Introduction to Pharmacology in Nursing

• 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.

Drug Names

Chemical name

• Describes the drug’s chemical composition and molecular structure

Generic name (nonproprietary name)

• Name given by the BFAD

Trade name (proprietary name)

• The drug has a registered trademark; use of the name restricted by the drug’s patent owner
(usually the manufacturer)

Example:

Chemical name

• (+/-)-2-(p-isobutylphenyl) propionic acid

Generic name

• ibuprofen

Trade name

• Motrin®, Advil®

Classification of Pharmacological Concepts

• Classification- Nurses learn to categorize medications with similar characteristics by their class

• Medication classification indicates the effect of the medication on the body system, the symptom
the medication relieves, or the medication’s desired effect (e.g. oral hypoglycemics)

• A medication may also be part of more than one class

• Aspirin is an analgesic, antipyretic, anti-inflammatory, and anti-platelet

Pharmacological Concepts: Medication Forms
 • Medications are available in a variety of forms and preparations
• The form of the medication will determine its route of administration
• Composition of medication is designed to enhance its absorption & metabolism

Many medicines are available in several forms:

• Tablet
• Capsule
• Elixir
• Enteric-coated
• Suppository
• Suspension
• Transdermal patch

Pharmacologic Principles

• Pharmaceutics
• Pharmacokinetics
• Pharmacodynamics
• Pharmacotherapeutics
• Pharmacognosy

A. Pharmaceutics - The study of how various drug forms influence pharmacokinetic and
pharmacodynamic activities.

B. Pharmacokinetics - The study of what the body does to the drug:

– Absorption
– Distribution
– Metabolism
– Excretion

C. Pharmacodynamics - The study of what the drug does to the body

- The mechanism of drug actions in living tissues

Phases of Drug Activity
D. Pharmacotherapeutics - The use of drugs and the clinical indications for drugs to prevent and treat
diseases

E. Pharmacognosy- The study of natural (plant and animal) drug sources

Phases of Pharmacokinetics

I. Absorption
II. Distribution
III. Metabolism
IV. Excretion
Phases of Pharmacokinetics: I. Absorption

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

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 drug’s route of administration affects the rate and extent of absorption of that drug

– Enteral (GI tract)

– Parenteral
– Topical

Routes of Administration: 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 first-pass effect)

– The same drug—given IV—bypasses the liver, preventing the first-pass effect from taking
place, and more drug reaches the circulation
Routes of Administration: Parenteral Route

• Intravenous (fastest delivery into the blood circulation) •

Intramuscular
• Subcutaneous
• Intradermal
• Intrathecal
• Intraarticular

Routes of Administration: Topical Route

• Skin (including transdermal patches)

• Eyes
• Ears
• Nose
• Lungs (inhalation)
• Vagina

Phases of Pharmacokinetics: II. 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
Phases of Pharmacokinetics: III. 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

Delayed drug metabolism results in:

• Accumulation of drugs
• Prolonged action of the drugs

Stimulating drug metabolism causes:

• Diminished pharmacologic effects

Phases of Pharmacokinetics: IV. Excretion

The elimination of drugs from the body

• Kidneys (main organ)

• Liver
• Bowel
– Biliary excretion
– Enterohepatic circulation
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

Pharmacodynamics: 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 A.

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
• 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 body’s 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
• 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)
B. 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 enzyme’s action (ACE Inhibitors)

C. 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
Pharmacodynamics: Type of Medication Action

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

A. 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

B. 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 discontinued or stopped
• People may stop taking medications because of the side effects
C. 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 Drug Events
• Adverse Drug Reactions (ADR)

D. Toxic Effects

• 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 respiratory depression
• Antidotes available to reverse effects

E. 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)

F. 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
• Medication acts as an antigen triggering the release of the body’s 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

G. 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

H. Iatrogenic Response

• 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 two medications combined is greater than the medications 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 ½
• 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

• 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 drug’s:
– Intended therapeutic action (beneficial)
– Unintended but potential side effects (predictable, adverse reactions) • Therapeutic

index – The ratio between a drug’s therapeutic benefits and its toxic effects • Tolerance –

A decreasing response to repetitive drug doses

• Dependence – A physiologic or psychological need for a drug

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
• Drug interactions

– Additive effect
– Synergistic effect
– Antagonistic effect
– Incompatibility

• Medication misadventures

– Adverse drug events

– Adverse drug reactions
– Medication errors

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 effect’s 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
Nursing Process

• Assessment
• Nursing diagnosis
• Planning (with outcome criteria)
• Implementation
• Evaluation

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

Assessment

• Data collection
– Subjective, objective
– Data collected on the patient, drug, environment
• Medication history
• Nursing assessment
• Physical assessment
• Data analysis

Nursing diagnosis

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

Planning
• Identification of goals and outcome criteria
 • Prioritization
• Time frame

Goals
• Objective, measurable, realistic
• Time frame specified

Outcome criteria

• Specific standard(s) of measure

• Patient oriented
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

10 Rights for Drug Administration

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

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
 • 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 patient’s response to drug therapy - expected and unexpected responses
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

Breastfeeding
• Breast-fed infants are at risk for exposure to drugs consumed by the mother •
Consider risk-to-benefit ratio
Pediatric Considerations (Pharmacokinetics)

• 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 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

• 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

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
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

• 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

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)
• 1951: Durham-Humphrey Amendment (to the 1938 act)
• 1962: Kefauver-Harris Amendment (to the 1938 act)
• 1970: Controlled Substance Act
• 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 patient’s 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
• 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 Errors

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

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 • 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 “5 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
• 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

Medication Administration

Preparing for Drug Administration

 Check the “10 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 patient’s 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 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)
Parenteral Route

 Never recap a used needle!

 May recap an unused needle with the “scoop method”
 Prevention of needlestick injury
 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
  Subcutaneous injections
◦ Insulin administration
◦ Heparin administration

Intramuscular Injection Sites

 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
 Adding medications to a primary infusion bag
 IVPB medications (secondary line)
 IV push medications (bolus)
 Through an IV lock
 Through an existing IV infusion
 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
 Nasal drugs
◦ Drops
◦ Spray

 Inhaled drugs
◦ Metered-dose inhalers
◦ Small-volume nebulizers

 Administering medications to the skin

 ◦ Lotions, creams, ointments, powders ◦
Transdermal patches

 Vaginal medications
◦ Creams, foams, gels
◦ Suppositories