pharm 1301

• –Therapeutic  Classification: describes what is being
• treated by the drug

• –Pharmacologic
• Classification: describes how the drug acts

  Label must declare presence of dangerous and possibly addicting drugs and designated designated The United States Pharmacopeia (USP) and National Formulary (NF) as    official standards for therapeutic use, patient safety, quality, purity, strength, package    safety, and dosage form.

prohibits fraudulent therapeutic claims

established legal term “narcotic”

significant as established mandatory testing for safety prior to marketing

• established “legend” drugs ( must be prescribed) versus  OTC and 
• also specified that narcotics, etc 
• not be refilled without a new prescription.

•  required that both safety & efficacy be proved prior to marketing
• new drug

• established schedules
• of drugs according to abuse potential (C-1 
• high; C-V low)

–Patient name

–Date order is written

–Name of medication

• –Dosage (size, frequency, &
• duration of order)

–Route (p.o., IM, IV, etc)

–Signature of prescriber

–Pain medication requires documentation 1-2 hours after the dose. 

• – Tablets and
• Capsules

• –Sublingual
• and Buccal

–Nasogastric and gastrostomy

• –Topical
• medications-skin

–Transdermal

–Ophthalmic/otic

–Intranasal

–Vaginal

–Intradermal

–Subcutaneous

–Intramuscular

–Intravenous

•  study of how various dosage “forms” influence
• pharmacokinetic and pharmacodynamics properties of drugs

• : study of what the
• body does to the drug

 study of what the drug does to the body 

–Absorption

–Distribution

–Metabolism

–Excretion

when does drug start to work

when is drugmost effective

how longdoes drug effect last

•  the movement of a chemical from an area of
• higher concentration to an area of lower concentration.

 drugs cross membranes against their gradient, from low concentrationto high concentration, and this requires energy on the part of the cell and acarrier protein (pumps).

• rate drug is absorbed form site of administration and extent to which it occurs
• –Routes of administration
• –Drug concentration and dose
• •Bioavailibility expresses the “quantity” extent
• of drug absorption.
• –GI tract environment
• –Blood flow to the absopriton site
• –Drug ionization
• –Drug interctions 
• –Surface area

• –Metabolism in the liver and
• return to circulation 
• ¨Absorption occurs through gastric mucosa, small
• intestine, or rectum, and passes through the portal circulation into the liver

–Enteral:

–Percutaneous

• –Sublingual, buccal, vaginal and IV routes BYPASS
• the LIVER and go directly to site of action (NO FIRST-PASS EFFECT)

• –Parenteral IM< IV SUBQ-IV fastest then
• IM and finally subq; depends upon blood flow (heat
• will increase) Suspensions are slower to absorb (Bicillin)

¨ application to body surfaces;

–Skin eyes, ears, nose and Lungs

Gels, creams inhalers, drops ect.

• Bypasses the “first-pass” effect
• by direct target effect

• Transdermal –examples: estrogen,
• nitroglycerin

• Inhalation- respiratory drugs,
• includes steroids

 transportation of drug by bloodstream.

–Blood flow to tissues:

• •Drugs distribute to highly
• vascular areas first: heart, liver, kidneys, and brain and muscle, skin and fat
• last

• •Bone has poor blood supply and
• the brain has a barrier that prevents distribution this meningitis and osteomyelitis are difficult to treat

–Drug solubility

–Tissue storage

–Special barriers to drug distribution

–Drug-protein binding

results in transformation of drug into:–Inactive metabolite–More soluble compound–Or more potent metabolite¨Liver is the organ most responsible forbiotransformation, but skeletal muscle, kidney, lungs, blood plasma &intestinal mucosa also cause biotransformation

–Elimination of drug from the body–Kidney is primary organ ofexcretion–Two other organs playing animportant role in excretion are:  liver  & bowel (fecal & biliary)–Pulmonaryexcretion–Glandularsecretion: breast milk

• in this range, the drug produces a therapeutic effect
• –Toxic concentration: a higher
• dose level of drug that results in serious adverse effects.

predictable, adverse drug reactions

time it takes for one half of the original amount of drug taken to beremoved from body.–Shorthalf-life–Longhalf-life¨Rule of Thumb: when a drug isdiscontinued it takes approximately four half-levels before the agent isconsidered ‘Functionally” eliminated. (94% is eliminated)

with regard to bloodlevels of a drug refers to the physiologic state in which the amount of drugremoved via elimination is equal to the amount of drug absorbed with each dose

is a higher amount of drug, often given only once or twice to “prime” thebloodstream with a level sufficient to quickly induce a therapeutic response.

before plasma levels drop back toward zero, intermittent doses are given tokeep the plasma drug concentration in the therapeutic range

mechanism ofdrug action in living tissue

–Drug-induced change in normalphysiologic function.  A positive changein faulty physiologic system

• Mechanism of
• Action”:  (therapeutic effect) produced
• in several ways:  Receptor Interaction,
• Enzyme Interaction,  Nonspecific
• Interaction

describes adrug’s margin of safety. TherapeuticIndex: the ratioof a drug’s toxic level to the level that provides therapeutic effects.

selective joining of drugmolecule with reactive site on cell surface- “affinity”–Agonists–Antagonists–Agonist-antagonists

 the  highest blood level of a drug

 thelowest blood level of a drug

–Arepredictable and which may occur even at therapeutic doses–Side effectsare less serious than adverse effects–Differencebetween side effect and adverse effect? Severity of symptoms (HA)

• –Medical
• history

• –Assess the
• patient and lab data

• –Prevent med
• error

• –Monitor
• pharmacotherapy carefully

• –Know the
• drugs

• –Be prepared
• for the unusual

• –Question
• unusual orders

• –Teach
• patients about adverse effects

 not a result of a know pharmacologic property ofdrug (G6PD deficiency)

causes structural defects in unborn fetus

permanent changes in genetic composition ofliving organism

can cause cancer particularly when taken overextended period of time. 

patientswith serious renal impairment should not receive nephrotoxic drugs

S/S of neurotoxicity include depression, mania, sedation, behavioral changes,hallucinations, and seizures

the incidence of drug-induced myopathy is low butmay be serious when it does occur

liver detoxify foreignchemicals that enter the body and the effects can be minor to major. It isimportant to check the liver enzymes and monitor the patient for s/s of liverproblems

 druginduced rash urticaria, angioedema Steven Johnson syndrome

 these canbe serious and fatal outcomes

• –When action of one drug is altered by a second drug
• •ADDITIVE
• •SYNERGISTIC
• •ANTAGONISTIC
• •Incompatibility 

two drugs with similar effect given togetherso each can be given in smaller doses.

effect greater than that of each given individually 

 effect is less than that drug would achieveseparately

¨Food, nutrients and dietary supplements may interact with medications and affect their actions

¨Grapefruit juice and enzyme CYP3A4: can last up to 3 days after drinking the juice.

¨In most cases with other food-drug interactions there should be a 2-hour time gap between ingestion of the food and drug.

• ¨Dietary Supplements:
• –St.John’s wort 
• –Ginkgo Biloba

–Right dose

• –Right
• medication

–Right patient

• –Right route
• of administration

• –Right time of
• delivery

• Assessment
• nursing Diagnosis- (never use a medical Dx)
• Planning
• Implementation
• Evaluation

collection of subjective and objectivedata on the patient & environment.–Tools used to collect: drughistory, physical assessment, review of chart, patient & family interview.•Must include use ofover-the-counter (OTC) medications, alcohol, past & present health history,& family history, health beliefs, socioeconomic status, educationlevel/cog- nitive ability, religious belief. 

• ¨From your assessment you develop a Nursing Diagnosis. 
• Common ones for drug therapy would include:
• –Knowledge deficit ( need to learn)
• –Ineffective management of therapeutic regimen (why? Financial, knowledge, forgetful, etc)
• –Impaired memory (elderly, or very ill)

–Prioritize nursing diagnoses–Gather information (teaching specifics, etc)–Identification and statement of goals and outcomecriteria.•Goal Ex.: Prior to discharge patient willdemonstrate ability to take prescribed medication in a safe manner.• Outcome Ex.: Prior to discharge patient will be able to identify which medicationshould not be taken with food.

• •Right drug
• •Right dose
• •Right time
• •Right route
• •Right patient
• •Most include “6th Right –“Documentation”

• –Patient DrugTherapy Education –First determine you patients“readiness” to learn–Second determine “learning needs”–Third determine “what can theylearn”–To do this you need a thoroughassessment of the patient.
• –Set goals with client/family

• –Implement according to assessment
• findings (cognitive/sensory ability)

• •Involve family in teaching for
• reinforcement

•Use A/V aids when able

• •Document all teaching and
• evaluation of the session

• –Much teaching takes place at
• discharge but should begin on admission.

–Monitoring patient response (expected andunexpected) to implemented plan of care.–Has the therapeutic effects of the drug beenprevented or kept to acceptable levels?–Was there an improvement over the baseline data?–Determines degree of attainment of Goals andOutcome Criteria.

pediatrics (birth to @ 13 yrs) and geriatrics( post 65 yrs) 

– A     Studies indicate no risk to human fetus– B     Studies indicate no risk ot “animal” fetus– C     Adverse effects in animal fetus reported                (no information available onhuman)– D    Possible human fetal risk reported  (consider benefit to risk before use)– X   Fetal abnormalities reported; positive risk   to human fetus is available.   Should not   beused in pregnant women. 

• –Neonate:  less than 1 month old
• –Infant:     1 month to 1 year
• –Child:      1 year to 12 years

• –Experience decline in organfunction (GI, Liver, Kidney, Heart) ( note similarity to peds)–Polypharmacy: (13% of population consumes 30% of prescription & > 40% ofOver-the-counter (OTC) drugs    (Greaterrisk of drug to drug interaction)
• –Important to monitor lab values
• (liver enzymes, kidney function most important)

–Decreased protein binding sites

• –Increase in body Fat content
• mainly due to decrease in body muscle mass.

• –Total Body Water is significantly
• decreased

• –Fat soluble drug will have
• prolonged effect

 (control contractions of smooth &skeletal muscle, and some glandular secretions)

 (skeletal muscle)

 (involuntary)

–Neurons–Synapse–Neurotransmitters–Excitatory–Inhibitory

–Controls the functionof most tissues, except skeletal muscle–Maintains a constant,internal/environment (homeostasis)–Responds to emergencysituations

•Norepinephrine: (NE, epinephrine, dopamine

• •Neurotransmitter secreted by adrenergic fibers (inc
• heart rate: pupillary dilation);

• •Adrenergic or sympathomimetic drugs produce same effect
• in body;

• •Adrenergic-blocking agents- block or inhibit adrenergic
• system/activity

• –Neurotransmitter s/b
• cholinergic fibers (dec. heart rate;
• pupillary constriction);

• –Cholinergic or
• parasympathomimetic drugs produce same effect;

• –Anticholinergic
• agents- BLOCK or INHIBIT cholinergic activity

• •Mechanism of action (MOA):
• •3 types of adrenergic receptors

• –Alpha:
• –Alpha 1 : causes vasoconstriction of blood vessels
• –Alpha 2: negative feedback preventing release of Norepinephrine

• –Beta: –Beta 1: increase in heart rate
• –Beta 2: relax smooth muscle in bronchi (bronchodilation): relax uterus: vasodilation

• –Dopaminergic:
• –Vasodilation (cerebral, coronary, mesenteric, & renal perfusion
• –Improves symptoms associated with Parkinson’s disease

• –Many drugs acts on
• more than ONE TYPE OF ADRENERGIC RECEPTOR;

• –Each drug acts to
• varying degrees

• –Asthma, hypotension,
• shock, nasal decongestant

–CHRONOTROPIC/DROMOTROPIC/INOTROPIC  Effect

• •AVAILABILITY: IV/IM/SQ/PO aerosol; usuallyimmediate-effect; EX: albuterol, epinephrine, isoproterenol, pseudoephedrine,dopamine, dobutamine
• •Side effects (S/E): palpitations; tachycardia; skin
• flushing ; dizziness; tremors; orthostatic hypotension
• •ADVERSE EFFECTS (A/E): arrhythmias; chest pain; severe hypotension; hypertension, anginal pain; n/v
• •Drug Interactions:

• –Increase effect:
• Monoamine Oxidase inhibitors
• (metabolized by monoamine oxidase); tricyclic antidepressants (vasopressor effects); atropine

• –Decrease effect:
• beta-adrenergic blocking agents/alpha-adrenergic blocking agents (antihypertensives)

• •Nursing implications: baseline vitals- HR/ BP ( take BP
• supine, sitting, standing), arise slowly

•S/E dose related- decease dose or d/c meds by physician

• •Assess for hepatic function, thyroid disease,
• hypertension, heart disease, DM

•Consult physician prior to d/c

• •Use nasal decongestants as ordered;  with increase/ inappropriate use- rebound
• effect

• •Mechanism of action (MOA): work opposite of adrenergic agents: INHIBIT/BLOCK stimulation
• •Uses: ALPHA BLOCKING: vasoconstrictive type of disorders (Raynaud’s phenomenon)
• –BETA BLOCKING: hypertension; angina, cardiac arrhythmias
• •Available: PO/IV/IM: increase dose slowly: decrease dose
• to adjust
• •A/E: bradycardia, peripheral vasoconstriction, bronchospasm; DM- hypoglycemia; heart failure
• •Drug Interactions:
• –Increase effect- anthihypertensive meds: lidocaine/ digitalis
• –Decrease effect= beta adrenergic agents; enzyme-inducing agent; indomethqacin/salicylates
• •Nursing Implications: beta-blockers used with caution in
• patients with respiratory conditions, DM, heart failure;
• •Monitor Heart rate and blood pressure
• •DO NOT STOP ABRUPTLY; gradually reduce the dose

• •Mechanism of action: actions of acetylcholine (decrease
• heart rate; increases GI motility & secretions)
• –Direct-acting-stimulate parasympathetic NS
• –Indirect-acting-inhibit acetylcholinesterate 
• –Nicontinic/muscarinic receptors: 
• •“REST & DIGESTS”
•  •SLUDGE

• •Uses: mysathenia gravis: reverse muscle relaxants; reverse toxicity of
• anticholinergic agents; disorders of the eye ( decrease intraocular pressure)

•Avaiable: PO/ INJ/ DROPS:

• –Bethanechol, pilocarpine, neostigmine
• •Side effects: dose –related; N/V/D abdominal cramps;
• dizziness;  hypotension

• •Adverse effects: BRONCHOSPASM, wheezing,
• bradycardia—STOP MEDS!!!

• •Drug Interactions: atropine/antihistamines- antagonizing
• effect

• •Nursing Implications: cholinergic fibers innervate
• entire body; monitor HR, BP; rise slowly; leg exercises

• •Mechanism of action: block action of acetylcholine:
• increase IOP of eye; tachycardia; decrease secretions

•

• •Uses: GI/ ophthalmic disorders; bradycardia; Parkinson’s
• disease; GU disorders; Preop drying agent;
• placing endotracheal tube

•Available: INJ/PO

• •Atropine, scopolamine, Ipratropium, Robinul
• •Side Effects: blurred vision; constipation, urinary
• retention: dryness of mucus membranes

•

• •Adverse effects: confusion, depression; nightmares;
• hallucination; orthostatic hypotension- decrease dose; palpitations;
• arrhythmias, glaucoma— STOP MEDS
• •Drug Interactions: increase effect- amantadine (Symmetrel); tricyclic antidepressants; phenothiazines

•

•Nursing Implications:

• –Not used with
• closed-angle glaucoma; enlarged prostate;

–Assess neuro/ cognitive status

• -reduction in anxiety
• -improved sleep patterns
• -elevated mood
• -management of psychotic symptoms
• -slowing the progression of chronic degenerative diseases of the brain
• -termination and prevention of seizures
• -reduction in muscle spasms and spasticity
• -reduction of hyperactivity and mania
• -reduction of pain
• -induction of anesthesia

• the "thinking" part of the brain
• for perception, speech, conscious motor movement, movement of skeletal muscles, memory, and smell

• occipital lobe- vision
• frontal- reasoning and planning
• others- language, hearing, motor or sensory functions

sensory information: sounds, sights, pain, touch, and temperature to cerebral cortex

disorders of thalamus: OCD, bipolar, anxiety, and panic disorder

• -regulation of hunger, thirst, water, balance, and body temperature
• -also limbic system: emotional expression, learning, and memory
• - connect to brain stem: heart rate, respiratory rate, blood pressure, and pupil size(ANS response)

muscle movement, balance, posture, tone

• -consist of medulla oblongata, pons, and midbrain
• - breathing, heart rate, vision, swallowing, coughing, and vomiting

sensory and motor function

oxygen and glucose to brain

• -from the brainstem to thalamus
• -sleeping and wakefulness and performs an alerting function

skeletal muscle movement

-controls locomotion, complex muscular movements, and posture