NURS 3304
PHARMACOTHERAPEUTICS
Adrianne Linton PhD RN
Jennie Shaw MSN RN
Blackboard Assistance by
MaryShannon Williams
Course
Objectives
Course Objectives
Examine the role of drug therapy in
relation to health promotion, disease
prevention and management across the
lifespan. (Essential VII, IX)
Incorporate understanding of drug
classifications and actions. (Essential VII,
IX)
Identify relevant assessment data,
appropriate nursing goals and
intervention, and evaluation data related
to drug therapy. (Essential IX)
Identify the need for customization of drug
therapy based on individual patient
variables including physiologic,
psychosocial, genetic, cultural, patient
belief system, knowledge base and
resources. (Essential VII, IX)
Integrate knowledge of physical and
behavioral sciences with legal and ethical
guidelines to plan for safe and effective
implementation of pharmacotherapeutics.
(Essential I, II, V, IX)
Identify strategies to employ
intraprofessional communication related to
patient’s drug therapy. (Essential VI, IX)
Describe how the nurse prepares patients
and their families to manage self-
pharmacotherapeutics. (Essential VI, IX)
Identify information technology sources for
the acquisition and application of
evidence-based guidelines to practice.
(Essential III. IV, IX)
Use critical thinking process to apply
knowledge of pharmacology to plan safe
and effective drug therapy. (Essential I, IX)
Drug Calculations….
The School of Nursing has adopted
Dimensional Analysis as the method of
performing math/drug calculations.
It is expected that you already know basic
math and you will have an opportunity to
review this skill.
Criteria for Evaluation
Grade Percentages:
25% - Exam 1
25% - Exam 2
30% - Final Exam
10% - Current Event Written Assignment
10% - Blackboard Activities and Participation
100% - Total
Textbooks
Required
Lehne, R. A. (2010) Pharmacology for Nursing Care
(7th ed.)
Mulholland, Joyce M. (2007) The Nurse, The Math,
The Meds: Drug Calculations using Dimensional
Analysis
Recommended
Basch & Ulbright: Natural Standard Herb and
Supplement Handbook (2005)
Publication Manual of the American Psychological
Association (2009)
Equivalencies
1 liter (L) = 1000 milliliters
(mL)
1 kilogram (kg) = 1000 grams
1 gram (g) = 1000 milligrams
(mg)
1 milligram (mg) = 1000
micrograms (mcg)
Equivalencies
1 tsp = 5 mL 1 gr = 60, 64, or 65
1 Tbsp = 15 mL mg
1 ounce = 30 mL 15 gr = 1 Gm
1 glass = 240 mL 1 kg = 2.2 lbs
Abbreviations
cc oz IV
g, gm, Gm ss OD
gr T.O. OS
gtt Unit OU
kg V.O. PO
L, l x – (times) PR
mcg, µg < SC, subc, sc
mEq > Sl, sl
Mg, mg ID Vag
ml IM
Abbreviations
AC PC STAT
Ad lib PRN TID
c Q, q
H, h Q AM
hs, HS QID
NPO s
“Do Not Use” Abbreviations
The Joint Commission
[Link]
Patient Safety
Do Not Use List
National Patient Safety Goals
Pharmacology
A science that draws on information from
multiple disciplines, including:
Anatomy
Physiology
Psychology
Chemistry
Microbiology
Basic Terms
Drug
Any chemical that can affect living
processes
Pharmacology
Study of drugs and their interactions
with living systems
Basic Terms
Clinical pharmacology
Study of drugs in humans
Therapeutics
The use of drugs to diagnose, prevent,
or treat disease or to prevent
pregnancy, or more simply: the medical
use of drugs
Conventional Drugs
Used in Western medicine
Production regulated
Meet standards for safety and efficacy
Include prescription and OTCs
Non-allopathic Agents
Folk remedies
Herbal supplements
Limited evidence of safety and efficacy
(but growing)
Promote consumer choice and self
treatment
USES OF DRUG THERAPY
Drugs modify existing functions on a tissue or
body organ
Drugs do not create new functions – important to
know this.
Restore normal level of deficient
substances
Block harmful physiologic processes
Stimulate healthy physiologic processes
USES (cont.)
Destroy pathogens
Destroy abnormal tissue
Protect vulnerable tissue-sunscreen ex, creams
to protect the skin
Eliminate excess or harmful substances-
direutics,
Reduce symptoms-ex Tylenol.
FUNDAMENTAL PRINCIPLES
All drugs are potential poisons when
taken in sufficiently high doses
No drug produces one, and only one,
effect
Orientation to Pharmacology
Properties of an ideal drug
The therapeutic objective
Factors that determine the intensity of
drug responses
Therapeutics
Three Most Important
Properties of an Ideal Drug
1. Effectiveness-does what is suppose to do
2. Safety-there is no such thing as a safe
drug
3. Selectivity-meaning that it doesn’t ONLY
what its meant to do, BUT NO SUCH
DRUG EXISTS.
Additional Properties of an Ideal Drug
Reversible action-ex. Anethesia, morphine
Predictability-can’t be totally predicted,
everyone is different.
Ease of administration-ex pill, insulin by
injection,
Freedom from drug interactions-
Low cost-
Chemical stability-
Simple generic name-
But because no drug is ideal …
Therapeutic Objective of
Drug Therapy
Provide maximum benefit with
minimum harm
Factors That Determine the Intensity of
Drug Responses
Administration-
Pharmacokinetics-how drugs “move”
through your body
Pharmacodynamics-how do they work
Sources of individual variation
Fig. 1-1. The four basic pharmacokinetic processes.
Dotted lines represent membranes that must be crossed as drugs move throughout the body.
Administration
Important determinants of drug responses:
dosage size, route, timing
Medication errors
Patient adherence
Pharmacokinetics
Determining how much of administered
dose gets to its sites of action
Impact of the body on drugs
Four major pharmacokinetic processes:
Drug absorption
Drug distribution
Drug metabolism
Drug excretion
Pharmacodynamics
Impact of drugs on the body
Drug-receptor interaction
Binding of the drug to its receptor
Sources of Individual Variation
Physiologic variables
Age, gender, weight
Pathologic variables
Diminished function of kidneys and liver
Genetic variables
Can alter metabolism of drugs and predispose
patient to unique interactions
Drug interactions
Key Points
There is no such thing as a safe drug; all
drugs can cause harm.
There is no such thing as a selective drug;
all drugs can cause side effects.
The objective of drug therapy is to provide
maximum benefit with minimum harm.
Because all patients are unique, drug
therapy must be tailored to each
individual.
Chapter 2
Application of Pharmacology in
Nursing Practice
Nursing Responsibilities Regarding Drugs
The nurse must know…
What medications are appropriate for
the patient
What drugs are contraindicated for the
patient
The probable consequences of the
interaction between drug and patient
Nursing Responsibilities Regarding Drugs
Correct administration, without
additional interventions, cannot ensure
that treatment will result in the
therapeutic objective.-
Therapeutic objective is to provide
maximum benefit with minimal harm.
Nursing Responsibilities Regarding Drugs
The nurse’s role as advocate
Follows the patient’s status most closely
First member of the health care team to
observe and evaluate drug responses and
intervene if required
Must know the response that a medication is
likely to elicit
Last line of defense for the patient-last person
the patient can count on
Pharmacology in Patient Care
Nurse responsibility and
accountability
Patient has a cardiac arrest after receiving a
rapid infusion of potassium.-
Nurse Responsibility and Accountability
Pregnant woman has
a preservative instead NICU babies die
of an anesthetic drug after overdose of
injected into her heparin.
spinal column. She is
totally paralyzed and
dies several months
later.
As a nurse you are responsible for
every drug that you administer.
The Nursing Process guides the
nurse in administering drugs safely.
The Nursing Process
Assessment
Nursing Diagnosis
Planning/Goals
Interventions
Evaluation
Assessment: Patient- this always
happens FIRST
Current status-level of conscious
Past (health) history
Medication history
Allergies
Assessment: Patient
Identifying high-risk patients
Liver and kidney impairment
Genetic factors
Drug allergies
Pregnancy
Elderly and pediatrics
Tools: patient history, physical exam,
and lab results
Assessment: Drug
Complete, legal order
Appropriateness (rationale for use of
this drug for this patient)
Action, dosage, route, adverse effects
Contraindications, interactions
Other data: lab results, vital signs, etc
Assessment: Delivery system
Drug administration and security
Drug handling
Dosage measuring
Obtaining the drug
Systems used to dispense the drug
How to document drug therapy on the
MAR (medication administration record)
Nursing Diagnoses
Acute pain related to tissue
trauma and reflex muscle spasms
secondary to surgery as evidenced
by grimacing, reluctance to get out
of bed, and a pain score of 8.
Risk for injury related to sedating
effects of opioid analgesics
Planning/Setting Goals
Patient will have pain level of 3 or less
within 30 minutes of administration of
morphine
Patient will remain safe after pain
medication is administered as
evidenced by no falls or injuries today
Interventions:
Drug Administration
Six rights
Is this enough to
Patient – 2 identifiers!
meet the
Drug therapeutic
Dose objective?
Route
Time
Right documentation
…right to refuse
Interventions:
Drug Administration
Keep medication secure-
Be knowledgeable about institution’s
policies and procedures
Never administer medication prepared by
another nurse-
Nurse must observe patient taking
medication-
Interventions:
Drug Administration
Certain drugs have more than one
indication. Dosage may differ depending
on which indication the drug is used for.
Many drugs can be administered by more
than one route. Dosage may differ
depending on the route selected.
Certain IV agents can cause severe local
injury if IV extravasates.
Interventions:
Documentation
When to chart-do it immediately after you give meds.
Where to chart-
What to chart
Why given or not (PRN vs routine)
Effects
Other relevant data
Military time……
Interventions:
Teaching
Considerations
Knowledge
Readiness to
learn
Environment
Teaching May Include…
Drug Effects of suddenly
Schedule discontinuing
Therapeutic effects What if dose
Adverse effects missed
Interactions Safety
considerations
Handling/storage
Evaluation
Of Drug Effects
Therapeutic response
Adverse effect (includes side effects)
Interactive effects
Further teaching needs
Promoting Therapeutic Effects
Promoting patient adherence
Also known as compliance or concordance
Extent to which a patient’s behavior coincides
with medical advice
Implementing nondrug measures
Drug therapy can often be enhanced by
nondrug measures.
Biofeedback, emotional support, weight
reduction, smoking cessation, sodium
restriction, etc.
Minimizing Adverse Effects
All drugs have the potential to produce
undesired effects.
Always know the following:
The major adverse effects the drug can produce
The time when these reactions are likely to occur
Early signs that an adverse reaction is developing
Interventions that can minimize discomfort and
harm
Minimizing Adverse Interactions
Take a thorough drug history.
Advise the patient to avoid OTC drugs that
can interact with the prescribed
medication.
Monitor for adverse interactions known to
occur.
Be alert for as-yet unknown interactions.
Making PRN Decisions
PRN – pro re nata, meaning “as needed”
Know the reason for drug use.
Be able to assess the patient’s medication
needs.
Managing Toxicity
Early identification makes early
intervention possible.
Know the early signs of toxicity.
Know the procedure for toxicity
management.
Chapter 3
Drug Regulation, Development,
Names, and Information
Overview of Chapter 3
Landmark drug legislation
New drug development
Drug names
Over-the-counter drugs
Sources of drug information
Landmark Drug Legislation
Federal Pure Food and Drug Act, 1906
Food, Drug, and Cosmetic Act, 1938
Harris-Kefauver Amendments, 1962
Controlled Substances Act, 1970
Food Drug and Cosmetic Act (1938)
Targeted safety and efficacy
Regulated manufacture, distribution,
advertising, labeling
Made USP official standard for strength
and purity
[Link]
Food Drug and Cosmetic Act (1938)
Designated FDA to enforce
Role of the FDA
[Link]
Harris Kefauver Amendment
First law to demand that drugs actually
offer some benefit
Comprehensive Drug Abuse
Prevention and Control Act (1970)
Classified and regulated drugs with
potential for abuse
Established drug abuse education and
treatment programs
Really focus on this ACT ***
Schedule 1: high abuse potential, no
approved medical use
Schedule 2: high abuse potential, accepted
medical use-codeine, anabolic steroids
Schedule 3: less abuse potential, accepted
medical use
Schedule 4: some abuse potential,
accepted medical use
Schedule 5: less abuse potential than
schedule 4, accepted medical use
Good idea to know these schedules ***
1992 Rx Drug User Fee Act
Shortened review process
1997 FDA Modernization Act
Permitted drug companies to provide
information about non-FDA approved uses
( off-label uses)-you CANT market a drug for a USE
that is not approved by the FDA. You can share the
information, that’s all.
New Drug Development
The randomized controlled trial
Control use
Randomization
Blinding
Stages of New Drug Development
Preclinical testing
Clinical testing
Phase 1: healthy subjects
Phase 2: target group
Phase 3: larger target group
Phase 4: FDA evaluation and
postmarketing surveillance
***Know these steps. *** usually an 8 year process.
Limitations of the Testing Procedure
Limited information for women and
children
Women
Children
Failure to detect all adverse effects
Exercising Discretion Regarding
New Drugs
Be neither the first to adopt the new nor
the last to abandon the old.
Balance potential benefits against inherent
risks.
New drugs generally present greater risks
than the old ones.
Drug Names
Which Name to Use—
Generic or Trade?
The little problems with generic names
More complicated than trade names
The big problems with trade names
Single drug can have multiple trade names.
U.S. drugs and drugs outside the U.S. may
have different active ingredients.
Products with the same trade name may have
different active ingredients.
Monistat and Kaopectate
Which Name to Use—
Generic or Trade?
Generic products versus brand-name
products
Are generic products and brand-name products
therapeutically equivalent?
Would a difference between brand-name and
generic products justify the use of trade
names?
Over-the-Counter Drugs
Americans spend about $20 billion
annually on OTC drugs.
OTC drugs account for 60% of all doses
administered.
40% of Americans take at least one OTC
drug every 2 days.
Four times as many illnesses are treated
by a consumer using an OTC drug as by a
consumer visiting a physician.
Over-the-Counter Drugs
With most illnesses (60% to 95%), initial
therapy consists of self-care, including
self-medication with an OTC drug.
The average home medicine cabinet
contains 24 OTC preparations.
Sources of Drug Information
People
Clinicians and pharmacists
Poison control centers
Pharmaceutical sales representatives
Published Information
Text-like books
Goodman & Gilman’s, The Pharmacological
Basis of Therapeutics
Pharmacotherapy: A Pathophysiologic
Approach
Applied Therapeutics: The Clinical Use of
Drugs
Published Information
Newsletters
The Medical Letter on Drugs and Therapeutics
Prescriber’s Letter
Reference books
Physicians’ Desk Reference
Drug Facts and Comparisons
Nursing drug references
Internet sources:
[Link]/cder/drug
[Link]-you can use this for the current event
article.
[Link]
Programs for smart phones, PDA, etc