Pharmacology in Nursing and Medication Administration

1. Pharmacology in Nursing and Medication Administration

2. Pharmacologic Concepts

3. Drug Names Chemical name Describes the drug�s chemical composition and molecular structure Generic name (nonproprietary name) Name given by the United States Adopted Name Council Trade name (proprietary name) The drug has a registered trademark; use of the name restricted by the drug�s patent owner (usually the manufacturer) Each drug has three given names. The chemical name describes the drug�s chemical makeup and its structure. The generic name, commonly seen in practice, is the name the drug has been given by the US Adopted Name Council. The trade name is the name by which most people know the drug. This name is given by the patent owner of the drug and has a registered trademark. Each drug has three given names. The chemical name describes the drug�s chemical makeup and its structure. The generic name, commonly seen in practice, is the name the drug has been given by the US Adopted Name Council. The trade name is the name by which most people know the drug. This name is given by the patent owner of the drug and has a registered trademark.

4. Drug Names (cont'd) Chemical name (+/-)-2-(p-isobutylphenyl) propionic acid Generic name ibuprofen Trade name Motrin�, Advil� Here�s an example of a drug�s three names.Here�s an example of a drug�s three names.

5. Pharmacological Concepts: Classification Classification- Functional Class vs Chemical Class Medication classification indicates the effect of the med on the body system, the symptom the med relieves, or the med�s desired effect (e.g. oral hypoglycemics)

6. Pharmacological Concepts: Classification A medication may also be part of more than one class Aspirin is an analgesic, antipyretic, anti-inflammatory, and anti-platelet

7. Pharmacological Concepts: Medication Forms Medications are available in a variety of forms and preparations The form of the med will determine its route of administration Composition of med is designed to enhance its absorption & metabolism Many meds are available in several forms

8. Medication Forms Tablet Capsule Elixir Enteric-coated Suppository Suspension Transdermal patch

11. Pharmacokinetics � The study of what the body does to the drug Absorption Distribution Metabolism Excretion It�s important to understand the difference between pharmacokinetics (drug movement) and pharmacodynamics (drug action). Pharmacokinetics involves how a drug is absorbed, distributed in the body, metabolized, and excreted.It�s important to understand the difference between pharmacokinetics (drug movement) and pharmacodynamics (drug action). Pharmacokinetics involves how a drug is absorbed, distributed in the body, metabolized, and excreted.

12. Pharmacodynamics � The study of what the drug does to the body The mechanism of drug actions in living tissues Pharmacodynamics examines how a drug effects living tissues within an organism. This is why we say to you, you have to know the action of the drug in the body what it does.Pharmacodynamics examines how a drug effects living tissues within an organism. This is why we say to you, you have to know the action of the drug in the body what it does.

14. Pharmacotherapeutics The use of drugs and the clinical indications for drugs to prevent and treat diseases Pharmacotherapeutics examines how and when drugs are used to prevent or treat specific diseases. It defines drug actions � what changes occur in cells as a result of the presence of the drug?Pharmacotherapeutics examines how and when drugs are used to prevent or treat specific diseases. It defines drug actions � what changes occur in cells as a result of the presence of the drug?

15. Pharmacokinetics: Absorption The rate at which a drug leaves its site of administration, and the extent to which absorption occurs Bioavailability Bioequivalent Let�s talk about the phases of pharmacokinetics. The first phase is absorption. Absorption rate is the rate at which a drug leaves the site of its administration. Bioavailability measures the extent to which the drug is absorbed. When two drugs have the same bioavailability and same concentration of active ingredient, they are said to be bioequivalent. An example of this is brand name vs. generic medications. Let�s talk about the phases of pharmacokinetics. The first phase is absorption. Absorption rate is the rate at which a drug leaves the site of its administration. Bioavailability measures the extent to which the drug is absorbed. When two drugs have the same bioavailability and same concentration of active ingredient, they are said to be bioequivalent. An example of this is brand name vs. generic medications.

16. 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 Many factors affect absorption � r Route of administration Food and fluids Dosage formulation Status of absorptive surface (GI mucosa, skin) Rate of blood flow to small intestine Stomach acidity (higher acidity breaks drugs down faster) Status of GI motility (how fast does the drug move through the body)Many factors affect absorption � r Route of administration Food and fluids Dosage formulation Status of absorptive surface (GI mucosa, skin) Rate of blood flow to small intestine Stomach acidity (higher acidity breaks drugs down faster) Status of GI motility (how fast does the drug move through the body)

17. Routes of Administration A drug�s route of administration affects the rate and extent of absorption of that drug Enteral (GI tract) Parenteral Topical Enteral administration of a drug requires the drug be broken down in the GI tract and moved through the system. Parenteral administration involves injecting the medication into the body. Topical application requires the medication be absorbed through the skin.Enteral administration of a drug requires the drug be broken down in the GI tract and moved through the system. Parenteral administration involves injecting the medication into the body. Topical application requires the medication be absorbed through the skin.

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

19. 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 A medication given orally must first pass through the liver before reaching the circulation. If a drug is given IV, the liver is bypassed and more drug reaches circulation/ more of the drug is bioavailable.A medication given orally must first pass through the liver before reaching the circulation. If a drug is given IV, the liver is bypassed and more drug reaches circulation/ more of the drug is bioavailable.

22. Parenteral Route Intravenous (fastest delivery into the blood circulation) Intramuscular Subcutaneous Intradermal Intrathecal Intraarticular Parenteral (or injectable) routes include: Intravenous � into the vein Intramuscular � into the muscle Subcutaneous � into the subcutaneous layer of the skin Intradermal � into the dermal layer of the skin Intrathecal � into the subarachnoid space (used for anesthesia) Intraarticular � into a jointParenteral (or injectable) routes include: Intravenous � into the vein Intramuscular � into the muscle Subcutaneous � into the subcutaneous layer of the skin Intradermal � into the dermal layer of the skin Intrathecal � into the subarachnoid space (used for anesthesia) Intraarticular � into a joint

23. Topical Route Skin (including transdermal patches) Eyes Ears Nose Lungs (inhalation) Vagina

24. 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 Protein-binding allows only a limited amount of the drug to be available for use. The rest is bound to protein. Clients with low albumin levels will have higher levels of circulating drugs, and are at risk for drug toxicity. Since the body is largely made up of water, drugs that are highly water soluble will have higher concentrations in the blood. Fat soluble drugs are attracted to the low water content of tissue and will have a low concentration in the blood. The blood-brain barrier prevents distribution of certain drugs into the brain (ie. dopamine). Organs with an extensive blood supply, such as the heart, liver, kidneys and brain, will distribute drugs rapidly. Those with decreased blood supply, such as muscle, skin, and fat, will distribute drugs more slowly.Protein-binding allows only a limited amount of the drug to be available for use. The rest is bound to protein. Clients with low albumin levels will have higher levels of circulating drugs, and are at risk for drug toxicity. Since the body is largely made up of water, drugs that are highly water soluble will have higher concentrations in the blood. Fat soluble drugs are attracted to the low water content of tissue and will have a low concentration in the blood. The blood-brain barrier prevents distribution of certain drugs into the brain (ie. dopamine). Organs with an extensive blood supply, such as the heart, liver, kidneys and brain, will distribute drugs rapidly. Those with decreased blood supply, such as muscle, skin, and fat, will distribute drugs more slowly.

26. 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

27. Metabolism/Biotransformation (cont'd) Delayed drug metabolism results in: Accumulation of drugs Prolonged action of the drugs Stimulating drug metabolism causes: Diminished pharmacologic effects Delayed drug metabolism causes a build-up of drugs in the system and creates a prolonged action. If drug metabolism is stimulated, the drug is used up more quickly and has a decreased effect.Delayed drug metabolism causes a build-up of drugs in the system and creates a prolonged action. If drug metabolism is stimulated, the drug is used up more quickly and has a decreased effect.

28. Excretion The elimination of drugs from the body Kidneys (main organ) Liver Bowel Biliary excretion Enterohepatic circulation Most drugs are eliminated from the body in the urine. The liver also contributes to drug excretion. With biliary excretion, drugs are taken up by the liver, released into bile, and eliminated in the feces. With enterohepatic recirculation, drugs in the bile are reabsorbed into the bloodstream, returned to the liver, and secreted a second time into the bile.Most drugs are eliminated from the body in the urine. The liver also contributes to drug excretion. With biliary excretion, drugs are taken up by the liver, released into bile, and eliminated in the feces. With enterohepatic recirculation, drugs in the bile are reabsorbed into the bloodstream, returned to the liver, and secreted a second time into the bile.

29. 1. You are caring for a client who has diabetes complicated by kidney disease. You will need to make a detailed assessment when administering medications because this client may experience problems with: A. Absorption B. Biotransformation C. Distribution D. Excretion Answer: DAnswer: D

30. 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

31. 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

32. Mechanism of Action Receptor Interaction Enzyme Interaction Non-Specific Interaction

33. 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

34. Receptor Interaction Affinity- degree to which a drug binds with a receptor The drug with the best �fit� or affinity will elicit the best response Drug can mimic 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

35. Receptor Interaction Agonist-Drug binds to receptor-there is a response (Adrenergic Agents) Antagonist-drug binds to receptor-no response-prevents binding of agonists (Alpha & Beta Blockers)

37. 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)

38. 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

40. Correct answer: 1 Explanation: The first-pass effect is the metabolism of a drug before it is systemically available, and it reduces the bioavailablity of the drug. Therefore, oral doses need to be higher than IV doses because of the first-pass effect.Correct answer: 1 Explanation: The first-pass effect is the metabolism of a drug before it is systemically available, and it reduces the bioavailablity of the drug. Therefore, oral doses need to be higher than IV doses because of the first-pass effect.

41. Correct answer: 4 Explanation: Parenteral routes result into the fastest absorption and therefore also the fastest effects. Correct answer: 4 Explanation: Parenteral routes result into the fastest absorption and therefore also the fastest effects.

42. Type of Medication Action Therapeutic Effect Side Effects Adverse Effects Toxic Effect Idiosyncratic Reactions Allergic Reaction Medication Interactions Iatrogenic Response

43. 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

44. Side Effects Unintended secondary effects a medication predictably will cause May be harmless or serious If side effects are serious enough to negate the beneficial effect of meds therapeutic action, it may be D/C�d People may stop taking medications because of the side effects

45. 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

46. Adverse Effects Adverse Drug Events Adverse Drug Reactions (ADR)

47. Toxic Effect May develop after prolonged intake or when a med accumulates in the blood because of impaired metabolism or excretion, or excessive amount taken Toxic levels of opioids can cause resp.depression Antidotes available to reverse effects

48. 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)

49. 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

50. Allergic Reaction 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

54. 2. A postoperative client is receiving morphine sulfate via a PCA. The nurse assesses that the client�s respirations are depressed. The effects of the morphine sulfate can be classified as: A. Allergic B. Idiosyncratic C. Therapeutic D. Toxic Answer: DAnswer: D

55. Other Drug Reactions Teratogenic-Structural effect in unborn fetus (thalidomide) Carcinogenic-Causes cancer Mutagenic- Changes genetic composition (radiation, chemicals)

56. Drug Interactions Occurs when one med modifies the action of another Common in people taking several medications at once One med may potentiate or diminish the action of another or alter the way it is absorbed, metabolized or eliminated Warfarin and Amiodarone

57. Iatrogenic Responses 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)

58. Synergistic Effect Effect of 2 meds combined is greater than the meds given separately Alcohol & Antihistamines, antidepressants, barbiturates, narcotics Not always undesirable, physician may combine meds to create an interaction that will have beneficial effects (Vasodilators & diuretics to control high BP)

59. 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

60. Medication Dose Responses Serum Half-Life:Time it takes for excretion processes to lower the serum medication concentration by � Regular fixed doses must be given to maintain therapeutic concentration Dosage schedules set by institutions (TID, q8h, HS, AC, STAT, PRN) Peak & Trough levels Therapeutic drug monitoring

61. 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 A drug�s half-life is used to determine how often a drug must be administered in order to maintain its therapeutic level. Half-life measures the rate at which a drug is removed from the body. It measures the time it takes for half of the original drug concentration to be removed.A drug�s half-life is used to determine how often a drug must be administered in order to maintain its therapeutic level. Half-life measures the rate at which a drug is removed from the body. It measures the time it takes for half of the original drug concentration to be removed.

62. Onset, Peak, and Duration Onset The time it takes for the drug to elicit a therapeutic response Peak The time it takes for a drug to reach its maximum therapeutic response Duration The time a drug concentration is sufficient to elicit a therapeutic response It is important for the nurse to know the onset, peak, and duration of each drug. The onset is the time it takes for the drug to start working. The peak is the time the drug is at its most effective. The duration is the time that the drug lasts in the body.It is important for the nurse to know the onset, peak, and duration of each drug. The onset is the time it takes for the drug to start working. The peak is the time the drug is at its most effective. The duration is the time that the drug lasts in the body.

63. Pharmacotherapeutics: Types of Therapies Acute therapy Maintenance therapy Supplemental therapy Palliative therapy Supportive therapy Prophylactic therapy Acute therapy drugs are used to sustain life or treat disease Maintenance therapy drugs are used to prevent the progression of chronic diseases, such as hypertension Supplemental drugs supply substances not available to the body, such as insulin for diabetic clients Drugs used for palliative therapy are used to maintain comfort Supportive drug therapy helps maintain body functions Prophylactic drugs help prevent illness and have scientific evidence to support their use Empiric drugs are used based on past experience with their actions rather than scientific evidenceAcute therapy drugs are used to sustain life or treat disease Maintenance therapy drugs are used to prevent the progression of chronic diseases, such as hypertension Supplemental drugs supply substances not available to the body, such as insulin for diabetic clients Drugs used for palliative therapy are used to maintain comfort Supportive drug therapy helps maintain body functions Prophylactic drugs help prevent illness and have scientific evidence to support their use Empiric drugs are used based on past experience with their actions rather than scientific evidence

64. 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)

65. Monitoring (cont'd) � Therapeutic index � The ratio between a drug�s therapeutic benefits and its toxic effects A drug�s therapeutic index determines the safety of the drug. If a drug has a low therapeutic index, it has a high risk for toxicity. The nurse is responsible for monitoring drug levels (ie. digoxin, theophylline, lithium)A drug�s therapeutic index determines the safety of the drug. If a drug has a low therapeutic index, it has a high risk for toxicity. The nurse is responsible for monitoring drug levels (ie. digoxin, theophylline, lithium)

66. Monitoring (cont'd) Interactions may occur with other drugs or food Drug interactions: the alteration of action of  a drug by: Other prescribed drugs Over-the-counter medications Herbal therapies Orange juice- synthriodOrange juice- synthriod

67. Monitoring (cont'd) � Drug interactions � Additive effect � Synergistic effect � Antagonistic effect � Incompatibility Drugs are said to have an additive effect when they have similar actions. Lower doses are needed when the drugs are given together. Synergistic drugs create a greater effect when combined than each one alone. Drugs are antagonistic when their combined effect is less than each of them alone. Drugs are incompatible when combining them causes chemical deterioration of one or bothDrugs are said to have an additive effect when they have similar actions. Lower doses are needed when the drugs are given together. Synergistic drugs create a greater effect when combined than each one alone. Drugs are antagonistic when their combined effect is less than each of them alone. Drugs are incompatible when combining them causes chemical deterioration of one or both

68. Monitoring (cont'd) Medication misadventures Adverse drug events Adverse drug reactions Medication errors Adverse drug events refer to any undesirable occurrence involving medications. Adverse drug reactions are unexpected, undesirable drug reactions occurring at therapeutic levels. Medication errors are preventable situations. One of the five rights is compromised. Adverse drug events refer to any undesirable occurrence involving medications. Adverse drug reactions are unexpected, undesirable drug reactions occurring at therapeutic levels. Medication errors are preventable situations. One of the five rights is compromised.

69. Monitoring (cont'd) Some adverse drug reactions are classified as side effects Expected, well-known reactions that result in little or no change in patient management Predictable frequency The effect�s intensity and occurrence are related to the size of the dose

70. 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 An adverse pharmacologic reaction occurs when a drug goes too far. For example, an antihypertensive drug lowers blood pressure to the point of unconsciousness. An idiosyncratic adverse reaction is an unexpected reaction in an individual client. A hypersensitivity reaction is a reaction of the immune system. It can range from a mild reaction to anaphylaxis. Drug interactions occur when the presence of two or more drugs in the body produce an unwanted effect.An adverse pharmacologic reaction occurs when a drug goes too far. For example, an antihypertensive drug lowers blood pressure to the point of unconsciousness. An idiosyncratic adverse reaction is an unexpected reaction in an individual client. A hypersensitivity reaction is a reaction of the immune system. It can range from a mild reaction to anaphylaxis. Drug interactions occur when the presence of two or more drugs in the body produce an unwanted effect.

71. Other Drug-Related Effects Teratogenic Mutagenic Carcinogenic Teratogenic effects cause structural defects in a fetus. The nurse should check the pregnancy category of a medication to ensure that it is not a teratogen. Mutagenic drugs cause permanent changes in the genetic structure. Such changes can be caused by exposure to radiation or heavy metals. Carcinogenic drugs are known to cause cancer. Teratogenic effects cause structural defects in a fetus. The nurse should check the pregnancy category of a medication to ensure that it is not a teratogen. Mutagenic drugs cause permanent changes in the genetic structure. Such changes can be caused by exposure to radiation or heavy metals. Carcinogenic drugs are known to cause cancer.

72. Toxicology The study of poisons and unwanted responses to therapeutic agents Clinical toxicology provides information on the care of the poisoned client. The nurse the must prioritize the care of the poisoned client: - preserve vital functions - prevent absorption or increase rate of elimination * ipecac * activated charcoal * catharticsClinical toxicology provides information on the care of the poisoned client. The nurse the must prioritize the care of the poisoned client: - preserve vital functions - prevent absorption or increase rate of elimination * ipecac * activated charcoal * cathartics

74. The Nursing Process Assessment Nursing diagnosis Planning (with outcome criteria) Implementation Evaluation Let�s review how the nursing process applies to the pharmacology of nursing.Let�s review how the nursing process applies to the pharmacology of nursing.

75. The Nursing Process (cont'd) Assessment Data collection Subjective, objective Data collected on the patient, drug, environment Medication history Nursing assessment Physical assessment Data analysis Subjective data is collected from the client, family, and significant others regarding the medications used by the client. Objective data is collected by examining the client�s current medications and by physical examination. Completion of a thorough medication history is essential, and should include: 1. Drug use, 2. Home or herbal remedies, 3. Substance use, 4. Illegal drug use, 5. OTC medications, 6. Hormone use, The nursing assessment should include a thorough Health history, Family history, Unusual drug responses, and Related growth and development issues. The subsequent physical assessment should provide evidence of the conditions for which the client�s medications have been ordered. The nurse must be sure that all drug orders contain the client�s name, date of the order, medication name, dosage, route, and prescriber�s signature. PRN orders must also include the reason for the medication�s use. Subjective data is collected from the client, family, and significant others regarding the medications used by the client. Objective data is collected by examining the client�s current medications and by physical examination. Completion of a thorough medication history is essential, and should include: 1. Drug use, 2. Home or herbal remedies, 3. Substance use, 4. Illegal drug use, 5. OTC medications, 6. Hormone use, The nursing assessment should include a thorough Health history, Family history, Unusual drug responses, and Related growth and development issues. The subsequent physical assessment should provide evidence of the conditions for which the client�s medications have been ordered. The nurse must be sure that all drug orders contain the client�s name, date of the order, medication name, dosage, route, and prescriber�s signature. PRN orders must also include the reason for the medication�s use.

76. The �Seven Rights� Right drug Right dose Right time Right route Right patient Right to refuse Right documentation Nurses learn the basic five rights of medication administration early on in their education. It is important that we not forget them as we progress in our learning. What step did the nurses for get or leave out when they made that heparin mistake with the twin babies�������. Many sources cite a sixth right of medication administration � right documentation. This is part of what we call constant system analysis.Nurses learn the basic five rights of medication administration early on in their education. It is important that we not forget them as we progress in our learning. What step did the nurses for get or leave out when they made that heparin mistake with the twin babies�������. Many sources cite a sixth right of medication administration � right documentation. This is part of what we call constant system analysis.

77. 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 Constant system analysis is an ongoing process that has but one goal � elimination of medication errors. System analysis begins when the provider orders the medication. It continues when the pharmacist dispenses the medication, and culminates when the nurse prepares, administers and documents administration of the drug. System analysis includes client education, as well. It is important for the nurse to remember to utilize each medication administration time as an opportunity for teaching.Constant system analysis is an ongoing process that has but one goal � elimination of medication errors. System analysis begins when the provider orders the medication. It continues when the pharmacist dispenses the medication, and culminates when the nurse prepares, administers and documents administration of the drug. System analysis includes client education, as well. It is important for the nurse to remember to utilize each medication administration time as an opportunity for teaching.

78. Other �Rights� Proper drug storage Proper documentation Accurate dosage calculation Accurate dosage preparation Careful checking of transcription of orders Patient safety The nurse must understand the importance of proper drug storage in order to maintain medications at their optimum potency. Some drugs must be refrigerated, some kept away from direct light, and some (narcotics) must be secured under double lock. Documentation of medication administration should only be completed after the client has taken the medication. If the nurse documents the medication as given and then the client refuses the medication, it is essentially a medication error. Calculation of drug dosages is the responsibility of the nurse. We will review the procedures for drug calculation a bit later. Dosage preparation involves pouring the medication or drawing it up in a syringe for administration. Some medications must be crushed and mixed with food or liquid for clients with difficulty swallowing. Transcription is an area that has a high potential for error. Most facilities are moving from handwritten orders to computer generated ones to reduce the error rate. Each of these interventions has patient safety as its goal.The nurse must understand the importance of proper drug storage in order to maintain medications at their optimum potency. Some drugs must be refrigerated, some kept away from direct light, and some (narcotics) must be secured under double lock. Documentation of medication administration should only be completed after the client has taken the medication. If the nurse documents the medication as given and then the client refuses the medication, it is essentially a medication error. Calculation of drug dosages is the responsibility of the nurse. We will review the procedures for drug calculation a bit later. Dosage preparation involves pouring the medication or drawing it up in a syringe for administration. Some medications must be crushed and mixed with food or liquid for clients with difficulty swallowing. Transcription is an area that has a high potential for error. Most facilities are moving from handwritten orders to computer generated ones to reduce the error rate. Each of these interventions has patient safety as its goal.

79. Other �Rights� (cont'd) Close consideration of special situations Prevention and reporting of medication errors Patient teaching Monitoring for therapeutic effects, side effects, toxic effects Refusal of medication

80. 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 During the evaluation phase of the process, the nurse must determine how much progress the client has made toward the previously determined goals. The nurse needs to ask: Is the medication doing what it was ordered to do? Is it doing it as well as expected? Are there any unexpected effects? Should the medication be changed, or continued as ordered?During the evaluation phase of the process, the nurse must determine how much progress the client has made toward the previously determined goals. The nurse needs to ask: Is the medication doing what it was ordered to do? Is it doing it as well as expected? Are there any unexpected effects? Should the medication be changed, or continued as ordered?

81. Correct answer: 2 Explanation: The Medication Administration Record is the legal documentation that the professional nurse uses to sign off medications that are given, so it should be checked first. Correct answer: 2 Explanation: The Medication Administration Record is the legal documentation that the professional nurse uses to sign off medications that are given, so it should be checked first.

82. Correct answer: 4 Explanation: The dosage for the IV route would not be the same as for the PO route. Holding the medications may cause drug levels to drop and result in seizure activity, and giving the medications PO without consent may alter the test results. The nurse must never assume the route of medication administration and should consult the physician for clarification of the orders.Correct answer: 4 Explanation: The dosage for the IV route would not be the same as for the PO route. Holding the medications may cause drug levels to drop and result in seizure activity, and giving the medications PO without consent may alter the test results. The nurse must never assume the route of medication administration and should consult the physician for clarification of the orders.

83. Life Span Considerations

84. Life Span Considerations Pregnancy Breast-feeding Neonatal Pediatric Geriatric

85. Pregnancy First trimester is the period of greatest danger for drug-induced developmental defects Drugs diffuse across the placenta FDA pregnancy safety categories

86. Table 3-1 Pregnancy safety categories

87. Breast-feeding Breast-fed infants are at risk for exposure to drugs consumed by the mother Consider risk-to-benefit ratio

88. Table 3-2 Classification of young patients

89. Pediatric Considerations: Pharmacokinetics Absorption Gastric pH less acidic Gastric emptying is slowed Topical absorption faster through the skin Intramuscular absorption faster and irregular

90. Pediatric Considerations: Pharmacokinetics (cont'd) 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 Total body water is high in full term infants. It decreases as a person ages. Water soluble drugs, therefore, are available in greater concentrations. There is a decreased level of protein binding because of the decreased production by the immature liver. This results in greater concentrations of medications in the body. An immature blood-brain barrier allows more drugs to enter the brain. For all these reasons, drug doses need to be lower for children. Total body water is high in full term infants. It decreases as a person ages. Water soluble drugs, therefore, are available in greater concentrations. There is a decreased level of protein binding because of the decreased production by the immature liver. This results in greater concentrations of medications in the body. An immature blood-brain barrier allows more drugs to enter the brain. For all these reasons, drug doses need to be lower for children.

91. Pediatric Considerations: Pharmacokinetics (cont'd) Metabolism Liver immature, does not produce enough microsomal enzymes Older children may have increased metabolism, requiring higher doses Other factors There are other factors that play a part in the metabolism of drugs in the pediatric population. The production of enzymes by the liver is less than in an adult. Genetic factors determine individual metabolic rates. Maternal exposure to substances that alter fetal development can affect the child�s ability to metabolize medications.There are other factors that play a part in the metabolism of drugs in the pediatric population. The production of enzymes by the liver is less than in an adult. Genetic factors determine individual metabolic rates. Maternal exposure to substances that alter fetal development can affect the child�s ability to metabolize medications.

92. Pediatric Considerations: Pharmacokinetics (cont'd) Excretion Kidney immaturity affects glomerular filtration rate and tubular secretion Decreased perfusion rate of the kidneys Kidneys in children have not developed the full filtration ability of the mature kidney. Decreased perfusion rate leads to decreased renal function, decreased ability of the kidney to concentrate urine, and decreased excretion of drugs.Kidneys in children have not developed the full filtration ability of the mature kidney. Decreased perfusion rate leads to decreased renal function, decreased ability of the kidney to concentrate urine, and decreased excretion of drugs.

93. 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

94. Methods of Dosage Calculation for Pediatric Patients Body weight dosage calculations Body surface area method There are several methods of calculating drug dosages for children. Dosages can be calculated by body weight or by body surface area. There are several methods of calculating drug dosages for children. Dosages can be calculated by body weight or by body surface area.

96. Geriatric Considerations Geriatric: older than age 65 Healthy People 2010: older than age 55 Use of OTC medications Polypharmacy The geriatric population uses the largest amount of medications of any population group. It is especially important for the nurse to review the OTC medications an older client uses, as they may interfere with prescription drugs ordered. Polypharmacy exists when two or more meds cause an interaction or adverse reaction, are used for the same purpose, or have no apparent clinical rationale for use Poly pharmacy is causes by: - Lack of information - Self-treatment - Multiple physicians - Use of folk remedies - Lack of communication with physicians - Overprescribing - Multiple chronic diseases needing meds The geriatric population uses the largest amount of medications of any population group. It is especially important for the nurse to review the OTC medications an older client uses, as they may interfere with prescription drugs ordered. Polypharmacy exists when two or more meds cause an interaction or adverse reaction, are used for the same purpose, or have no apparent clinical rationale for use Poly pharmacy is causes by: - Lack of information - Self-treatment - Multiple physicians - Use of folk remedies - Lack of communication with physicians - Overprescribing - Multiple chronic diseases needing meds

97. Table 3-4 Physiologic changes in the geriatric patient

98. 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

99. Geriatric Considerations: Pharmacokinetics (cont'd) Distribution TBW percentages lower Fat content increased Decreased production of proteins by the liver, resulting in decreased protein binding of drugs

100. Geriatric Considerations: Pharmacokinetics (cont'd) Metabolism Aging liver produces less microsomal enzymes, affecting drug metabolism Reduced blood flow to the liver

101. Geriatric Considerations: Pharmacokinetics (cont'd) Excretion Decreased glomerular filtration rate Decreased number of intact nephrons

102. Geriatric Considerations: Problematic Medications Analgesics Anticoagulants Anticholinergics Antihypertensives Digoxin Sedatives and hypnotics Thiazide diuretics Analgesics � commonly cause confusion, constipation, urinary retention, nausea, vomiting, respiratory depression, decreased LOC, and falls Anticoagulants � major/minor bleeding, many drug interactions, dietary interactions Anticholinergics � blurred vision, dry mouth, constipation, confusion, urinary retention, tachycardia Antihypertensives � nausea, hypotension, diarrhea, bradycardia, heart failure, impotence Digoxin � visual disorders, dysrhythmias, hallucinations, weight loss Sedatives/Hypnotics � confusion, daytime sedation, ataxia, lethargy, forgetfulness, risk for falls Thiazide diuretics � electrolyte imbalance, rash, fatigue, leg cramps, dehydrationAnalgesics � commonly cause confusion, constipation, urinary retention, nausea, vomiting, respiratory depression, decreased LOC, and falls Anticoagulants � major/minor bleeding, many drug interactions, dietary interactions Anticholinergics � blurred vision, dry mouth, constipation, confusion, urinary retention, tachycardia Antihypertensives � nausea, hypotension, diarrhea, bradycardia, heart failure, impotence Digoxin � visual disorders, dysrhythmias, hallucinations, weight loss Sedatives/Hypnotics � confusion, daytime sedation, ataxia, lethargy, forgetfulness, risk for falls Thiazide diuretics � electrolyte imbalance, rash, fatigue, leg cramps, dehydration

103. Legal, Ethical, and CulturalConsiderations

104. 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) 1906 � Federal Food & Drug Act � required manufacturers to list dangerous/addictive substances on the label; recognized US Pharmacopeia & National Formulary as printed standard reference for drugs 1912 � Sherley Amendment � prohibited fraudulent claims for drug products 1914 � Harrison Narcotic Act � established the term narcotic; regulated manufacture and sale of habit-forming drugs 1938 � Federal Food, Drug, & Cosmetic Act � manufacturers required to provide safety information with FDA review; established the process for new drug application process1906 � Federal Food & Drug Act � required manufacturers to list dangerous/addictive substances on the label; recognized US Pharmacopeia & National Formulary as printed standard reference for drugs 1912 � Sherley Amendment � prohibited fraudulent claims for drug products 1914 � Harrison Narcotic Act � established the term narcotic; regulated manufacture and sale of habit-forming drugs 1938 � Federal Food, Drug, & Cosmetic Act � manufacturers required to provide safety information with FDA review; established the process for new drug application process

105. U.S. Drug Legislation (cont'd) 1951: Durham-Humphrey Amendment (to the 1938 act) 1962: Kefauver-Harris Amendment (to the 1938 act) 1970: Controlled Substance Act 1951 � Durham-Humphrey Amendment � required prescriptions to carry the legend �Caution � Federal law prohibits dispensing without a prescription� 1962 � Kefauver-Harris Amendment � manufacturers required to demonstrate both therapeutic efficacy and safety 1970 � Controlled Substance Act � established schedules for controlled substances; promoted drug addiction education, research and treatment 1951 � Durham-Humphrey Amendment � required prescriptions to carry the legend �Caution � Federal law prohibits dispensing without a prescription� 1962 � Kefauver-Harris Amendment � manufacturers required to demonstrate both therapeutic efficacy and safety 1970 � Controlled Substance Act � established schedules for controlled substances; promoted drug addiction education, research and treatment

106. U.S. Drug Legislation (cont'd) 1983: Orphan Drug Act 1991: Accelerated drug approval 1983 � Orphan Drug Act � enabled the FDA to promote research and marketing of orphan drugs used to treat rare diseases 1991 � Accelerated drug approval � enabled faster approval process by the FDA for drugs used to treat life-threatening illnesses (AZT for AIDS)1983 � Orphan Drug Act � enabled the FDA to promote research and marketing of orphan drugs used to treat rare diseases 1991 � Accelerated drug approval � enabled faster approval process by the FDA for drugs used to treat life-threatening illnesses (AZT for AIDS)

109. New Drug Development Investigational new drug (IND) application Informed consent Investigational drug studies Expedited drug approval Investigation new drug application � completed after animal testing Informed consent � must be obtained for all human test subjects Investigational drug studies � can be completed only after FDA approval Expedited drug approval � a shortened process used for life-saving drugs; the medications must show early promise in Phases I & IIInvestigation new drug application � completed after animal testing Informed consent � must be obtained for all human test subjects Investigational drug studies � can be completed only after FDA approval Expedited drug approval � a shortened process used for life-saving drugs; the medications must show early promise in Phases I & II

110. U.S. FDA Drug Approval Process Preclinical investigational drug studies Clinical phases of investigational drug studies Phase I Phase II Phase III Phase IV In Phase I studies, a small number of healthy subjects are used. Phase II studies use a small number of volunteer subjects who have the illness. In Phase III studies, a large number of subjects is used and they are tracked by researchers. Phase IV studies occur post-marketing (about 2 years after release). The drug may be recalled if it is problematic.In Phase I studies, a small number of healthy subjects are used. Phase II studies use a small number of volunteer subjects who have the illness. In Phase III studies, a large number of subjects is used and they are tracked by researchers. Phase IV studies occur post-marketing (about 2 years after release). The drug may be recalled if it is problematic.

111. Ethical Nursing Practice American Nurses Association (ANA) Code of Ethics for Nurses

112. 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 The nurse must consider how strong an influence a client�s culture has on their use of medications. Drug polymorphism considers the effect of a client�s age, gender, size, body composition, and other characteristics on the pharmacokinetics of a drug. How does the client�s culture influence compliance? Are there factors in the environment that might affect a client�s drug use? There may be genetic factors present that affect how a drug is used by the body. African- Americans respond better to diuretics than beta blockers or ACE inhibitors. Calcium channel blockers work best, and usually need to be used in combination with other drugs. Asians & Hispanics respond better to lower dosages of antidepressants and other antipsychotics and antianxiety drugs.The nurse must consider how strong an influence a client�s culture has on their use of medications. Drug polymorphism considers the effect of a client�s age, gender, size, body composition, and other characteristics on the pharmacokinetics of a drug. How does the client�s culture influence compliance? Are there factors in the environment that might affect a client�s drug use? There may be genetic factors present that affect how a drug is used by the body. African- Americans respond better to diuretics than beta blockers or ACE inhibitors. Calcium channel blockers work best, and usually need to be used in combination with other drugs. Asians & Hispanics respond better to lower dosages of antidepressants and other antipsychotics and antianxiety drugs.

113. Cultural Assessment Health beliefs and practices Past uses of medicine Folk remedies Home remedies Use of nonprescription drugs and herbal remedies OTC treatments

114. Cultural Assessment (cont'd) Usual response to treatment Responsiveness to medical treatment Religious practices and beliefs Dietary habits

115. Medication Errors:Preventing and Responding

116. Medication Misadventures Medication errors (MEs) Adverse drug events (ADEs) Adverse drug reactions (ADRs) Medication errors have been examined by the Institute of Medicine in their publication �To Err Is Human�. Medication errors have been examined by the Institute of Medicine in their publication �To Err Is Human�.

117. Medication Misadventures (cont'd) By definition, all ADRs are also ADEs But all ADEs are not ADRs Two types of ADRs Allergic reactions Idiosyncratic reactions Adverse drug reactions include allergic reactions and idiosyncratic reactions. Allergic reactions are usually predictable, while idiosyncratic reactions are usually unpredictable.Adverse drug reactions include allergic reactions and idiosyncratic reactions. Allergic reactions are usually predictable, while idiosyncratic reactions are usually unpredictable.

118. Medication Errors Preventable Common cause of adverse health care outcomes Effects can range from no significant effect to directly causing disability or death 68% of medication errors are preventable! They cost the US on average of 60 billion dollars 7000 patients died last year as a result68% of medication errors are preventable! They cost the US on average of 60 billion dollars 7000 patients died last year as a result

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

120. http://www.usp.org/pdf/EN/patientSafety/ismpAbbreviations.pdf

121. 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

123. Preventing Medication Errors (cont'd) Never assume anything about items not specified in a drug order (i.e., route) Do not hesitate to question a medication order for any reason when in doubt Do not try to decipher illegibly written orders; contact prescriber for clarification

124. Preventing Medication Errors (cont'd) NEVER use �trailing zeros� with medication orders Do not use 1.0 mg; use 1 mg 1.0 mg could be misread as 10 mg, resulting in a tenfold dose increase

125. Preventing Medication Errors (cont'd) ALWAYS use a �leading zero� for decimal dosages Do not use .25 mg; use 0.25 mg .25 mg may be misread as 25 mg �.25� is sometimes called a �naked decimal�

126. Preventing Medication Errors (cont'd) Check medication order and what is available while using the �7 rights� Take time to learn special administration techniques of certain dosage forms

127. Preventing Medication Errors (cont'd) Always listen to and honor any concerns expressed by patients regarding medications Check patient allergies and identification Medication Reconciliation

128. 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

129. 3. Nurses are legally required to document medications that are administered to clients. The nurse is mandated to document: A. Medication before administering it B. Medication after administering it C. Rationale for administering the medication D. Prescriber�s rationale for prescribing the medication Answer: BAnswer: B

130. 4. If a nurse experiences a problem reading a physician�s medication order, the most appropriate action will be to: A. Call the physician to verify the order. B. Call the pharmacist to verify the order. C. Consult with other nursing staff to verify the order. D. Withhold the medication until the physician makes rounds. Answer: AAnswer: A

131. Medication Administration

133. Preparing for Drug Administration Check the �7 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

134. Preparing for Drug Administration (cont'd) Check expiration dates Check the patient�s identification (2 identifiers) 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

135. 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

136. Oral Route Easiest, most commonly used Slower onset of action More prolonged effect Preferred by clients Sublingual Administration Buccal Administration

138. 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

139. Parenteral Route Injecting a medication into body tissues Subcutaneous (SQ) Intramuscular (IM) Intravenous (IV) Intradermal (ID) Advanced techniques

140. Parenteral Drugs Never recap a used needle! May recap an unused needle with the �scoop method� Prevention of needlesticks Filter needles Filter needles should be used when drawing up reconstituted medications in order to prevent precipitate from entering syringe.Filter needles should be used when drawing up reconstituted medications in order to prevent precipitate from entering syringe.

141. Parenteral Drugs (cont'd) Removing medications from ampules Removing medications from vials Disposal of used needles and syringes Needle Selection

146. Injections Needle angles for various injections Intramuscular (IM) Subcutaneous (SC or SQ) Intradermal (ID) Z-track method for IM injections Air-lock technique

150. Injection Techniques Intradermal injections Subcutaneous injections Insulin administration Anticoagulant administration (Heparin/Lovenox)

154. Injection Techniques (cont'd) Intramuscular injections Ventrogluteal site (preferred) Vastus lateralis site Dorsogluteal site Deltoid site

156. Preparing Intravenous Medications Needleless systems Compatibility issues Expiration dates Mixing intravenous piggyback (IVPB) medications Labeling intravenous (IV) infusion bags when adding medications

159. Intravenous Medications Adding medications to a primary infusion bag IVPB medications (secondary line) IV push medications (bolus) Through an IV lock Through an existing IV infusion

162. Intravenous Medications (cont'd) Volume-controlled administration set Using electronic infusion pumps Patient-controlled analgesia (PCA) pumps

164. Topical Drugs Eye medications Drops Ointments Ear drops Adults Infant or child younger than 3 years of age Adult ear drops � pull pinna up and back Children younger than 3 � pull pinna down and backAdult ear drops � pull pinna up and back Children younger than 3 � pull pinna down and back

166. Topical Drugs (cont'd) Nasal drugs Drops Spray Inhaled drugs Metered-dose inhalers Small-volume nebulizers

168. Topical Drugs (cont'd) Administering medications to the skin Lotions, creams, ointments, powders Transdermal patches Vaginal medications Creams, foams, gels Suppositories