2/11/2016
N111: Introduction to
Pharmacology
Leslie Martinez, MSNEd, RN
Los Angeles County College of Nursing & Allied Health
[email protected] Drug Action
Pharmaceutic Phase
Disintegration Dissolution
Breaking down A drug becoming a
of a tablet into solution to aid crossing
smaller particles the biologic membrane
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Pharmaceutic Phase
Excipients
Inert fillers that enhance
drug dissolution & absorption
Enteric Coated
Resists disintegration in the acidic stomach
Teaching considerations
Food Considerations
Enhances or interferes with dissolution 4
Dilutes drug concentration = irritation
Pharmacokinetic Phase
1~Absorption 2~Distribution
Movement of drug Process of drug
from GI tract to becoming available to
body fluids body fluids & tissues
Pharmacokinetic Phase
3~Metabolism 4~Excretion
Inactivated by liver Via urine
enzymes converted: 1. Renal dysfunction
1. H20 soluble 2. Urine pH
substance
2. Metabolite for
renal excretion
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Absorption Variables
1. Lipid-soluble & 1. IM injections
Nonionized Deltoid vs. Gluteus
Absorbed faster
through GI membrane 2. subQ injections
2. Water-soluble &
Ionized (carrier)
Bioavailability
% of drug that reaches systemic circulation
Oral Route
Occurs after absorption & hepatic drug metabolism
< 100% bioavailability
3-5 times higher dose than IV dose
IV Route 8
100% bioavailability
Bioavailability Variables
1. Drug form
2. Route of administration
3. GI mucosa & motility
4. Food & other drugs
5. Liver metabolism changes or inadequate
hepatic blood flow
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Aspirin 650 mg Half-life
3 hrs - 325 mg - 1st ½ life 50%
6hrs - 162 mg - 2nd ½ life 25%
9 hrs - 81 mg - 3rd ½ life 12.5%
12 hrs - 40 mg - 4th ½ life 6.25%
15 hrs - 20 mg - 5th ½ life 3.1%
18 hrs - 10 mg - 6th ½ life 1.55%
Short ½ life: 4 to 8 hrs 10
Long ½ life: > 24 hrs
Pharmacodynamic Phase
Study of drug concentration &
the way it effects the body
Primary
Desired effect
Secondary 11
Desirable or undesirable effect
Pharmacodynamic Phase
Onset
Time it takes for drug
to take minimal effects
Peak
Time of highest blood or
plasma concentration
Duration
Length of time drug has 12
a pharmacologic effect
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Creatinine Clearance
CLcr
Most accurate lab test
determining renal function
GFR function =
CLcr
Dose adjusting
Elderly 13
Renal dysfunction
Pharmacodynamic Phase
Agonist
Drug that produces a response
i.e. Isoproterenol; stimulates beta 1 & 2
receptors HR increase & bronchodilation
Antagonist
Drugs that block a response
i.e. Cimetidine; blocks histamine
prevents gastric acid secretion 14
Pharmacodynamic Interactions
Additive
When two drugs with similar actions are
administered simultaneously
= sum of the effect of 2 drugs
Desirable or undesirable
Synergistic (Potentiating)
When two or > drugs are given together, one
can potentiate the other (increase effectiveness)
Desirable or undesirable 15
Pages 32-38
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Pharmacodynamic Interactions
Antagonistic
When two drugs have opposite effect,
the meds cancel each other out
Desirable (antidote) or undesirable
Common symptoms of drug-drug interactions
Nausea, GI upset
Headache, dizziness
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Pages 32-38
Toxic Effects
Therapeutic Range
Range between min & max effective
concentration in the blood
Therapeutic Index
Ratio that measures the margin of the
effective dose & the lethal dose
Low ~ Narrow margin of safety 17
High ~ Wide margin of safety
Pharmacodynamics
MEC = Minimum Effective Concentration
MTC = Minimum Toxic Concentration
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The time-response curve evaluates three parameters of drug action:
(1) Onset, (2) Peak, and (3) Duration.
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Therapeutic Ranges & Toxic Levels
(mcg/ml) Therapeutic Range Toxic Level
Dilantin 10-20 >30
Tegretol 6-12 >12-15
Depakote 50-100 >100
Loading dose
Lrg dose to achieve rapid MEC in the plasma 19
Special Considerations
Side Effects
Physiologic effects not
r/t desired drug effects
Teaching opportunity
Adverse Reactions
Unintended, undesirable mild to
severe side effects at normal doses
i.e. Anaphylaxis & Hypersensitivity
Report & document
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Peak & Trough
Peak
Indicates rate of drug absorption
Highest level of plasma concentration
at a specific time
Blood drawn at proposed peak time
Peak time is dependent on route
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Peak & Trough
Trough
Indicates rate of drug elimination
Lowest level of plasma concentration
just before med administration
Blood drawn minutes before med 22
administration
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Peak & Trough
Narrow Therapeutic Index Meds
Aminoglycosides
Anticonvulsants
Gentamicin
Peak = 30 min after IV infusion completed
Peak 5-10 mcg/dl Toxic Peak > 12 mcg/dl
Trough < 2 mcg/dl Toxic Trough > 2 mcg/dl 24
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Food & Drug
Administration (FDA)
Protects Public Health by assuring the safety, efficacy
& security of:
Human & animal drugs, 80% food supply, biological
products, medical devices, radiation emitting devices…
Responsibilities
Speeding innovations that make meds more
effective, safe & affordable
Helping public get accurate, science-based info on 25
meds & foods to improve health
Federal Legislation:
Federal Food, Drug & Cosmetic Act
Monitors & regulates the manufacturing
& marketing of drugs
Requires approval before marketing
Clinical Trials
Labels & packaging 26
Federal Legislation:
Controlled Substance Act
Regulation of Controlled Substances
Narcotic Drug Use & Abuse
1. Promotion of drug education & provisions
2. Strengthening of enforcement authority
3. Establishment of tx & rehab. facilities
4. Designation of schedules for controlled drugs 27
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Schedule I
High abuse potential
No accepted medical use in U.S.
Not accepted for use under medical
supervision
Heroin, Hallucinogens & Marijuana
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Schedule II 2.5 years later
Accepted for
medical use
High potential
for drug abuse
Severe physical &
psychological
dependency risk
Meth, Demerol, Morphine,
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Oxycodone, Cocaine
Schedule III
Medically accepted
Potential abuse
< Schedule I & II
Moderate or low
physical dependence or
high psychological
dependence risk
Anabolic steroids, Codeine
preparations, barbiturates 30
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Schedule IV
Medically accepted
May cause dependence
Limited physical dependence or
psychological dependence relative
to the drugs in Schedule III
Phenobarbital, Benzodiazepines, Lorazepam,
Valium, Xanax 31
Schedule V
Medically accepted Very limited
potential for
dependence
Cough syrups with
codeine, lomotil 32
Nursing Responsibilities
Account for controlled Double lock
substances Locked room & Pyxis
Records/Inventory Access to keys
Med room
Countersign~
Waste vs. lost Mandatory abuse
Morphine 6 mg IVP reporting
Scan medications 33
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Over the Counter (OTC) Medications
Advantages
Convenience, cost
Potential serious complications
Additive effect, non disclosure, reactions
Nursing responsibilities/Teaching
Reconciliation, use of 1 pharmacy, labels, dosing
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Herbal Therapies
Plant/plant part used for its scent, flavor, or
therapeutic property
>$60 billion annual industry
Non-FDA regulated
Dietary Supplement Health and Education Act 1994
Reclassified as “Dietary Supplements”
Can note physiological effects
Can not state preventative, diagnostic or curative effects
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Herbs: Potential Hazards
Black Cohosh
Potentiates effects of insulin, oral
hypoglycemic, and antihypertensive drugs
Goldenseal and Kava
Contraindicated in pregnancy
Licorice (excessive)
Increased BP & potassium excretion, lethargy,
heart failure 36
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Herbs: Nursing Responsibility
Complete list of herbal & OTC preparations
Include teas, tinctures, tablets, and dried herbs
Name, brand, dose, frequency, side effects and
client’s perceived effectiveness
Teaching
Encourage as “integrative” modality
Potential interactions w/ prescribed medications
High risk: elderly & three or more drugs for
chronic conditions 37
Dietary considerations
Pediatric Considerations
Pediatric pharmaceutical
Research/profit margin
Pediatric Equity Act
Pharmacokinetics
Absorption: varies by age/weight/health status
Distribution: affected by body fluid composition
Metabolism: neonate/infant vs. adolescent
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Excretion: decreased < 9 months and adolescence
Pediatric Considerations
Family-centered care
Caregiver teaching
Cognitive assessment
Atraumatic care
Eliminate/minimize psychological &
physical distress of children and their family 39
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Older Adult Considerations
85% take medications
Polypharmacy
Multiple HCPs, herbal/OTC therapies,
shared/duplicate meds, discontinued meds
Intentional vs. unintentional noncompliance
Effects
Confusion, falls, malnutrition, renal/liver issues 40
Older Adult Considerations
Absorption
Distribution
Metabolism
Excretion
Dose adjusting
Weight, adipose tissue, labs, health problems
Teaching 41
Use of one pharmacy/Carry list
Nurse Practice Act
Drug Administration Laws
Vary state to state
Civil Court prosecution
Misfeasance
Wrong drug or dose 42
resulting in death
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Nurse Practice Act
Malfeasance Nonfeasance
Correct drug by Omission that
wrong route that results in death
causes death
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Drug Names
Trade (Brand) Name
Tylenol
Generic Name
Universally accepted
acetaminophen
Orders
acetaminophen (Tylenol) 44
Drug Information Resources
1. Nursing Drug Guides
2. Online sites
Micromedix (Intranet)
3. Smartphone applications
1. Davis
2. Micromedix
3. Nurse Reference Center
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Black Box Warning: Policy 909
Given when safe administration of drug carries
risk of serious/life-threatening adverse effects
Strongest drug warning by FDA
LAC+USC BBW list
1. The Licensed Nurse will review & implement “RN
Actions to Consider” prior to administering the drug
2. Report adverse findings on Patient Safety Network
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High Alert Medications
Medications that carry the risk of
causing injury when misused
Safeguard to reduce the risk of error
Limiting access
Auxiliary labels and automated alerts
Standardizing ordering, storage, preparation,
& administration
Double checks/signature
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High Alert Medications
Examples:
Insulin (subQ & IV)
Opiates & Narcotics
Anticoagulants
Chemotherapy
Thrombolytics
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Joint Commission
2015 National Pt Safety Goals: Hospitals
Medication reconciliation
Goal 1: Improve accuracy of pt identification
Goal 2: Improve staff communication
Goal 3: Improve medication safety
Goal 6: Improve alarm safety
Goal 7: Reduce HAI risks
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LAC+USC Policy 721
Medication Reconciliation
Ensures the development of a complete
& accurate list of medications
Pt moves from one area to another
Change in setting
New practitioner
Change in level of care
5 steps of Reconciliation 50
Nursing Process in Medication Administration
Quality & Safety Education for Nurses (QSEN)
Knowledge, Skills, & Attitude
1. Patient & Family Centered Care
2. Collaboration & Teamwork
3. Evidence-based Practice
4. Quality Improvement
5. Safety
6. Informatics
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Assessment
Systematic validation &
documentation of info.
Subjective Data
Current health hx, symptoms, current meds/
herbs/OTC, past health hx, and environment
Objective Data
Physical health assessment
Gross/fine motor skills, visual impairment, dosing 52
Labs and diagnostics
Nursing
Diagnosis
1. Deficient knowledge r/t lack of information about
drug interactions and OTC drugs AEB ingesting
meds with dangerous additive effect.
2. Impaired urinary elimination r/t decreased fluid
volume and renal immaturity AEB UO > 10
mL/hr and Cr level of 2.67.
3. Ineffective health maintenance r/t lack of
transportation and income AEB multiple missed 53
appointments and noncompliance with medication.
Planning & Goal
Goal setting
Client centered
Specify activity
Time frame
Nursing intervention development
Focused on goal attainment
The client will independently administer prescribed 54
insulin by end of 4th session instruction.
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Implementation
General teaching
Administration
Nurse vs. client
Diet
Side effects
Cultural considerations
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Evaluation
Goal evaluation
Not met/partially met
Nursing interventions/plan revision
Teaching
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