Pharmacolog

y
Professor Mary Cris T. Rombaoa, RN RM MAN

Part I
Pharmacology

 Simply defined, from the Greek, as

the study of medicine
 Pharmacology is an expansive subject
encompassing:
 How drugs are administered
 Where drugs travel in the body
 Responses that drugs produce
 it is the body of knowledge concerned
with the action of chemicals on biologic
systems (chemical processes)
Modern Pharmacology Began
in the 1800s

 Chemists isolated pharmacological substances

from natural substances
 Early researchers used themselves as test
subjects
 First department of pharmacology established at
Estonia in 1847
Always Changing

 10,000 drugs currently available

 Each drug has its own characteristics:
 Therapeutic applications
 Interactions
 Adverse effects
 Mechanisms of action
Which substances are inside the drugs?

 Drugs in common use include inorganic

ions, nonpeptide organic molecules, small
peptides and proteins, nucleic acids, lipids,
and carbohydrates. Some are found in
plants or animals, and others are partially
or completely synthetic
Natur Natur
e e
Endogenou
Organic
s

Synthetic Exogenous
Size and Molecular weight

MW varies from 7 – 50,000

Most medicines have MW 0f 100 – 1000
What is the significance of this?
Do you mind how drugs are being
produced?
 arecommercially produced in cell,
bacteria, or yeast cultures using
recombinant DNA technology.
 Drug-
Receptor
Bonds

Covalent
bonds

Electrostati
c bonds

Weaker
Interactions
Medical Pharmacology

 isthe area of pharmacology concerned with

the use of chemicals in the prevention,
diagnosis, and treatment of disease,
especially in humans.
Toxicology

 isthe area of pharmacology concerned with

the undesirable effects of chemicals on
biologic systems.
Pharmacokinetics

describes the effects of the body on

drugs, eg, absorption, metabolism,
excretion, etc
Pharmacodynamics

 denotesthe actions of the drug on the

body, such as mechanism of action and
therapeutic and toxic effects
What are the ideal properties of a drug?

EFFECTIVENESS
 THE DRUG SHOULD ELICIT THE RESPONSE IT WAS MEANT TO

SAFETY
 SAFE EVEN IN HIGH CONCENTRATIONS AND FOR LONG
PERIODS OF ADMINISTRATION

SELECTIVITY
 THE ONE WITH THE LEAST SIDE EFFECTS
ALERT!
NO DRUG IS IDEAL!
NO DRUG IS SAFE!
ALL DRUGS PRODUCE SIDE EFFECTS!
DRUGS RESPONSES MAY BE
DIFFICULT TO PREDICT!

SO, WHY YOU STILL GIVE DRUGS?

 PROVIDE MAXIMUM
BENEFIT WITH MINIMUM
HARM 
Pharmacology In Nursing

 Knowledge of pharmacology essential to the nursing profession

 Nurses are health care providers most often directly involved in
patient care
 Applies to nurses in all settings from clinics and hospitals to home care
 Applies to nurses who teach and to students entering nursing profession
 Study of pharmacology is gradual process that continues throughout
life
Therapeutic Classification of
Drugs

 Based on therapeutic usefulness in treating

particular diseases or disorders
 Examples:
 Antidepressants
 Antipsychotics
 Antineoplastics
DRUG CLASSES
Therapeutic Classification

Table 1.1 Therapeutic Classification

FOCUS: CARDIOVASCULAR FUNCTION
Usefulness Drug Classification
Influence blood clotting Anticoagulant

Lower blood cholesterol Antihyperlipidemic

Lower blood pressure Antihypertensive

Restore normal cardiac rhythm Antidysrhythmic

Treat angina Antianginal

Pharmacological Classification of Drugs

 Based on the way a drug works at the molecular, tissue, or body

system level
 Addresses a drug’s mechanism of action
 How a drug produces its physiological effect in the body
Pharmacologic Classification

Table 1.2 Pharmacologic Classification

FOCUSING ON THERAPEUTIC APPLICATION:
PHARMACOTHERAPY FOR HYPERTENSION
Mechanism of Action Drug Classification
Lowers plasma volume Diuretic

Blocks heart calcium channels Calcium channel blocker

Blocks hormonal activity Angiotensin-converting enzyme Inhibitor
Blocks physiological reactions to stress Adrenergic antagonist
Dilates peripheral blood vessels Vasodilator
PROTOTYPES
“Prototype” Drug—Serves as Model
for a Drug Class
 Is well understood
 Has known action and adverse effects
 Is used to compare other drugs in the same pharmacologic class
 May not be the most widely used drug in its class
 Disagreements may exist over which drug should serve as prototype
drug
SCHEDULES
Philippine Schedules of Dangerous Drugs
(R.A. 9165 SECTION 93 ARTICLE XI)
 SCHEDULE 1/ LEVEL 1
 HAS NO CURRENTLY ACCEPTED MEDICAL USE IN TREATMENT IN THE PHILIPPINES; HAS LACK OF
ACCEPTED SAFETY FOR USE OF THE DRUG UNDER MEDICAL SUPERVISION
 SCHEDULE 2/ LEVEL 2
 MAY HAVE CURRENTLY ACCEPTED MEDICAL USE IN TREATMENT IN THE PHILIPPINES; HAS HIGH
POTENTIAL FOR ABUSE THAT MAY LEAD TO SEVERE PSYCHOLOGICAL OR PHYSICAL DEPENDENCE
 SCHEDULE 3/ LEVEL 3
 HAS A CURRENTLY ACCEPTED MEDICAL USE IN TREATMENT IN THE PHILIPPINES; HAS A POTENTIAL FOR
ABUSE LESS THAN THE DRUG IN SCHEDULE 1 & 2 THAT MAY LEAD TO MODERATE OR LOW PHYSICAL
DEPENDENCE.
 SCHEDULE 4/ LEVEL 4
 HAS A CURRENTLY ACCEPTED MEDICAL USE IN TREATMENT IN THE PHILIPPINES; HAS A LOW POTENTIAL
FJOR ABUSE LESS THAN THE DRUG IN SCHEDULE 3 THAT MAY LEAD TO PHYSICAL DEPENDENCE OR
PSYCHOLOGICAL DEPENDENCE.
 SCHEDULE 5/ LEVEL 5
 HAS A CURRENTLY ACCEPTED MEDICAL USE IN TREATMENT IN THE PHILIPPINES; HAS A POTENTIAL FOR
ABUSE THAT MAY LEAD FROM LOW TO HIGH PSYCHOLOGICAL OR PHYSICAL DEPENDENCE. DANGEROUS
DRUGS IN THE PHILIPPINES ONLY
WHAT IS YOUR NURSING RESPONSIBILITY?
SAMPLES ONLY
DRUG NOMENCLATURE
Most drugs are ordered in what
name format?

a. generic
b. brand
c. trade
d. chemical
CHEMICAL NAME
DESCRIBES THE DRUG’S CHEMICAL STRUCTURE

GENERIC NAME
OFFICIAL AND NON-PROPRIETY NAME OF THE DRUG

TRADE/BRAND NAME
PROPRIETY NAME CHOSEN BY THE DRUG COMPANY
Generic Name

 Assigned by the U.S. Adopted Name

Council
 Less complicated and easier to
remember
 Lowercase
 Each drug has only one generic name
 Used by many organizations
 U.S. Food and Drug Administration (FDA)
 U.S. Pharmacopoeia
 World Health Organization (WHO)
A Drug Has Several Trade Names

 Assigned by company marketing the drug

 Short, easy to remember
 Also called proprietary, product, or brand name
 Drug developer has exclusive rights to name and market a new drug
for 17 years in the United States
 Example:
diphenhydramine is the generic name for Benadryl (one of many trade names)
Table 1.3 Examples of Trade-Name Products
Containing Popular Generic Substances

Table 1.3 Examples of Trade-Name Products Containing

Popular Generic Substances
Generic Substance Trade Names
aspirin Acuprin, Anacin, Aspergum, Bayer, Bufferin,
Ecotrin, Empirin, Excedrin, Maprin, Norgesic,
Salatin, Salocol, Salsprin, Supac, Talwin,
Triaphen-10, Vanquish, Verin, Zorprin
diphenhydramine Allerdryl, Benadryl, Benahist, Bendylate,
Caladryl, Compoz, Diahist, Diphenadril,
Eldadryl, Fenylhist, Fynex, Hydramine,
Hydril, Insomnal, Noradryl, Nordryl, Nytol,
Tusstat, Wehdryl
ibuprofen Advil, Amersol, Apsifen, Brufen, Haltran,
Medipren, Midol 200, Motrin, Neuvil,
Novoprofen, Nuprin, Pamprin-IB, Rufen,
Trendar
GENERIC DRUGS
A generic drug is a medication that has exactly the
same active ingredient as the brand name
drug and yields the same therapeutic effect. It is
the same in dosing, safety, strength, quality, the
way it works, the way it is taken, and the way it
IN ES
should be used ILIP P
E PH
F T H
CT O
G A
IC DRU
NE R
GE
ORPHAN DRUGS

Drugs for rare diseases—so-called orphan

drugs
 can be difficult to research, develop, and market. Proof of
drug safety and efficacy in small populations must be
established, but doing so is a complex process.
Over-the-Counter Drugs

 NON_PRESCRIPTION MEDICINES
 Directly dispensed to buyer
DRUG DEVELOPMENT
DRUG REGULATION
Drug Screening

 Itinvolves a variety of assays at the

molecular, cellular, organ system, and
whole animal levels to define the
pharmacologic profile, ie, the activity and
selectivity of the drug
PRE-CLINICAL SAFETY AND TOXICITY
TESTING
NO EFFECT DOSE
Maximum dose at which a specified toxic
effect is NOT SEEN

MINIMUM LETHAL DOSE

smallest dose that is observed to KILL any
experimental animal

MEDIA LETHAL DOSE (LD50)

the dose that kills approximately 50% of the
animals in a test group
FDA/BFAD

 isthe administrative body that oversees the

drug evaluation process and grants approval
for marketing of new drug products
ETHICAL CONSIDERATIONS

INSTITUTIONAL POLICIES

NIGHTINGALE’S PLEDGE

PHILIPPINE NURSING ACT OF 2002

PREGNANCY CATEGORIES
Pregnancy Categories

 FDA Pregnancy Categories

 A: No risk to fetus.
 B: No risk in animal studies, and well-controlled studies in pregnant
women are not available.
 C: Animal studies indicate a risk to the fetus. Risk versus benefit of the
drug must be determined.
 D: A risk to the human fetus has been proved. Risk versus benefit of the
drug must be determined.
 X: A risk to the human fetus has been proved. Risk outweighs the benefit,
and drug should be avoided during pregnancy.

14
Medication Administration
Chapter 3
The Nursing
Process in Drug
Administration
 Nurses are expected to
understand the
pharmacotherapeutic principles
for all medications given to each
patient
Nurse Responsibilities

 What drug is ordered

 Name (generic and trade) and drug classification
 Intended purpose or use
 Effects on body
 Contraindication
 Special considerations (e.g., how age affects response)
 Side effects
 Why the medication was prescribed
Nurse Responsibilities

 Before drug is administered, the nurse must

know all variables of the patient's condition
 Be prepared to recognize and react to adverse
effects (adverse events)
Five Rights of Drug Administration

 Five rights used as the basis of safe delivery of medications. They

are:
 Right patient
 Right medication
 Right dose
 Right route of administration
 Right time of delivery
Special Drug-
Administration
Abbreviations
 STAT—medication is to be given
immediately, and only once
 ASAP—drug should be available for
administration within 30 minutes of
the written order
 PRN—drug is administered as required
by the patient's condition
Table 3.1 Drug Administration Abbreviations
(1 of 2)

Table 3.1 Drug Administration Abbreviations

Abbreviation Meaning
ac before meals
ad lib as desired/as directed
AM Morning
bid twice a day
cap capsule
gtt drop
h or hr hour
IM intramuscular
IV intravenous
no number
pc after meals; after eating
PO by mouth
PM afternoon
Table 3.1 Drug Administration
Abbreviations (2 of 2)
Table 3.1 Drug Administration Abbreviations
Abbreviation Meaning
prn when needed/necessary
qid four times per day
q2h every 2 hours (even or when first given)
q4h every 4 hours (even)
q6h every 6 hours (even)
q8h every 8 hours (even)
q12h every 12 hours
Rx take
STAT immediately; at once
tab tablet
tid three times a day
Note: The Institute for Safe Medical Practices recommends the following abbreviations be avoided
because they can lead to medication errors: q: instead use “every”; qh: instead use “hourly” or
“every hour”; qd: instead use “daily” or “every day”; qhs: instead use “nightly”; qod: instead use
“every other day.” For these and other recommendations, see the official Joint Commission “Do
Not Use List” at http://www.jointcommission.org/assets/1/18/dnu_list.pdf
Drug-
Administration
Abbreviations
 Do not use these abbreviations as
they can lead to medication errors: q,
qh, qd, qhs, qod
Drug-
Administration
Written Orders
 Single order—drug is to be given
only once at a specific time
 Orders not written as STAT, ASAP,
NOW, or PRN are called routine
orders
 Standing order—written in advance
of a situation that is to be carried out
under specific circumstances
Drug-Administration Procedures

 Nurses must educate patients carefully about timing of taking

medications
 Nurses must document carefully the details of medications given to
patient—after they have been given
 Refusal or omission of medication must be documented
Three Systems
of
Measurement
Used in
Pharmacology
 Metric—
most
common
 Apothecary
—oldest
 Household
Nurse Must Be Able to Convert
Among All Three Systems
 Metric, Apothecary, and Household Approximate
Measurement Equivalents
 Joint Commission (JCAHO), the accrediting
organization for health care agencies, has placed
apothecary measurements on its “do not use” list
 Nurses should encourage use of accurate medical
dosing devices at home
Routes of Drug
Administration

 Three broad routes are enteral,

topical, and parenteral
 Subsets within each
Common Protocols and Techniques
for All Routes of Administration
 Verify medication order, check allergy history
 Wash hands and apply gloves, if indicated
 Use aseptic technique when preparing and administering
parenteral medications
 Identify patient (two forms of ID)(Scan Patient)
 Ask patient about known allergies
 Inform patient about drug
 Position patient
 Scan Drug and Remove prepackaged drug at bedside
Enteral Route

 Enteral route includes drugs administered

 By mouth
 Tablets, capsules, sublingual, and buccal
 Via nasogastric tube or gastrostomy tube
Enteral Route

 Tablets and capsules most common

form of drugs
 Can be crushed or opened only if
manufacturer instructed; enteric-
coated tablets must remain intact
 Sustained-release tablets or capsules
are designed to dissolve very slowly
 Created to increase compliance by
reducing frequency of dosage
Table 3.3 Enteral Drug Administration

Table 3.3 Enteral Drug Administration

Drug Form
(Example) Administration Guidelines
A. Tablet, capsule, 1. Assess that the patient is alert and has the ability to swallow.
or liquid (Orally 2. Place the tablets or capsules into a medication cup.
disintegrating tablets 3. If the medication is in liquid form, shake the bottle to mix the agent, and measure
and soluble films are the
placed on the tongue dose into the cup at eye level.
and then swallowed) 4. Hand the patient the medication cup.
5. Offer a glass of water to facilitate swallowing the medication. Milk or juice may be
offered
if not contraindicated.
6. Remain with the patient until all the medication is swallowed.
B. Sublingual 1. Assess that the patient is alert and has the ability to hold the medication under the
tongue.
2. Place the sublingual tablet under the tongue.
3. Instruct the patient not to chew or swallow the tablet or move the tablet around with

tongue.
4. Instruct the patient to allow the tablet to dissolve completely.
5. Remain with the patient to determine that all the medication has dissolved.
6. Offer a glass of water after the medication has dissolved, if the patient desires.
Table 3.3 Enteral Drug Administration

Table 3.3 Enteral Drug Administration

Drug Form
(Example) Administration Guidelines
D. Nasogastric 1. Administer liquid forms when possible to avoid clogging the tube. Contact the
and gastrostomy pharmacist or health care provider if unsure if the medication may be given through
the tube.
2. If the medication is solid, crush finely into a powder and mix thoroughly with at least
30 mL of warm water until dissolved. Enteric-coated, extended-release, and other
dosage types may not be crushed. Always check the drug information before
crushing.
3. Assess and verify tube placement per agency protocol.
4. Turn off the enteric feeding, if applicable to the patient.
5. Aspirate stomach contents and measure the residual volume as per agency
protocol. If greater than 100 mL for an adult, check agency policy.
6. Return the residual via gravity and flush with water.
7. Pour the medication into the syringe barrel and allow to flow into the tube by gravity.
Give each medication separately, flushing between with water.
8. Keep the head of the bed elevated for 1 hour to prevent aspiration.
9. Reestablish continual feeding, as scheduled. Keep the head of the bed elevated 45°
to prevent aspiration.
Sublingual and
Buccal Drug
Administration
 Tablet is kept in mouth
 Sublingual
 Medication is placed under the tongue
and allowed to dissolve slowly
 Rich blood supply causes rapid onset
 Used only after oral medications have
been swallowed, if multiple drugs are
ordered
 No food or drink until completely
dissolved
Rapid-Dissolving
Tablets and Films
 Orally distintegrating tablets
(ODTs) or oral dissolving films
 Medication placed on the tongue
 Dissolves in less than 30 seconds
 Eliminates need for external
source of water and aids
compliance
 Ondansetron first FDA-approved
drug in this form
Enteral Drug Administration
Advantages
 Convenient
 Overdose can be countered by retrieval of undigested medicines
through vomiting
 Safest route because skin barrier not compromised
 Uses vast absorptive surfaces of the oral mucosa, stomach, or small
intestine
Enteral Drug Administration
Disadvantages
 Difficulty swallowing by some patients
 May be inactivated if tablets or capsules crushed or opened
 Can be inactivated by enzymes
 Depends on patient gastrointestinal motility and mobility
 First-pass metabolism: inactivation of drug by processing in the liver
Topical Drugs Applied to Skin or
Mucous Membranes
 Applications:
 Dermatologic preparations: applied to skin—most common
 Instillations and irrigations: applied into body cavities and orifices
 Inhalations: applied to the respiratory tract by inhalers, nebulizers, or
positive-pressure breathing
Transdermal Delivery System

 Transdermal patches provide effective means of delivering some

medications
 Rate of delivery and dose may vary with drug
 Avoids first-pass effect of liver and enzymes
 Full documentation by nurses applies
 Do NOT apply over pacemakers, wounds, rashes, or non
intact skin!
 Fold and witness discard for patches of controlled substances
 Figure 3.2b Transdermal patch administration: patch immediately applied
to clean, dry, hairless skin and labeled with date, time, and initials

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Ophthalmic Administration

 Used to treat local conditions of the eye and surrounding structures

 Common indications of problems:
 Excessive dryness, infections, glaucoma, and dilation of the pupil during
eye examinations
 Special procedures, sometimes even immobilization, may be needed
for children
 Figure 3.3 Instilling an eye ointment into the lower conjunctival sac

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Otic Administration

 Used to treat local conditions of the ear, including infections and soft
blockages of the auditory canal
 Eardrops, irrigations
 Usually used for cleaning purposes
 Figure 3.4 Instilling eardrops
Source: Andy Crawford/DK Images.

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Nasal Administration

 For both local and systemic administration

 Ease of use, avoids first-pass effect and digestive enzymes
 Mucosal irritation common; potential for damage
 Figure 3.5 Nasal drug administration
Source: Ph College/Pearson Education, Inc.

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Vaginal Administration

 For treating local infections and to relieve vaginal pain and itching
 Suppositories, creams, jellies, or foams
 Nurse must explain purpose of treatment and provide for privacy and
patient dignity
 Figure 3.6a Vaginal drug administration: instilling a vaginal suppository

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Rectal
Administration

 Local or systemic administration

 Usually suppository form, but
sometimes administered as enema
 First-pass effect and digestive
enzymes avoided
Parenteral Drugs Are Administered
via Needle
 Types: intradermal, subcutaneous, intramuscular,
intravenous
 Require aseptic technique
 Nurse must have knowledge of anatomical
locations
 Nurse must know correct equipment to use
 Nurse must know procedure for disposing of
hazardous equipment
Parenteral Locations

 Intradermal: dermis layer of skin

 Subcutaneous: deepest layers of the skin
 Intramuscular: specific muscles
 Intravenous: directly into bloodstream
 Advanced parenteral delivery may be directly into body cavities or
organs
Intradermal and Subcutaneous
Administrations
 Avoid the hepatic first-pass effect and digestive enzymes; offer
method for those who cannot take medicine orally
 Only small volumes can be administered; injections can cause pain
and swelling
Intradermal
Administrations
 Intradermal (ID) injection
administered into the dermis
layer of the skin
 More easily absorbed than in
subcutaneous
 Small amount of drug
 Figure 3.7a Intradermal drug administration: cross section of skin showing depth of
needle insertion

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Table 3.5 Parenteral Drug
Administration

Table 3.5 Parenteral Drug Administration

Drug Form Administration Guidelines
A. Intradermal route 1. Verify the order and prepare the medication in a tuberculin or 1-mL syringe with a
preattached 26- to 27-gauge, 3/8- to 5/8-inch needle.
2. Apply gloves and cleanse the injection site with antiseptic swab in a circular motion.

Allow to air dry.

3. With the thumb and index finger of the nondominant hand, spread the skin taut.
4. Insert the needle, with the bevel facing upward, at an angle of 10–15°.
5. Advance the needle until the entire bevel is under the skin; do not aspirate.
6. Slowly inject the medication to form a small wheal or bleb.
7. Withdraw the needle quickly, and pat the site gently with a sterile 2 × 2 gauze pad.
Do
not massage the area.
8. Instruct the patient not to rub or scratch the area.
9. Draw a circle around the perimeter of the injection site. Read in 48 to 72 hours.
 Subcutaneous
Administrations

 Subcutaneous injection delivered to

the deepest layers of the skin
 Used for easy access and rapid
absorption
 Important to rotate injection sites
 Aspiration not usually necessary, but
depends on drug
 Figure 3.8a Subcutaneous drug administration: cross section of skin showing depth of
needle insertion

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Table 3.5 Parenteral Drug
Administration
Table 3.5 Parenteral Drug Administration
Drug Form Administration Guidelines
B. Subcutaneous route 1. Verify the order and prepare the medication in a 1- to 3-mL syringe using a 23- to 25-
gauge, 1⁄2- to 5⁄8-inch needle. For heparin, the recommended needle is 3⁄8 inch and
25–26
gauge.
2. Choose the site, avoiding areas of bony prominence, major nerves, and blood vessels.
For
heparin and other parenteral anticoagulants, check with agency policy for the preferred
injection sites.
3. Check the previous rotation sites and select a new area for injection.
4. Apply gloves and cleanse the injection site with antiseptic swab in a circular motion.
5. Allow to air dry.
6. Bunch the skin between the thumb and index finger of the nondominant hand.
7. Insert the needle at a 45° or 90° angle depending on body size: 90° if obese; 45° if
average
weight. If the patient is very thin, gather the skin at the area of needle insertion and
administer at a 90° angle.
8. Inject the medication slowly.
9. Remove the needle quickly, and gently massage the site with antiseptic swab. For
heparin
and other parenteral anticoagulants, do not massage the site, as this may cause
increased
bruising or bleeding.
Intramuscular Administration

 Delivers medication into specific muscles

 More rapid onset of action than with oral, ID, or subcutaneous
administration
 Can accept larger volume of medication than subcutaneous
 Injection site very important; must avoid bone, blood vessels, and
nerves
Z-track injection

A, Pull the skin to one side and hold; insert needle. B, Holding skin to side,
inject medication. C, Withdraw needle and release skin.

97
Three Common Intramuscular
Injection Sites
 Ventrogluteal
 Deltoid
 Vastus lateralis
Ventrogluteal
Injection Site
Locate the site by placing the
hand with the heel on the
greater trochanter and the
thumb

toward the umbilicus. Point

to the anterior iliac spine with
the index finger, spreading
the

middle finger to point

toward the iliac crest (forming
a V). Inject the medication
within the V-

shaped area of the index

and third finger. (Note: This is
how to locate the
ventrogluteal

site.)
Deltoid Injection
Site for IM
Vastus lateralis
Injection Site
for IM
 Figure 3.9a Intramuscular drug administration: cross section of skin showing depth of
needle insertion

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Intravenous Administration (IV)

 Medications and fluids are administered directly into the bloodstream

and are immediately available for use by the body
 Fastest drug onset action, but also most dangerous method
 Contamination
 Swift adverse reactions
Parenteral Advantages and
Disadvantages
 Advantages:
 Bypasses first-pass effect and enzymes
 Available to patients unable to take medication orally
 Disadvantages:
 Only small doses can be used
 Possible pain and swelling at injection site
Nursing process In Pharmacology
Chapter 6
Steps of Nursing
Process
 Assessing
 Diagnosing
 Planning
 Implementing
 Evaluating
Assessment of the Patient

 Systematic collection, organization, validation, and documentation of patient data

 Health history and physical assessment

 Baseline data gathered; will be compared to later information from observations
 Medications that patient takes
 OTC herbal supplements
 Allergies
 Trouble swallowing
 Fear of needles

 Subjective versus Objective

Assessment of Patient

 Once pharmacotherapy is initiated, assessment focuses on reaction

to medication. Watch for:
 Desired response
 Adverse effects
 Patient capability of assuming responsibility for self-administration
Nursing Diagnoses for Drug
Administration
 Often most challenging part of nursing
 Focus is on patient’s needs, not nurse’s
 Three main areas of concern
 Promoting therapeutic drug effects
 Minimizing adverse drug effects and toxicity
 Maximizing patient ability for self-care (including knowledge, skills, and
resources necessary for safe and effective drug administration)
 PRIMARY MEDICAL PROBLEM
 SECONDARY MEDICAL PROBLEM
 SOCIAL,
PSYCHOLOGIC, EDUCATIONAL,
ENVIRONMENTAL, SAFETY AND
NUTRITIONAL PROBLEMS
Most Common Nursing Diagnoses
for Medication Administration
 Deficient Knowledge
 Patient not properly educated about medication
 Noncompliance
 Patient properly educated, but chooses not to take medication
Goals for Patient Receiving
Medications
 Based on nursing diagnosis
 Focused on what patient will achieve or do
 Prioritized
 Discussed with patient or caregiver
 Can be short- or long-term goals
 Measurable
 Patient Centered
 THERAPEUTIC GOAL
 MEDICATION KNOWLEDGE
 SPECIAL NEEDS EQUIPMENT
 TEACHING NEEDS
Monitoring Drug Effects Is Primary
Intervention
 Monitor for identified therapeutic effect
 Reassessing patient
 Physical condition
 Vital signs
 Body weight
 Lab values
 Serum drug levels
Documentation of Medication
Administration
 INTERPRETATION MEDICATION ORDERS
 CONSIDER THE 10R’S OF MED AD
 Administration of medication


USING MAR
 Therapeutic and adverse effects
 Patient statements
 Objective assessment data
 ENSURING PATIENT’S SAFETY IN MEDICATION ADMINISTRATION
EVALUATION

THERAPEUTIC EFFECTS
ADVERSE EFFECTS
ALLERGIC REACTION
 Patient Education

 Primary role for nurses

 Directly related to
 Deficient knowledge
 Noncompliance
 Provide written, verbal, and demonstration to patient
 Elderly and pediatric patients are special challenges
 May need to co-teach patient’s caregiver
Important Areas of Teaching for a Patient
Receiving Medications
Table 6.3 Important Areas of Teaching for a Patient Receiving Medications

Area of Teaching Important Questions and Observations

Therapeutic use • Can you tell me the name of your medication and what it is used for?
and outcomes • What will you look for to know that the medication is effective? (How will
you know that the medicine is working?)

Monitoring side and • Which side effects can you handle by yourself (e.g., simple nausea,
adverse effects diarrhea)?
• Which side effects should you report to your health care provider (e.g.,
extreme cases of nausea or vomiting, extreme dizziness, bleeding)?
 Important Areas of Teaching for a Patient
Receiving Medications
Table 6.3 Important Areas of Teaching for a Patient Receiving Medications

Area of Teaching Important Questions and Observations

Medication • Can you tell me how much of the medication you should take (milligrams,
administration number of tablets, milliliters of liquid, etc.)?
• Can you tell me how often you should take it?
• What special requirements are necessary when you take this medication
(e.g., take with a full glass of water, take on an empty stomach, and
remain upright for 30 minutes)?
• Is there a specific order in which you should take your medications (e.g.,
using a bronchodilator before using a corticosteroid inhaler)?
• Can you show me how you will give yourself the medication
(e.g., eyedrops, subcutaneous injections)?
• What special monitoring is required before you take this medication (e.g.,
pulse rate)? Can you demonstrate this for me? Based on that monitoring,
when should you not take the medication?
• Do you know how, or where, to store this medication?
• What should you do if you miss a dose?
Other monitoring • Are there any special tests you should have related to this medication
and special (e.g., finger-stick glucose levels, therapeutic drug levels)?
requirements • How often should these tests be done?
• What other medications should you not take with this medication?
• Are there any foods or beverages you must not have while taking this
medication?
Medication Errors and Risk
Reduction
Chapter 7
Healthcare Provider Factors
Contributing to Medication Errors
 Omitting one of the rights of drug administration
 Failing to perform an agency system check
 Failing to take into account for patient variables such as age, body
size, and renal or hepatic function
 Giving medications based on verbal orders or phone orders
 Giving medication based on an incomplete order or an illegible order
 Practicing under stressful work conditions
Patient/Caregiver Factors
Contributing to Medication Errors
 Taking drugs prescribed by several practitioners
 Getting prescriptions filled at more than one pharmacy
 Not filling or refilling prescriptions
 Patient/Caregiver Factors
Contributing to Medication Errors
 Taking medications incorrectly
 Taking medications that may be left over from a previous illness
 Taking medications prescribed for someone else
Impact of
Medication
Errors
 Common cause of morbidity and
preventable death in hospitals
 Emotionally devastating to nurse and
patient
 Increased cost to patient and facility,
as it may extend patient's stay
Reporting and Documenting
Medication Errors
 Documentation in medical record must include specific nursing
interventions implemented after the error to protect the patient
 Document all individuals notified of error
 Give details of what medication was given or omitted in medication-
administration record (MAR)
Reporting with an Incident Report

 Recorded in factual and objective manner

 Allows nurse to identify factors contributing to the error
 Is not part of patient's hospital record
 Used by agency's risk management personnel for quality
improvement
Sentinel Events

 Unexpected occurrences involving death or serious physical or

psychological injury, or risk thereof
 Always investigated
 Interventions to ensure no repetition

• Root cause analysis (RCA) seeks to prevent

another occurrence by asking what happened
and why, and what can be done to prevent it
Reduction of Medication Errors and
Incidents—Planning
 Avoid using abbreviations that can be misunderstood
 Question unclear orders
 Do not accept verbal orders
 Follow facility policies and procedures
 Ask patient to demonstrate understanding of therapy goals
Reduction of Medication
Errors and Incidents—
Implementation
 Be aware of potential distractions during
medication administration
 Remove distractions, if possible
 Focus on task of administering medications
 Practice the rights of medication administration
 Keep in mind the following steps:
 Confirm patient has swallowed medication
 Be alert for long-acting oral dosage forms with
indicators such as LA, XL, and XR
 Be alert for drugs whose names look and sound alike
Governmental and Other Agencies
that Track Medication Errors
 FDA's MedWatch
 Allows health care providers and the public to report errors anonymously
 Provides up-to-date clinical information about safety issues involving
medical products
 Institute for Safe Medication Practices (ISMP)
 FDA’s Division of Medication Error Prevention and Analysis (DMEPA) reviews all
medication error reports
High Alert and Look Alike Sound Alike

 High alerts cause higher  Look/sound alike easily

consequences confused
 Standardizing the orders,  Tall man Letters
storage, preparations, and
administration of these
products
 Heparin, insulin,
anesthetics, …..
 DRUG CALCULATION

Golden Formula: Dosage x volume

Stock
 Scenario: ORAL – PEDIA

Start Cefixime
(Tergecef) 100mg BID for
7 days. How many ml of
this antibiotic treatment
will the patient receive
for the next two days?
Solution:
100mg x 5ml = 5ml per dose
100mg

5ml x 4 doses = 20ml

ANSWER = 20ml
Scenario: ORAL - ADULT

Start Clonazepam
(Rivotril) 0.5mg ODHS.
Compute for the tablet
per dose.
Solution:

0.5mg x 1 tablet
2mg
1 x 1 tablet
4
Answer = 1 tablet
4
Scenario: IV – PEDIA
Start Metronidazole (Flagyl) 100mg q8o

What is the volume of this infusion will you give

to your patient each dose?
Solution:

100mg x 100 ml
500mg

0.2 x 100 ml = 20ml

Scenario: IV – Adult
Give Diazepam (Valium)
5mg IV now. What is the
volume of the drug will
you give your patient?
Solution:

5mg x 2ml
10mg

0.5 x 2ml = 1ml

Calculating Fluids Drip Rate

Drop Factors:

10 gtt/ml
15 gtt/ml
60 gtt/ml - PEDIA!
Formula: Volume x df
time
Scenario:

Compute for the drip rate of 5% Dextrose in

Lactated Ringer – S (D5LRS) IL to run for 8
hours using df 15 gtt/ml
Solution:

1000ml x 15 gtt/ml = 31.25 gtt/min

480 minutes
31 – 32 gtt/min
PHARMACOLOGY

PART 2
GENERAL PRINCIPLES OF DRUG ACTION

PHARMACEUTIC
PHARMACOKINETIC
PHARMACODYNAMIC
PHARMACEUTIC
PHASE
 The drug becomes a solution so
that it can cross the biologic
membrane.
 Applicable only to tablets and
capsules
 DISINTEGRATION – Breaking down
of tablets into smaller particles.
 DISSOULTION – is the dissolving
of smaller particles in the GI
fluid before absorption
 RATE LIMITING – is the drug it
takes for the drug to disintegrate
and dissolve
ENTERIC COATED TABLETS
Sustained-Release Capsules
PHARMACOKINETIC
 IS THE PROCESS OF DRUG MOVEMENT TO ACHIEVE
DRUG ACTION

Biotransformatio
Absorption Distribution Excretion
n
 ABSORPTION
 ISTHE MOVEMENT OF DRUG PARTICLES FROM THE GI
TRACT TO THE BODY FLUIDS.
• The drug does not require energy to move
Passive across the membrane.

• This requires a carrier such as an enzyme or

Active protein to move across the concentration
gradient. Energy is required.

• Is a process by which cells carry a drug

Pinocytosis across their membrane by engulfing the drug
particles
 Lipid- Soluble
VS.
Water-Soluble Drugs
 ALERT!
DRUGS THAT ARE LIPID
SOLUBLE NAS NON-IONIZED
ARE ABSORBED FASTER THAN
WATER SOLUBLE AND IONIZED
DRUGS
First-pass effect/Hepatic first pass

 Is the process by which a drug passes to the

liver first
Bioavailability

Itis the percentage of the

administered drug dose that reaches
the systemic circulation
Distribution
 ISTHE PROCESS BY WHICH THE DRUG BECOMES
AVAILABLE TO BODY FLUIDS AND TO BODY TISSUES

Pharmacologic
effect
Body
Blood Tissue
flow Affinity

Protein-
binding
PROTEIN BINDING

 HIGHLY PROTEIN BOUND DRUGS - >89%

 HIGHLY MODERATELY PROTEIN BOUND DRUGS – 61%-
89%
 MODERATELY PROTEIN BOUND DRUGS – 30-60%
 LOW PROTEIN BOUND DRUGS - < 30%
INACTIVE VS. FREE DRUG

HOW DOES IT LEADS TO TOXICITY?

BIOTRANSFORMATION
 REFERS TO THE PROCESS OF CHANGE
 WHAT IS THE PRIMARY SITE FOR METABOLISM?
 MOST DRUGS ARE CONVERTED TO INACTIVE
METABOLITES OR WATER SOLUBLE SUBSTANCES
(RENAL) FOR EXCRETION BY THE LIVER ENZYMES.
 SOME ARE TRANSFORMED INTO ACTIVE
METABOLITES
HALF-LIFE (t1/2)

 IS THE TIME IT TAKES FOR ONE HALF OF THE DRUG CONCENTRATION

TO BE ELIMINATED
 THE LESSER THE DRUG IS METABOLIZED, THE LONGER THE HALF
LIFE
 THE HIGHER THE DRUG IS METABOLIXED, THE FASTER THE HALF LIFE

Scenario: Aspirin 650mg t1/2 = 3hrs, Can you make a half-life

table?
Number t1/2 Time of Dosage Remaining Percentage left
Elimination (hr) (mg)
1

6
Short Half-life – 4 – 8 hrs
Long Half-life – 24 hrs or longer

HALF LIFE IS THE KEY FOR YOU TO

COMPUTE THE DRUG’S “STEADY STATE”
ELIMINATION
 THE MAIN ROUTE OF DRUG EXCRETION IS THROUGH THE KIDNEYS

KIDNEYS LIVER/BILE FECES

LUNGS SALIVA SWEAT

BREASTMILK
 ACID URINE – WEAK BASE DRUGS
 ALKALINE URINE – WEAK ACID
DRUGS
NORMAL LEVELS
PHARMACODYNAMIC
 ISTHE STUDYY OF DRUG CONCENTRATION
AND ITS EFFECTS ON THE BODY
DOSE RESPONSE

 IS THE RELATIONSHIP BETWEEN THE MINIMUM AND MAXIMUM DOSE

NEEDED TO PRODUCE DESIRED DRUG RESPONSE
 DRUG RESISTANCE AND TRESHOLD
MAXIMAL EFFICACY

 THEREARE DRUGS WITH GREATER EFFECTS THAN

THE OTHER REGARDLESS HOW HIGH THE DOSAGE
IS.
ONSET OF ACTION

 IS THE TIME IT TAKES TO REACH THE MINIMUM

EFFECTIVE CONCENTRATION (MEC) AFTER A DRUG
IS ADMINISTERED
PEAK ACTION

 OCCURSWHEN THE DRUG REACHES ITS HIGHEST

BLOOD OR PLASMA CONCENTRATION
DURATION OF ACTION

ISTHE LENGTH OF TIME THE DRUG

HAS PHARMACOLOGIC EFFECT
Time Response Curve
RECEPTOR THEORY

 RECEPTORS ARE DRUG BINDING SITES

 PROTEIN
 GLYCOPROTEIN
 PROTEOLIPIDS
 ENZYMES
THE FOUR RECEPTOR FAMILIES
 KINASE-LINKED RECEPTOR – ON THE CELL SURFACE
 LIGAND-GATED ION CHANNELS – ON CELL MEMBRANE
ALLOWING IONS TO PASS THRU IT (SODIUM AND CALCIUM IONS)
 G-PROTEIN COUPLED RECEPTOR SYSTEMS –
1. RECEPTOR
2. G-PROTEIN BINDS TO GTP
3. EFFECTOR (ENZYME OR ION CHANNEL)
 NUCLEAR RECEPTORS – ON THE CELL NUCLEUS

LIGAND-BINDING DOMAIN
AGONIST VS. ANTAGONIST

AGONISTS ARE ANTAGONISTS ARE

DRUGS THAT DRUGS THAT
PRODUCE A BLOCK A RESPONSE
RESPONSE
SELECTIVE VS. NON-SELECTIVE

ANTICHOLINERGIC ORGAN CHOLINERGIC

MYDRIASIS EYE MIOSIS
TACHYCARDIA HEART BRADYCHARDIA
VASOCONSTRICTION BLOOD VESSEL VASODILATION

DECREASED HCL STOMACH INCREASES HCL

BRONCHODILATION BRONCHUS BRONCHOCONSTRICTION

URINARY RETENTION BLADDER INCREASED BLADDER CONTRACTION

CONSTIPATION INCREASED PERISTALSIS

DRY MOUTH INCREASED SALIVARY SECRETION

HYPOTENSION
HPN
THE FOUR CATEGORIES OF DRUG ACTION

1. STIMULATION OR DEPRESSION (INCREASED OR REDUCED)

2. REPLACEMENT (REPLACE ESSENTIAL BODY COMPOUNDS E.G INSULIN)
3. INHIBITION OR KILLING OF ORGANISM (INTERFERES WITH BACTERIAL CELL GROWTH)
4. IRRITATION (E.G. INNER WALL COLON IRRITANTS/LAXATIVES)
THERAPEUTIC INDEX T1)
 ESTIMASTES THE MARGIN OF SAFETY OF A DRUG THROUGH THE USE OF A RATIO
THAT MEASURES THE EFFECTIVE DOSE (ED) IN 50% OF ANIMALS LD50 AND LETHAL
DOSE TO 50% OF ANIMALS LD50

THE CLOSER THE RATIO IS TO 1THE GREATER THE DANGER OF TOXICITY

PEAK DRUG LEVELS

HIGHEST PLASMA CONCENTRATION OF DRUG

AT A SPECIFIC TIME

ORAL – 1 – 3 HRS
IV – 10 MINUTES
LOADING DOSE

 LARGEINITIAL DOSE GIVEN TO INDUCE

IMMEDIATE DRUG RESPONSE (MINIMUM
EFFECTIVE PLASMA CONCENTRATION)
SIDE EFFECTS

 HAPPENES TO DRUGS WITHOUT SPECIFICITY

ADVERSE REACTIONS

 UNINTENDED,ALWAYS UNDESIRABLE, MORE SERIOUS

EFFECTS OCCURING AT NORMAL DOSES
TOXIC EFFECTS

DRUGS WITH NARROW THERAPEUTOC

INDEX
WHEN THE DRUG LEVEL EXCEEDS THE
THERAPEUTIC RANGE TOXIC EFFECTS
OCCUR FROM OVERDOSING OR DFUG
ACCUMULATION
TOLERANCE

 DEREASE RESPONSIVENESS OVER COURSE OF

THERAPY

ACUTE TOLERANCE
 TACHYPHYLAXIS
 RAPID DECREASE IN RESPONSE TO THE DRUG
PLACEBO

ISA PSYCHOLOGIC BENEFIT FROM A

COMPOUND THT MAY NOT HAVE THE
CHEMICAL STRUCTURE OF A DRUG
EFFECT.