatic function Reduce dosages on medications that are extensively metabolized by the liver such as: cimetidine, phenytoin, ranitidine, theophylline Older Adults Critical Illnesses Be aware that all medications may have variable effects in this scenario Know the actions, usual dosages and side effects of medications Closely monitor renal and liver function tests Monitor serum protein and albumin levels Older Adults Critical Illness Most drugs will be given IV-for this reason, medications may have faster onset Many factors may interfere with drug effects if given orally Considerations when giving medications via feeding tube Appropriate scheduling very important Drug Therapy in Home Care On patient’s turf Schedule visit at convenient time for patient and caregiver Assess patient’s ability to perform self-care Assess patient’s understanding and attitude regarding medication regimen Inquire if patient is taking any herbal preparations Drug Therapy in Home Care Inquire if patient is taking any OTC meds Assess environment for safety Educate patient and caregiver indication, proper administration and side effects of administered medications Between visits, maintain contact with patient to monitor progress and serve as a resource Herbal and Dietary Supplements Black cohosh-used to relieve menopausal s/s Capsaicin-post-herpetic neuralgia Echinacea-anti-infective, for common cold Ginger—nausea. Not for morning sickness. Garlic-cholesterol lowering Herbal and Dietary supplements Feverfew-for migraines, menstrual complaints. Can cause withdrawal s/s. Ginseng-increase stamina, endurance and mental acuity. Can affect bleeding time, BP, increase hypoglycemia. No longer than 3 weeks use with Siberian ginseng. Questions