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FOUNDATIONSFOUNDATIONSOF PHARMACOLOGYOF PHARMACOLOGY

Slide 1



Greek ³pharmakon´, drugs

and ³logos´, science



DefinitionDefinition

Deals with the study of drugs and their actions in

living microorganisms



History of PharmacologyHistory of Pharmacology

Since time immemorial, medicaments havebeen used for treating disease in humans andanimals.

Belief in the curative powers of plants and

certain substances rested exclusively upontraditional knowledge, that is, empiricalinformation not subjected to criticalexamination.

The birth date of pharmacology is not asclear-cut.




Ancient Times A series of scattered facts exists thatspeak of the early history of humankind's efforts to harness thehealing properties of naturalcompounds. However, what we knowfor certain is that ancient peoples madeextensive use of plant, animal andmineral sources for this purpose.




The Ebers papyrus, written in Egypt in the 16th centuryB.C., lists the extensive pharmacopia of that civilization.Included in this are: beer, turpentine, myrrh, , juniper

berries., poppy, lead, salt andcrushed precious stones. Also

included were products derivedfrom animals, including lizard's

blood, swine teeth, goose grease,ass hooves and the excreta from

various animals. The effects of many of these drugs on patients of

antiquity can only be imagined.




From ancient China comes evidence of thatculture's extensive efforts to heal through theuse of natural products. The P en Tsao, or Great Herbal, comprised forty volumes

describing several thousands of prescriptions.




Interestingly, the easternherb Artemisia annuaL. (wormwood), usedin China since antiquity

to treat fevers, is thesource of the moderndrug qinghaosu, whichshows great promise

as a modern anti-malarial compound.




Antiquity to themodern eraThe ancientsconsidered disease aconsequence of demonic possession,or the wrath of god.Thus, in ancienttimes, the treatmentof illness with natural

products wasinvariablyaccompanied byreligious ritualsdeemed essential to

the healing process.



Claudius Galen (129Claudius Galen (129± ±200 A.D.)200 A.D.)

first attempted toconsider thetheoreticalbackground of

pharmacology. Both theory andpractical experiencewere to contributeequally to the rationaluse of medicines

through interpretationof observed andexperienced results




With time, the thoughts returned to theappreciation that the natural productsthemselves held the power to cure.

Although, traditional

remedies still generallyconsisted of complexmixtures of distinctherbs and minerals,

perhaps only one of which possessed any

activity. Many poisonous mixtures

were made.



Theophrastus vonTheophrastus von HohenheimHohenheim(1493(1493± ± 1541 A.D.)1541 A.D.)

called Paracelsus, beganto question doctrineshanded down fromantiquity, demandingknowledge of the activeingredient(s) in prescribedremedies, while rejectingthe irrational concoctionsand mixtures of medievalmedicine

He prescribed chemicallydefined substances withsuch success thatprofessional enemies hadhim prosecuted as apoisoner



JohannJohann JakobJakob Wepfer Wepfer (1620(1620± ±16951695))

the first to verifyby animalexperimentationassertions about

pharmacologicalor toxicologicalactions.





Claude BernardClaude Bernard

In 1842,discovered thatthe arrow poisoncurare acts at the

neuromuscular junction tointerrupt thestimulation of muscle by nerveimpulses





OswaldOswald SchmiedebergSchmiedeberg(1838(1838± ±1921)1921)

recognized as thefounder of modernpharmacology

helped toestablish the highreputation of

pharmacology.



showed that muscarine evoked thesame effect on the heart as electricalstimulation of the vagus nerve

published a classic text, Outline of P harmacology , and in 1885, heintroduced urethane as a hypnotic.



John J. AbelJohn J. Abel(1857(1857± ±1938)1938)

The ³Father of AmericanPharmacology´, wasamong the first Americans to train in

Schmiedebergµslaboratory and wasfounder of the J ournal of P harmacology and Experimental

Therapeutics (published from 1909 until thepresent)



After 1920, pharmacological laboratoriessprang up in the pharmaceutical industry,outside established university institutes.

After 1960, departments of clinical

pharmacology were set up at manyuniversities and in industry.



Fundamental concepts such as structure-activityrelationship, drug receptor, and selective toxicityemerged from the work of, respectively, T. Frazer (1841±1921) in Scotland, J. Langley(1852± 1925) in England, and P. Ehrlich (1854±

1915) in Germany. Alexander J. Clark (1885±1941) in England first formalized receptor theory inthe early 1920s by applying the Law of Mass Action to drug-receptor interactions.

Together with the internist, Bernhard Naunyn(1839±1925), Schmiedeberg founded the first

journal of pharmacology, which has since beenpublished without interruption.




For example, the purplefoxglove, Digitalis

purpurea, was one of twenty herbs used in a

folk remedy to treatdropsy in 18th centuryEngland.

From the leaves of this

plant was isolated thecardiac glycosidedigitalis, a drug stillused today to treatheart failure.




Over time, as a moresophisticated view of illness evolved, anincreasingly scientific

approach to theisolation of drugsfrom natural productswas taken. In the

early 19th

century,morphine was isolated from the opium poppy ( Papaver

somniferum) and the anti-malarial compound quinine from the bark of the cinchona tree (Cinchona officinalis).




M ateria M edicaThe ancient discipline of M ateria

M edica was born, devoted tounderstanding the origin,preparation and therapeuticapplications of medicinal

compounds.It postulated that:

Each disease has a uniquecause for which there is aspecific remedy.

Each remedy has an identifiable nature or essence that is extracted fromthe natural product by chemical extraction.

The administration of a remedy is based on testing the amount of drugneeded to achieve an effect (dose-response).

F rom Stata Norton






Paul Ehrlich described drug-receptor binding:

³Corpora non agunt nisi fixate´. P. Ehrlich (1908)

(³Agents do not act unless they are

bound´)

In the United States, transformation was marked by thecreation of the American Society for Pharmacology and

Experimental Therapeutics (ASPET) in 1908.




The modern eraThese, and additional advances in the fields of chemistry and physiology, lead to the birth of modern pharmacology in the latter half of the

19th

century.T

hus,M

ateriaM

edica evolvedinto the

experimental scienceof pharmacology,

which is devoted tounderstanding the

physiological actionof these molecules.




The 20th

century has witnessed the discovery of a steady stream of important new drugs thathave immeasurably improved the humancondition.

Not very long ago, vast numbers of humansperished prematurely or suffered an existencefilled with pain due to the effects of infection or disorders that are now successfully treated.

chemotherapy of cancer

microbial infections

diabetes

hypertension

depression

AIDS



SignificanceSignificance

The goal of studying pharmacology is tounderstand how such therapeutics work andto use this knowledge, along with techniquessuch as molecular modeling and computer-

aided design, to develop new ideas that maylead to the miracle drugs of the future.

Additionally, toxicology is an important areaof pharmacology that focuses onunderstanding the adverse effects of certaindrugs and environmental pollutants



Introduction to DrugsIntroduction to Drugs

Until the end of the 19th century,medicines were natural organic or inorganic products, mostly dried, butalso fresh, plants or plant parts.

These might contain substancespossessing healing (therapeutic)properties or substances exerting a

toxic effect.



In order to secure a supply of medicallyuseful products not merely at the time of harvest but year-round, plants werepreserved by drying or soaking them invegetable oils or alcohol.

Drying the plant or a vegetable or animalproduct yielded a drug (from French³drogue´ ± dried herb).

Colloquially, this term nowadays often refers

to chemical substances with high potential for physical dependence and abuse



Sources Of DrugsSources Of Drugs



Therapeutic MethodsTherapeutic Methods

Drug therapy Treatment with drugs

Diet therapy Treatment with diet Such as low salt low fat for CVD

Physiotherapy Treatment with natural physical forces Such as water, light and heat

Psychological therapy

Identification of stressors and methods toreduce or eliminate stress or the us of drugs



Slide 34

Definitions, Names,Definitions, Names,Standards, and InformationalStandards, and Informational

SourcesSources



Slide 35

Foundations of Foundations of PharmacologyPharmacology

Types of drug names Chemical

Most meaningful to chemist, he understands exactly thechemical constitution of drug and exact placing of its atoms or molecular groupings

Generic Common name

Official Name under the drug is listed by the USFDA

Trademark (brand) Proprietary name

Name is registered and that is use is restricted to the owner of the drug





Slide 37

Foundations of Foundations of Pharmacology (cont¶d)Pharmacology (cont¶d)

CHEMIC AL N AME 2S,5R,6R)-6-([(2R)-2-amino-2-phenylacetyl]amino)

-3,3-dimethyl-7-oxo-4-thia-1-azabicyclo[3.2.0]heptane-2-carboxylic acid



Drugs ClassificationDrugs Classification

According to the body system they affect According to their therapeutic use

According to physiologic or chemical action

Prescription or Non-prescription OTC or

Illegal ( Recreational)

Slide 38



Legal Regulations of Drugs inLegal Regulations of Drugs inthe Philippinesthe Philippines

Many laws have been enacted over the lastcentury that affect drug distribution andadministration

Congress passed this law that gave the

BFAD control over the manufacture and saleof drugs, food, and cosmetics



Drug Standards and ControlsDrug Standards and Controls

A. Drug ControlB. Drug Standards

C. Drug Preparations

D. Classification of Drugs



Drug ControlDrug Control

International: USFD A National: BFAD, National DrugBoard

Local Regulations: DTI Institutional: Hospital

regulations

Individual: Client and Physician



Drug StandardDrug Standard

Purity freedom from contaminants

the absence, or degree of absence, of anythingharmful, inferior, unwanted, or of a different

Potency Strength of medicine or drug

Bioavailability

measure of drug absorption

the extent and rate to which a drug is taken up bythe body in a physiologically active form




Efficiency To achieve desired result

Safety

freedom from danger: protection from, or not

being exposed to, the risk of harm or injury Toxicity

degree of poisonousness: the degree towhich something is poisonous




Testingprocedures



Slide 45

Sources of Drug InformationSources of Drug Information

American Drug Index Index all medicines in US annually

American Hospital Formulary Service

Drug Interaction Facts

Drug Facts and Comparisons

Handbook on Injectable Drugs

Handbook of Nonprescription Drugs

M artindale±The Complete

Drug Reference



Slide 46

Sources of Drug InformationSources of Drug Information(cont¶d)(cont¶d)

Package inserts

Natural M edicines Comprehensive Database

P hysicians¶ Desk Reference ( PDR)

Nursing journals



Sources of Drug InformationSources of Drug Information

Goodman and Gilman, ThePharmacologic Basis of Therapeutics

Cochrane Library

USFD A/

BFAD

Drug Handbook



Slide 48

Sources of Drug InformationSources of Drug Information(US)(US)

US P harmacopeia (US P ) / National Formulary (NF)

US P Dictionary of US AN and International Drug Names



Slide 49

Sources of Drug InformationSources of Drug Information(Canada)(Canada)

Compendium of P harmaceuticals and Specialties

P atient Self-Care: Helping P atients M akeTherapeutic Choices

Compendium of Self-Care P roducts Electronic databases



Slide 50

Sources of PatientSources of PatientInformationInformation

United States P harmacopeia Dispensing Information (US PDI)

Therapeutic Choices



Slide 51

U.S. Drug LegislationU.S. Drug Legislation

Federal Food, Drug, and Cosmetic Act (1938,1952, 1962)

Controlled Substances Act (1970)



Drug DevelopmentDrug Development

This process starts with the synthesis of novel chemical compounds.

Substances with complex structures may beobtained from various sources, e.g., plants(cardiac glycosides), animal tissues (heparin),

microbial cultures (penicillin G), or humancells (urokinase), or by means of genetechnology (human insulin).

As more insight is gained into structureactivity relationships, the search for newagents becomes more clearly focused.



Preclinical testingPreclinical testing

yields information on the biological effectsof new substances.

Initial screening may employ biochemical- pharmacological investigations (e.g.,

receptor-binding assays) or experiments oncell cultures, isolated cells, and isolatedorgans

T i l i l i ti tiT i l i l i ti ti



Toxicological investigationsToxicological investigations serveserveto evaluate the potential for:to evaluate the potential for:

(1) toxicity associated with acute or chronicadministration;

(2) genetic damage (genotoxicity, mutagenicity);

(3) production of tumors (onco- or carcinogenicity);

and (4) causation of birth defects (teratogenicity). In animals, compounds under investigation also

have to be studied with respect to their absorption, distribution, metabolism, andelimination (pharmacokinetics)



Clinical testingClinical testing

PH ASE I studies on healthy subjects and seeks to

determine whether effects observed in animalexperiments also occur in humans.

Dose-response relationships are determined

PH ASE II potential drugs are first tested on selected patients

for therapeutic efficacy in those disease states for which they are intended.

Should a beneficial action be evident and the

incidence of adverse effects be acceptably small



Clinical testingClinical testing

PH A

SE III involving a larger group of patients in whom the

new drug will be compared with standardtreatments in terms of therapeutic outcome.

As a form of human experimentation, theseclinical trials are subject to review and approval by

institutional ethics committees according tointernational codes of conduct (Declarations of Helsinki, Tokyo, and Venice).

During clinical testing, many drugs are revealed tobe unusable.

Ultimately, only one new drug remains from

approximately 10,000 newly synthesizedsubstances.



Drug is made by a national regulatory body (Food& Drug Administration in the U.S. A., the HealthProtection Branch Drugs Directorate in Canada, UK,Europe, Australia) to which manufacturers arerequired to submit their applications.

Applicants must document by means of appropriatetest data (from preclinical and clinical trials) that the

criteria of efficacy and safety have been met and thatproduct forms (tablet, capsule, etc.) satisfy generalstandards of quality control.

Following approval, the new drug may be marketedunder a trade name and thus become available for prescription by physicians and dispensing by

pharmacists.



As the drug gains more widespread use,regulatory surveillance continues in the formof post-licensing studies (Phase IV of clinicaltrials).

Only on the basis of long-term experience willthe risk: benefit ratio be properly assessedand, thus, the therapeutic value of the newdrug be determined



Phases of Drug DevelopmentPhases of Drug Development



Slide 60

Drug review processDrug review process





Principles of Drug Action andPrinciples of Drug Action andDrug InteractionsDrug Interactions

Slide 1Mosby items and derived items © 2007, 2004 by Mosby, Inc., an af filiate of Elsevier Inc.

Principles of Drug Action andPrinciples of Drug Action and



Slide 63

Principles of Drug Action andPrinciples of Drug Action andDrug InteractionsDrug Interactions

Basic principles A strong understanding of the human body¶s

processes are important to grasp drug actionsand drug interactions in the body

How do drugs act in theHow do drugs act in the



How do drugs act in theHow do drugs act in thebody?body?

1. Drugs do not create new responses but alter existing physiologic activities

2. Drugs interact with the body in several differentways

3. Most drugs have several different atoms within each

molecule that interlock into various location on areceptor

4. Drugs that interact with a receptor to stimulate aresponse is called agonists and the one who do notis called antagonists

Slide 64

Principles of Drug Action andPrinciples of Drug Action and



Slide 65

Principles of Drug Action andPrinciples of Drug Action andDrug Interactions (cont¶d)Drug Interactions (cont¶d)

Examples: Antagonist²beta blockers

Agonist²epinephrine

Partial agonist²pentazocine

How do drugs act in theHow do drugs act in the



How do drugs act in theHow do drugs act in thebody?body?

5. Once administered, all drugs gothrough ADME

Absorption

Distribution

Metabolism

Excretion

Slide 66



PharmacokineticsPharmacokinetics

Is what the body does to the drug.The magnitude of the pharmacological effectof a drug depends on its concentration at thesite of action.

Absorption Distribution

Metabolism

Elimination



Most drugs have an affinity for certain organsor tissues and exert their greatest action atthe cellular level on those specific areas,which are called target sites.

There are two main mechanisms of action:1. Alteration in cellular environment

2. Alteration in cellular function

Alteration in CellularAlteration in Cellular



Alteration in Cellular Alteration in Cellular EnvironmentEnvironment

Some drugs act on the body by changing thecellular environment, either physically or chemically.

Physical changes in the cellular environment

include changes in osmotic pressures,lubrication, absorption, or the conditions onthe surface of the cell membrane



ExampleExample

a drug that changes osmotic pressure ismannitol, which produces a change in theosmotic pressure in brain cells, causing areduction in cerebral edema

drug that acts by altering the cellular environmentby lubrication is sunscreen

a drug that acts by altering absorption isactivated charcoal, which is administered orallyto absorb a toxic chemical ingested into thegastrointestinal tract.

The stool softener docusate is an example of adrug that acts by altering the surface of the

cellular membrane



Alteration in Cellular FunctionAlteration in Cellular Function

Most drugs act on the body by alteringcellular function.

A drug cannot completely change the functionof a cell, but it can alter its function.

A drug that alters cellular function canincrease or decrease certain physiologicfunctions, such as increase heart rate,decrease blood pressure, or increase urineoutput



PharmacodynamicsPharmacodynamics

deals with the drug¶s action and effect within thebody.

After administration, most drugs enter thesystemic circulation and expose almost all bodytissues to possible effects of the drug.

All drugs produce more than one effect in thebody. The primary effect of a drug is the desired or

therapeutic effect.

Secondary effects are all other effects, whether

desirable or undesirable, produced by the drug



RReceptor eceptor

is a specialized macromolecule (a large group of molecules linked together) that attaches or binds tothe drug molecule.

This alters the function of the cell and produces thetherapeutic response of the drug.

For a drug±receptor reaction to occur, a drug must beattracted to a particular receptor.

Drugs bind to a receptor much like a piece of apuzzle.

The closer the shape, the better the fit, and the better the therapeutic response.

The intensity of a drug response is related to how

good the ³fit´ of the drug molecule is and the number of receptor sites occupied





Slide 75



DrugDrug--Receptor Interactions (cont¶d)Receptor Interactions (cont¶d)

.

Agonists, antagonists, and partialagonists

Agonists Antagonists

Noncompetitive versus competitiveantagonists

Partial agonists Regulation of receptor sensitivity



DoseDose--responseresponse curves in the presence of competitivecurves in the presence of competitiveand noncompetitive antagonists.and noncompetitive antagonists.

.



DrugDrug Responses That Do Not InvolveResponses That Do Not InvolveReceptorsReceptors

.



InterpatientInterpatient Variability In DrugVariability In DrugResponsesResponses

.

Measurement of interpatient variability

The ED50

Clinical implications of interpatient variability



InterpatientInterpatient variation in drug responses.variation in drug responses.

.



DrugDrug--Receptor InteractionsReceptor Interactions

Chemical BondsVan der Waals Interactions

Hydrophobic Interactions



Drug-receptor interactions serve as signals totrigger a cascade of events. This cascade or signaling pathway, is a collection of manycellular responses which serve to amplify thesignal and produce a final effect.

Effectors are thus the molecules that translatethe drug-receptor interaction into changes incellular activity.




y y + Ä EFFECT

DRUG DRUG + RECEPTOR DRUG + RECEPTOR EFFECTOR EFFECTOR

INTERACTION COMPLEX SYSTEM

STIMULUS BINDING ACTIVATION TRANSDUCTION AMPLIFICATION RESPONSE

SIGNALLING PATHWAY



Receptor Signaling PathwaysReceptor Signaling Pathways

Second Messengers:1. Ions (Ca2+, Na+, K+, Cl-)

2. c AMP, cGMP, IP3, Diacylglycerol

3. DN A binding ± Transcriptional regulation.

4. Phosphorylated proteins and enzymes viatyrosine kinase receptors.

Third Messengers:

1. Enzymes (PKC, PK A)

2. Ions (Ca2+, K+)




cAMP

cGMP

DAG and IP3

Arachidonic acid

NO and CO

Na+, Ca2+

, K+, Cl-

EFFECTORS

Adenylate Cyclase (AC)

Guadenylyl Cyclase (GC)

Phospholipase C (PLC)

Phospholipase A (PLA2)

Nitric oxide Synthase

Ions

SECONDMESSENGER








Theory and assumptions of drug-receptor interactions. Drug Receptor interaction follows simple mass-action

relationships, i.e. only one drug molecule occupies eachreceptor and binding is reversible (We know now there aresome exceptions).

For a given drug the magnitude of the response is proportionalto the fraction of total receptor sites occupied by drug molecules.

Combination or binding to receptor causes some event whichleads to a response.

Response to a drug is graded or dose-dependent.

L f M A tiL f M A ti



Law of Mass ActionLaw of Mass Action

When a drug (D) combines with a receptor (R), it does so at a rate which is dependenton the concentration of the drug and theconcentration of the receptor.

D = drug

R = receptor

DR = drug-receptor complex

k1 = rate for association

k2 = rate for dissociation

KD = Dissociation Constant

K A = Affinity Constant

k 1[D] + [R] [DR]

k 2

k 2 = K D = [D][R]

k 1

[DR]

1 = K A = k 1 = [DR]

K D k 2 [D] [R]




Receptor Sites R eceptor-Mediated Drug Effects

The number of available receptor sites influences theeffects of a drug. If only a few receptor sites areoccupied, although many sites are available, theresponse will be small.

If the drug dose is increased, more receptor sites areused and the response increases. If only a fewreceptor sites are available, the response does notincrease if more of the drug is administered.However, not all receptors on a cell need to beoccupied for a drug to be effective.

Some extremely potent drugs are effective even

when the drug occupies few receptor sites




Dose-response relationships Drug-receptor interactions

Drug responses that do not involve

receptors Interpatient variability in drug

responses

The therapeutic index

.




.

Introduction to drug receptors

The four primary receptor families:

Cell membrane-embedded enzymes

Ligand-gated ion channels G protein±coupled receptor systems

Transcription factors





DrugDrug--Receptor Interactions (cont¶d)Receptor Interactions (cont¶d)

.

Agonists, antagonists, and partialagonists

Agonists Antagonists

Noncompetitive versus competitiveantagonists

Partial agonists Regulation of receptor sensitivity



Figure 5Figure 5--7 Dose7 Dose--response curves in the presence of competitive andresponse curves in the presence of competitive andnoncompetitive antagonists.noncompetitive antagonists.

.



DrugDrug Responses That Do Not InvolveResponses That Do Not InvolveReceptorsReceptors

.



InterpatientInterpatient Variability In DrugVariability In DrugResponsesResponses

.

Measurement of interpatient variability

The ED50

Clinical implications of interpatient variability



InterpatientInterpatient variation in drug responses.variation in drug responses.

.

The Therapeutic IndexThe Therapeutic Index



The Therapeutic IndexThe Therapeutic Index

.

D A tiD A ti



Slide 99

Drug ActionDrug Action

Desired effect: when a drug enters a patient,is absorbed and distributed, and produces theexpected response

Side effects - side effects to explain mild,common, and nontoxic reactions

Adverse effect: ³ Any noxious, unintended andundesired effect of a drug, which occurs atdoses used in humans for prophylaxis,diagnosis or therapy´ (World Health Organization)



H lfH lf lif f Dlif f D



Slide 101

Half Half--life of Drugslife of Drugs

Factors modifying thequantity of drugreaching a site of actionafter a single oral dose

D A tiD A ti



Slide 102

Drug ActionDrug Action

Tolerance term used to describe a decreased response

to a drug, requiring an increase in dosage toachieve the desired effect

Dependence

The individual who takes these drugs at homeincreases the dose when the expected drugeffect does not occur

Principles of Drug Action andPrinciples of Drug Action andD I t ti ( t¶d)D I t ti ( t¶d)



Slide 103

Drug Interactions (cont¶d)Drug Interactions (cont¶d)

Drug interaction Drug interactions represent 3% to 6% of

preventable in-hospital adverse drug reactioncases

Drug interactions are a major component of the number of hospital emergency departmentvisits and admissions

DD DD



DrugDrug--DrugDrug

taking of numerous drugs that can potentiallyreact with one another.

Polypharmacy leads to an increase in thenumber of potential adverse reactions.

Slide 104

DD F dF d



DrugDrug -- FoodFood

When a drug is given orally, food may impair or enhance its absorption.

A drug taken on an empty stomach isabsorbed into the bloodstream at a faster ratethan when the drug is taken with food in thestomach.

Some drugs (eg, captopril) must be taken onan empty stomach to achieve an optimaleffect.

Drugs that should be taken on an emptystomach are administered 1 hour before or 2hours after meals.

Slide 105

Dr gDr g LaboratorLaborator



DrugDrug -- LaboratoryLaboratory

The presence of disease may influence theaction of some drugs.

Sometimes disease is an indication for notprescribing a drug or for reducing the dose of a certain drug.

Both hepatic (liver) and renal (kidney)disease can greatly affect drug response.

Slide 106

Drug Across Life SpanDrug Across Life Span




Slide 107

The age of the patient may influence theeffects of a drug.

Infants and children usually require smaller doses of a drug than adults do.

Immature organ function, particularly the liver and kidneys, can affect the ability of infantsand young children to metabolize drugs.

An infant¶s immature kidneys impair theelimination of drugs in the urine.

Liver function is poorly developed in infantsand young children.

Drugs metabolized by the liver may producemore intense effects for longer periods.





Slide 108

rug erapy n spec arug erapy n spec apopulationspopulations--pediatricspediatrics



populationspopulations--pediatricspediatrics

Pediatrics-all aspects must be guided by thechild¶s age, weight and level of growth anddevelopment

Safe therapeutic ranges are less well-defined

Choice of drug is restricted because manydrugs used in adults have not beensufficiently investigated

Pediatric physiologic characteristicsPediatric physiologic characteristicsaffecting pharmacokineticsaffecting pharmacokinetics



affecting pharmacokineticsaffecting pharmacokinetics

Thin, permeable skin ±increased absorptionof topicals

Immature blood-brain barrier²increaseddistribution into the CNS until age 2

Altered protein binding until age 1

Decreased activity of metabolizing enzymesin infants, increased in children

Pediatric physiologic effectsPediatric physiologic effects



Pediatric physiologic effectsPediatric physiologic effects

Increased percentage of body water

Decreased GFR until one year of age

PediatricsPediatrics



PediatricsPediatrics

Oral route for meds is preferable For injections, may wish to use EML A (eutectic mixture of lidocaine and prilocaine,local anesthetics)

Site selection for injections²infants, usethigh muscles; older than 18 months of age,

use deltoid; older than 3, use ventroglutealmuscle

Drug Therapy in Older AdultsDrug Therapy in Older AdultsPhysiologic characteristics andPhysiologic characteristics and

h ki ti i th ki ti i t



pharmacokinetic impactpharmacokinetic impact

Decreased GI motility²slower absorption

Decreased cardiac output²slower absorptionfrom site of administration, decreaseddistribution to sites of action in tissues

Decreased blood flow to liver and kidneys-delayed metabolism and excretion

Drug Therapy in Older AdultsDrug Therapy in Older Adults




Decreased total body water and lean bodymass-fat soluble meds stay with patientlonger, water soluble drugs are distributed insmaller area, greater risk for toxicity

Decreased blood flow to liver-slowedmetabolism and detox of drugs





Decreased albumin-decreased availability of protein for binding and transporting. Will alsohave higher concentration of free active drug.

Decreased blood flow to kidneys²impaireddrug excretion, potential toxicity

er u ser u sRenal ImpairmentRenal Impairment



Renal ImpairmentRenal Impairment

Know baseline renal function

Tailor dosages

Avoid nephrotoxic medications

Be aware of need for additional dosing if

patient is receiving renal replacement therapy

Older AdultsOlder AdultsHepatic ImpairmentHepatic Impairment



Hepatic ImpairmentHepatic Impairment

Those with cirrhosis, hepatitis, receivinghepatotoxic drugs, have heart failure, areundergoing major surgery or have hadtrauma are at higher risk for toxicities r /tmedications

Know drug effects on hepatic function

Reduce dosages on medications that areextensively metabolized by the liver such as:cimetidine, phenytoin, ranitidine, theophylline

er u ser u sCritical IllnessesCritical Illnesses



Critical IllnessesCritical Illnesses

Be aware that all medications may havevariable effects in this scenario

Know the actions, usual dosages and sideeffects of medications

Closely monitor renal and liver function tests Monitor serum protein and albumin levels

er u ser u sCritical IllnessCritical Illness



Critical IllnessCritical Illness

Most drugs will be given IV-for this reason,medications may have faster onset

Many factors may interfere with drug effects if given orally

Considerations when giving medications viafeeding tube

Appropriate scheduling very important

Drug Therapy in Home CareDrug Therapy in Home Care




On patient¶s turf

Schedule visit at convenient time for patientand caregiver

Assess patient¶s ability to perform self-care

Assess patient¶s understanding and attituderegarding medication regimen

Inquire if patient is taking any herbalpreparations





Inquire if patient is taking any OTC meds

Assess environment for safety

Educate patient and caregiver indication,proper administration and side effects of

administered medications Between visits, maintain contact with patientto monitor progress and serve as a resource

Herbal and DietaryHerbal and DietarySupplementsSupplements



SupplementsSupplements

Black cohosh-used to relieve menopausal s/s

Capsaicin-post-herpetic neuralgia

Echinacea-anti-infective, for common cold

Ginger²nausea. Not for morning sickness.

Garlic-cholesterol lowering

Herbal and DietaryHerbal and Dietarysupplementssupplements



supplementssupplements

Feverfew-for migraines, menstrualcomplaints. Can cause withdrawal s/s.

Ginseng-increase stamina, endurance andmental acuity. Can affect bleeding time, BP,increase hypoglycemia. No longer than 3weeks use with Siberian ginseng.





.

Application of pharmacokinetics intherapeutics

Passage of drugs across membranes

Absorption

Distribution

Metabolism

Excretion

Time course of drug responses





Application of Pharmacokinetics inApplication of Pharmacokinetics inTherapiesTherapies

.

By applying knowledge of pharmacokineticsto drug therapy, we can help maximizebeneficial effects and minimize harm.



Slide 127



Passage of Drugs Across MembranesPassage of Drugs Across Membranes

.

Membrane structure

Three ways to cross a cell membrane

Polar molecules

Ions



Three Ways to Cross a Cell MembraneThree Ways to Cross a Cell Membrane

.

Channels and pores

Transport system

P-glycoprotein

Direct penetration of the membrane

Membrane permeation:Membrane permeation:diffusiondiffusion



Slide 130

Membrane permeation:Membrane permeation:transporttransport



pp

Slide 131

Membrane permeation: receptor Membrane permeation: receptor--mediatedmediatedendocytosisendocytosis, vesicular uptake, and, vesicular uptake, and

transporttransport



transporttransport

Slide 132



Polar molecules.

.

IonsIons



.

Quaternary ammonium compounds

pH-dependent ionization

Ion trapping (pH partitioning)



Figure 4Figure 4--4 Quaternary ammonium compounds.4 Quaternary ammonium compounds.

.



Figure 4Figure 4--5 Ionization of weak acids and weak bases.5 Ionization of weak acids and weak bases..



IonIon trapping of drugs.trapping of drugs.

.

AbsorptionAbsorption



.

Factors affecting drug absorption

Characteristics of commonly used routes of administration

Pharmaceutical preparations for oraladministration

Additional routes of administration



Factors Affecting Drug AbsorptionFactors Affecting Drug Absorption

.

Rate of dissolution

Surface area

Blood flow Lipid solubility

pH partitioning



Characteristics of Commonly UsedCharacteristics of Commonly Used

Routes of AdministrationRoutes of Administration

.

Intravenous

Barriers to absorption

Absorption pattern Advantages

Disadvantages

Intramuscular

Barriers to absorption

Absorption pattern

Advantages

Disadvantages



DrugDrug movement at typical capillary beds.movement at typical capillary beds.

.



Characteristics of CommonlyCharacteristics of CommonlyUsed Routes of AdministrationUsed Routes of Administration(cont¶d)(cont¶d)

.

Subcutaneous

± No significant barriers to absorption

Oral

± Barriers to absorption

± Absorption pattern

± Drug movement following absorption

± Advantages

± Disadvantages



MovementMovement of drugs following GI absorptionof drugs following GI absorption..



Pharmaceutical Preparations for OralPharmaceutical Preparations for OralAdministrationAdministration

.

Tablets

Enteric-coated preparations Sustained-release preparations



Additional Routes of AdministrationAdditional Routes of Administration

.

Topical

Transdermal

Inhaled

Rectal

Vaginal



DistributionDistribution

.

Blood flow to tissues

Exiting the vascular system

Entering cells



Blood Flow To TissuesBlood Flow To Tissues

.

Exiting the Vascular SystemExiting the Vascular System



Exiting the Vascular SystemExiting the Vascular System

.

Typical capillary beds

Blood-brain barrier

Placental drug transfer

Protein binding



DrugDrug movement across the bloodmovement across the blood--brain barrier.brain barrier.

.



Figure 4Figure 4--10 Placental drug transfer.10 Placental drug transfer.

.



Slide 151



ProteinProtein binding of drugs.binding of drugs.

.



ProteinProtein binding of drugs.binding of drugs.

.



Entering CellsEntering Cells

.

D M t b liD M t b li



Drug MetabolismDrug Metabolism

.

Hepatic drug-metabolizing enzymes

Therapeutic consequences of drugmetabolism

Special considerations in drugmetabolism



Hepatic DrugHepatic Drug--Metabolizing EnzymesMetabolizing Enzymes

.

Most drug metabolism that takes place inthe liver is performed by the hepatic

microsomal enzyme system, also know asthe P450 system.



Therapeutic Consequences of DrugTherapeutic Consequences of DrugMetabolismMetabolism

.

Accelerated renal drug exertion

Drug inactivation

Increased therapeutic action

Activation of prodrugs

Increased or decreased toxicity

S i l C id ti i DS i l C id ti i D



Special Considerations in DrugSpecial Considerations in Drug

MetabolismMetabolism

.

Age

Induction of drug-metabolizing enzymes

First-pass effect

Nutritional status

Competition between drugs

ExcretionExcretion



ExcretionExcretion

.

Renal routes of drug excretion

Nonrenal routes of drug excretion



Renal Routes of Drug ExcretionRenal Routes of Drug Excretion

.

Steps in renal drug excretion

Glomerular filtration

Passive tubular reabsorption

Active tubular secretion

Factors that modify renal drug excretion

pH-dependent ionization

Competition for active tubular transport

Age



Slide 161



RenalRenal routes of drugroutes of drug excretionexcretion

.



Slide 163





Time Course of Drug ResponsesTime Course of Drug Responses

.

Plasma drug levels

Single-dose time course

Drug half-life

Drug levels produced with repeated doses



Plasma Drug LevelsPlasma Drug Levels



Plasma Drug LevelsPlasma Drug Levels

.

Clinical significance of plasma drug levels

Two plasma drug levels defined

Minimum effective concentration

Toxic concentration

Therapeutic range

SingleSingle--Dose Time CourseDose Time Course



SingleSingle--Dose Time CourseDose Time Course

.

The duration of effects is determined largely bythe combination of metabolism and excretion





Passage of Drugs Across MembranesPassage of Drugs Across Membranes

.

Drugs must cross membranes to enter theblood from their sites of administration.

Therapeutic RangeTherapeutic Range



Therapeutic RangeTherapeutic Range

.

The objective of drug dosing is to maintainplasma drug levels within the therapeutic range.



Drug Levels Produced with RepeatedDrug Levels Produced with RepeatedDosesDoses

.

D L l P d d ith R t dD L l P d d ith R t d



Drug Levels Produced with RepeatedDrug Levels Produced with Repeated

DosesDoses

.

The process by which plateau drug levelsare achieved

Time to plateau Techniques for reducing fluctuations in

drug levels

Loading doses versus maintenance doses

Decline from plateau



DrugDrug accumulation with repeatedaccumulation with repeatedadministrationadministration..

.



NURSING PROCESS

AND PHARMACOLOGY

AND PATIENT

EDUCATION

The Nursing ProcessThe Nursing Process

Th i i th f d ti f th



Slide 176

The nursing process is the foundation for the

clinical practice of nursing. It involves: Assessment

Nursing diagnosis

Planning

Nursing intervention or implementation

Evaluating and recording therapeuticoutcomes



Nursing ProcessNursing Process

A t



Assessment

Subjective data

Current health history

Includes dysphagia

Client symptoms as verbalized by client

Current medications Dosage, frequency, route, who prescribed

Dug allergies, OTC, herbal drugs, alcohol, smoking

Past health history

Client¶s environment Primary language and communication needs

Cli t th h d t i t d t



Clients even those who do not intend to

withhold information, do not always tell abouttheir medications

AssessmentAssessment

Comprehensive collection of data including:



Slide 180

Comprehensive collection of data including:

Physical examination

Nursing history

Medication history

Professional observation

Assessment is an ongoing process that startswith admission and continues until the patientis discharged from care

Nursing Process (cont¶d)Nursing Process (cont¶d)

Assessment



Assessment

Objective data ± baseline data Physical assessment

Gross and fine motor control, hand joint range of motion, muscle strength, visual impairment

Laboratory tests Diagnostic studies

Must identify high-risk clients

Client's attitudes and values about taking

medications Client's support system

Nursing DiagnosisNursing Diagnosis

A clinical judgment about individual family or



Slide 182

A clinical judgment about individual, family, or

community responses to actual or potentialhealth problems/life processes (N AND A-International)

DiagnosisDiagnosis

Five types of nursing diagnoses:



Slide 183

Five types of nursing diagnoses:

Actual: based on human responses andsupported by defining characteristics

Risk/high-risk: patient may be moresusceptible to a particular problem

Possible: suspected problems requiringadditional data

Wellness: clinical judgment about a transitionfrom one level to a higher level

Syndrome: cluster signs and symptoms topredict certain circumstances or events

Nursing DiagnosesNursing Diagnoses

Common nursing diagnoses related to drug




therapy Deficient knowledge about drug action,

administration, and side effects related tocultural/language barrier

Pain related to hesitancy to take prescribedmeds due to fear of addiction

Ineffective health maintenance related to nothaving recommended preventive care

Nursing DiagnosesNursing Diagnoses





therapy Noncompliance related to forgetfulness

Risk for injury related to side effects of drug

Ineffective therapeutic regimen management

related to lack of finances



PlanningPlanning

Priority setting: identified problems are



Slide 187

Priority setting: identified problems are

prioritized and needs levels established Measurable goal statements: short- and

long-term goals are established and written

PlanningPlanning

Characterized by goal setting



Characterized by goal setting

Example: Client EV will independentlyadminister prescribed dose of albuterol by theend of the first session of instruction

Planning (cont¶d)Planning (cont¶d)

Characteristics of a goal



Characteristics of a goal

Client centered; clearly states the expectedchange

Realistic and measurable

Realistic deadlines

SM ART

Nursing Intervention or Nursing Intervention or ImplementationImplementation

The actual process of carrying out the



Slide 190

The actual process of carrying out the

established plan of care Nursing actions are suggested

Dependent actions: performed by a nursebased on health care provider¶s orders

Interdependent actions: implemented withthe cooperation of a team

Independent actions: provided by nurse byvirtue of education and license



Evaluating and RecordingEvaluating and RecordingTherapeutic and Expected OutcomesTherapeutic and Expected Outcomes

All care is evaluated against:



Slide 192

All care is evaluated against:

Nursing diagnoses (goal statements)

Planned nursing actions

Anticipated therapeutic outcomes

Plans for evaluation must involve patient,family, and significant others

EvaluationEvaluation

Ongoing and related to progress and goal



Ongoing and related to progress and goal

achievement Related to achievement of goals; if not met,

reassess and continue

Determine need for follow-up

Refer to community resources

DRUG CARDSDRUG CARDS

Name of the drug



Name of the drug

Reason for taking the drug

Dose amount

Specific times taking the drug

What specific things should or should not bedone while taking the medications

Possible side effects

Possible adverse effects

Helpful and Healthful PointsHelpful and Healthful Pointsto Remember to Remember

Take medication as prescribed by your health



Take medication as prescribed by your health

care provider. If you have questions, call. Keep medication in original labeled container

and store as instructed

Keep all medicines out of reach of children.

Remind grandparents and visitors to monitor their purses and luggage when visiting.



Helpful and Healthful PointsHelpful and Healthful Pointsto Remember (cont¶d)to Remember (cont¶d)

Know why you are taking each medication



Know why you are taking each medication

and under what circumstances to notify thehealth care provider

Alcohol may alter the action and absorption of the medication. Use of alcoholic beverages is

discouraged around the time you take your medications and is absolutely contraindicatedwith certain medications.

Helpful and HealthfulHelpful and HealthfulPoints to Remember (cont¶d)Points to Remember (cont¶d)

Smoking tobacco alters absorption of some



Smoking tobacco alters absorption of some

medications (e.g., theophylline-type drugs,tranquilizers, antidepressants, and painmedications). Consult your health careprovider or pharmacist for specific

information.

Checklist for HealthChecklist for HealthTeaching in Drug TherapyTeaching in Drug Therapy

Comprehensive drug and health history



Comprehensive drug and health history

Reason for medication therapy

Expected results

Side effects and adverse reactions

When to notify health care provider or pharmacist

Drug-drug, drug-food, drug-laboratory, drug-environment interactions

Checklist for Health TeachingChecklist for Health Teachingin Drug Therapy (cont¶d)in Drug Therapy (cont¶d)

Required changes in ADL



q g

Demonstration of learning; may take severalforms, such as listening, discussing, or returndemonstration of psychomotor skills (insulinadministration)

Medication schedule, associated with ADLand drug level of action as appropriate

Checklist for Health TeachingChecklist for Health Teachingin Drug Therapy (cont¶d)in Drug Therapy (cont¶d)

Recording system



g y

Discussion and monitoring of access tofinancial resources, medication, andassociated equipment

Development and support of backup system

Community resources

Patient and family teaching.Patient and family teaching.



Slide 202



Medication and CalculationsMedication and Calculations



Section A: Systems of Measurement withConversion

Section B: Methods for Calculation

Section C: Calculations of Oral Dosages Section D: Calculations of Injectable Dosages

Section E: Calculations of Intravenous Fluids

Section F: Pediatric Drug Calculations

Methods of CalculationMethods of Calculation

Method 1: B ASIC FORMUL A (BF)

dj1



D (desired) × V (vehicle-amt) = Amount to give

H (on hand)

Ex: Order: ciprofloxacin (Cipro) 0.5 g, po, q12h

Available: Cipro 250-mg tablet

Change 0.5 g to 500 mg (move decimal point 3 spaces toright)

2

500 mg × 1 tab = 2 tablets of Cipro

250 mg

1

Slide 205

dj1 set per ms with strike-through lines in last line to indicate canceling--see ms Valued Gateway Client, 7/18 /2005





Methods of CalculationMethods of Calculation(cont¶d)(cont¶d)

Method 3: FR ACTION AL EQU ATION (FE)



H (on hand) = D (desired)

V (vehicle-amt) X

Order: ciprofloxacin (Cipro) 0.5g, po, q12h (0.5 g = 500mg)

Available: Cipro 250-mg tablet

250 mg = 500 mg (cross multiple)

1 tab X

250 X = 500

X = 2 tablets of Cipro




Method 4: DIMENSION AL AN ALYSIS (D A)

V (form) = V (vehicle) x C (H) x D (desired) =H (on hand) x C (D) x 1

Drug label conversion x drug order

factor

4

tab = 1 tablet x 1000 mg x 0.5 g = 2 tablets

250 mg x 1g x 1

1

dj

Slide 208

dj2 see ms to insert diagonal strike-through lines to indicate canceling Valued Gateway Client, 7/18 /2005




Method 5: BODY WEIGHT



D (desired) × kg × 1 day or dose =

Order: Cipro 20 mg × kg × day in 2 divided doses

Client¶s weight: 88 pounds ( 88 lb ÷ 2.2 = 40 kg) Available: Cipro 100 mg/mL in oral suspension

20 mg × 40 kg × day = 800 mg/day or 400 mg/dose

Give: 4 mL of oral suspension of Cipro

Intravenous Flow RateIntravenous Flow Rate



Amount of fluid ÷ hours to administer = mL/hr mL/hr x gtt/mL (IV set) = gtt/minute

60 minutes

Ex: Order: 1000 mL of 5% D/0.45% NaCl, q8h

IV set: 10 gtt/mL

1000 mL ÷ 8 hours = 125 mL/hr

1

125 mL x 10gtt/mL = 125 20.8 or 21 gtt/minute

60 minutes 66

Intermittent IntravenousIntermittent IntravenousAdministrationAdministration



Amount of solution × gtt/mL (IV set) = gtt/min

minutes to administer

Ex: Order: ticarcillin (Ticar) 500 mg, IV, q6h

Available: Ticar 1 g (add 4 mL of diluent)

Set and solution: calibrated cylinder, drop factor: 60 gtt/mLInstruction: dilute drug in 75 mL of D5W and infuse over 40 minutes

3

75 ml × 60 gtt/mL = 225 = 112.5 or 113 gtt/min

40 min to admin 2

2

dj3

Slide 211

dj3 see ms to insert diagonal lines that indicate cancellation in last line Valued Gateway Client, 7/18 /2005



Infusion Pump RateInfusion Pump Rate Amount of solution ÷ minutes to admin = mL/hr



60 min/hr Ex: Order: ticarcillin (Ticar) 500 mg, IV, q6h

Available: Ticar 1 g (add 4 mL of diluent)

Infusion pump

Dilute drug in 100 mL of D5W; infuse over 45 minutes

100 mL ÷ 45 min to admin = (invert the divisor and multiply)

60 min/hr

4

100 mL × 60 = 400 = 133 mL/hr (infusion rate)

45 3

3

dj4

Slide 212

dj4 see ms for diagonal lines as strike through to indicate cancellation Valued Gateway Client, 7/18 /2005





PRINCIPLESPRINCIPLES OFOFMEDICATIONMEDICATIONADMINISTRATIONADMINISTRATION

Legal and EthicalLegal and EthicalConsiderationsConsiderations

Standards of care: developed by the state¶s



Slide 214

nurse practice act, state and federal law,JC AHO, professional organizations

Before administering medication, nurse musthave:

Current license to practice Clear policy statement authorizing the act

Signed medication order

Understanding of rationale for drug use

Understanding of drug action, dosing, dilution,route and rate of administration, side effects,adverse effects to report, contraindications

Legal ResponsibilitiesLegal Responsibilities

Nurse is legally responsible for safe and



accurate administration of medications

Nurse is expected to have sufficient drugknowledge to recognize and question

erroneous orders

Unit dose wrappings of oral drugs should beleft in place until the nurse is in the presence

of the client and ready to administer themedication



Contents of Patient ChartsContents of Patient Charts(cont¶d)(cont¶d)

Graphic record



Slide 217

Flow sheets Consultation reports

Other diagnostic reports

Medication administration record (M AR) or medication profile

PRN or unscheduled medication record

Case management

Patient education record

TheThe KardexKardex



Slide 218

³Five Plus Five Rights´³Five Plus Five Rights´of Drug Administrationof Drug Administration



gg

Right client

Right drug

Right dose Right time

Right route



Safety in MedicationSafety in MedicationAdministrationAdministration



Institute of Medicine Report (1999)

To Err Is Human: Building a Safer Health Care

System

Bar Code

Safety in MedicationSafety in MedicationAdministration (cont¶d)Administration (cont¶d)

2004 National Patient Safety Goals

dj5



JC AHO requirements must not use: U for unit

IU for international unit

QOD for every other day

Trailing zero and lack of leading zero MS, MSO4



Factors Modifying theFactors Modifying theDrug ResponseDrug Response



Absorption Distribution

Metabolism (biotransformation)

Excretion

Age

Body weight

Toxicity



Drug Order / PrescriptionDrug Order / Prescription

Date and time the order written



Drug Name (Generic preferred) Drug Dosage

Route of administration

Frequency and duration of administration

Any special instructions

Physician¶s signature

Drug LabelDrug Label



Slide 226

Four categories of drug order Four categories of drug order

Standing



May be an ongoing order or may be given for a specific number of doses or days

One time

Given once and usually at specific time

PRN Given at the client¶s request and nurse¶s

judgment concerning need and safety

ST AT

Given once immediately

To avoid drug error To avoid drug error

Dug label should be read 3 times



At the time of contact with drug bottle Before pouring the drug

After pouring the drug

Nursing ImplicationsNursing Implications

Check that the medication order is complete



and legible Know the reason for which the client is to

receive the medication

Check the drug label 3 times before

administration Know the date was ordered and the ending

date



Administration of OralAdministration of OralMedicationsMedications

Enteral is direct administration to the GI tract

M d il bl i l d f



Slide 231

Most drugs are available in oral dose forms: Capsules²small, cylindrical gelatin containers

used to administer unpleasant tastingmedications; timed-release capsules (provides agradual and continuous release of the drug);lozenges or troches²flat disks in a flavored base

Tablets (powdered drugs that have beencompressed)

Elixirs²drugs dissolved in water and alcohol

Emulsions of water-in-oil or oil-in-water Liquid suspensions and syrups

Administration of OralAdministration of OralMedications (cont¶d)Medications (cont¶d)

C th d d t d i i t l



Slide 232

Common methods used to administer oralmedications Unit dose packaging providing a single dose

Soufflé cups

Medicine cups

Medicine droppers

Teaspoons

Oral syringes: plastic syringes calibrated and usedto measure liquid medications

Nipples with additional holes, used for infants

Administration of SolidAdministration of Solid--FormFormOral MedicationsOral Medications

Two techniques for administering medications:

th di ti d d it d di t ib ti



Slide 233

the medication card and unit dose distribution Perform premedication assessment in all cases

All techniques follow FIVE RIGHTS procedure: RIGHT patient

RIGHT drug

RIGHT route of administration RIGHT dose

RIGHT time of administration

ALWAYS check or recheck the FIVE RIGHTS



Administration of SolidAdministration of Solid--FormFormOral Medications (cont¶d)Oral Medications (cont¶d)

D t ti f di ti d i i t ti d



Slide 235

Documentation of medication administration andresponses to drug therapy is called the ³Sixth Right´

General principles apply to all medicationadministration Chart date, time, drug name, dosage, and route of

administration Regularly record patient assessments to evaluate

therapeutic effectiveness

Chart and report any sign of adverse drug effects

Perform and validate essential education about drugtherapy and other aspects of intervention for theindividual

Administration of LiquidAdministration of Liquid--FormFormOral MedicationsOral Medications

General procedures are the same as with

lid f l di ti



Slide 236

solid-form oral medications Perform premedication assessment in all

cases

All techniques follow the FIVE RIGHTS

procedure

Administration of LiquidAdministration of Liquid--FormFormOral Medications (cont¶d)Oral Medications (cont¶d)

G l i i l f i f t hild d



Slide 237

General principles for infants, children, andadults Give adults and children the most important

medications first

NEVER dilute medications without specific

orders. DO NOT leave a medication at thebedside without an order to do so

Check an infant¶s ID and be certain the infantis alert

Provide complete documentation of administration and responses to therapy

Administration of LiquidAdministration of Liquid--FormFormOral Medications (cont¶d)Oral Medications (cont¶d)

M i t h i di t



Slide 238

Measuring techniques vary according toreceptacle used

With a measuring cup: Cover label to prevent smearing; place

fingernail at exact level on measuring cup;read the volume at the level of meniscus

Recheck FIVE RIGHTS.

With an oral syringe: Select syringe of appropriate size. Draw up

prescribed volume of medication from bottle or medicine cup

Administration of MedicationsAdministration of Medicationsbyby NasogastricNasogastric TubeTube

Drugs are administered via NG tube for

ifi ti t i li id f



Slide 239

specific patients, using a liquid formwhenever possible. Remember: Always flush the tube before and after

administration

Perform premedication assessment

Assemble equipment before administration

Administration of MedicationsAdministration of Medicationsbyby NasogastricNasogastric Tube (cont¶d)Tube (cont¶d)

P d f d i i t ti f lid



Slide 240

Prepare doses as for administration of solid-form or liquid-liquid form oral medications

Three methods for checking NG tube location

Follow procedure for administering

medication DO NOT attach suction for 30+ minutes




Administration of Administration of EnteralEnteral Feedings ViaFeedings ViaGastrostomyGastrostomy or or JejunostomyJejunostomy Tube (cont¶d)Tube (cont¶d)

Formula should be fully labeled



Slide 242

Formula should be fully labeled Discard unused formula every 24 hours

Follow the guidelines specific for patientsreceiving general nutrition via intermittent or

continuous feedings Follow FIVE RIGHTS

RIGHT patient, RIGHT drug (formula), RIGHT route of administration, RIGHT dose (amount,

dilution, strength), RIGHT time

Administration of Administration of EnteralEnteral Feedings viaFeedings viaGastrostomyGastrostomy or or JejunostomyJejunostomy Tube (cont¶d)Tube (cont¶d)

Verify tube placement and initiate feeding



Slide 243

Verify tube placement and initiate feeding Flush, then clamp tube

Proceed with tube feeding technique

Intermittent: use Toomey syringe

Continuous: use disposable feeding container and enough formula for a 4-hour period




Administration of RectalAdministration of RectalSuppositories (cont¶d)Suppositories (cont¶d)

Technique begins with FIVE RIGHTS



Slide 245

Technique begins with FIVE RIGHTS Explain procedure and check pertinent

parameters

Patient bends uppermost leg

Apply lubricant to tip of suppository. Placesuppository about 1 inch beyond orifice, pastinternal sphincter


Administration of a DisposableAdministration of a DisposableEnemaEnema

The dose form will be a prepackaged,

disposable type enema solution



Slide 246

disposable-type enema solution Equipment is simple

Perform standard premedication assessment

Administration of a DisposableAdministration of a DisposableEnema (cont¶d)Enema (cont¶d)

Technique begins with FIVE RIGHTS



Slide 247

Technique begins with FIVE RIGHTS Explain procedure and check pertinent

parameters

Time of last defecation

Patient bends uppermost leg

Apply lubricant to rectal tube

Insert lubricated tube and insert solution

Provide complete documentation of

administration and responses to therapy

PercutaneousPercutaneous AdministrationAdministration

Application of medications to the skin or

mucous membranes for absorption



Slide 248

mucous membranes for absorption Includes:

Topical application of ointments, creams,lotions, or powders to the skin

Inhalation of aerosolized liquids or gases Installation of solutions into the mucous

membranes of the mouth, eye, ear, nose, or vagina

Always follow the six rights of drugadministration

PercutaneousPercutaneous AdministrationAdministration(cont¶d)(cont¶d)

Premedication assessment and explanation

P ti t t hi



Slide 249

Patient teaching

Hygiene requirements

Proper application techniques and timing

Cautions particular to drug or drugadministration

Side effects

When to contact physician

PercutaneousPercutaneous AdministrationAdministration(cont¶d)(cont¶d)

Documentation



Slide 250

Documentation Date, time, drug, dosage, route

Record ongoing assessment data, includingsigns of adverse drug effects

Creams, Lotions, OintmentsCreams, Lotions, Ointments

Wash hands, put on gloves

Position the patient



Slide 251

Position the patient Clean the area

Wear gloves

Shake lotion bottle; use tongue blade to

remove desired amount of ointment or creamfrom container

Use dressings according to orders

Patch TestingPatch Testing

Method to identify sensitivity to contact

materials (soaps pollen dyes)



Slide 252

materials (soaps, pollen, dyes) Allergens on patch placed in contact with

back, arms, or thighs

Patch left in place for 48 hours

Site aired for 15 minutes, then read Emergency equipment must be available in

case of anaphylactic response



TransdermalTransdermal Drug DeliveryDrug Delivery

Disk or patch providing controlled release of

medication



Slide 254

medication Wash hands and put on gloves

Position the patient

Apply topical disk or patch

Application frequency depends on drug Wash hands after application

Label disk with time, date, nurse initials

Topical PowdersTopical Powders

Particles of medication in a talc base

Wash hands put on gloves



Slide 255

Wash hands, put on gloves Position the patient

Wash and thoroughly dry area

Apply powder, smooth over area for even

coverage



Eye Drops, Ointments, andEye Drops, Ointments, andDisksDisks

OD (right eye), OS (left eye), OU (both eyes)

Wash hands put on gloves



Slide 257

Wash hands, put on gloves Position the patient

Inspect affected eye

Expose lower conjunctival sac

Approach eye from below

Never touch eye with dropper, tube

Forms and Routes (cont¶d)Forms and Routes (cont¶d)

Instillations



Instillations Eye drops:


Eye ointment:






Ear drops:




Nose drops and sprays:



Nose Drops, Nasal SprayNose Drops, Nasal Spray

Patient should blow nose gently

Nose drops



Slide 263

Nose drops Position patient lying down with head hanging

back

Nose spray

Patient is upright Block one nostril

Shake bottle and insert tip into nostril

Spray while patient inhales

Nebulizers and InhalersNebulizers and Inhalers

Nebulizers

Prepare medication and fill nebulizer P ti t h l



Slide 264

epa e ed ca o a d ebu e Patient exhales

Put nebulizer in mouth; do not seal completely

Patient inhales

Metered-dose inhalers Follow instructions on inhaler

Dry powder inhalers

Follow instructions on inhaler

Vaginal MedicationsVaginal Medications

Wash hands, put on gloves

Fill applicator



Slide 265

Fill applicator Place patient in lithotomy position, elevate

hips with pillow

Spread labia and insert applicator or

suppository

ParenteralParenteral AdministrationAdministration

P arenteral means drug administration by any

route other than the gastrointestinal tract Parenteral route



Slide 266

route other than the gastrointestinal tract Parenteral route

Intradermal

Subcutaneous

Intramuscular (IM) Intravenous (IV)

Safe Preparation,Safe Preparation,Administration, and DisposalAdministration, and Disposal

Attention to detail is necessary in all facets of drug preparation and administration



Slide 267

ydrug preparation and administration

Injection of drugs requires skill and specialcare

Safety must be practiced to avoid ³sharps´injuries

Equipment Used inEquipment Used in ParenteralParenteralAdministrationAdministration

The syringe has three parts: barrel, plunger,

and tip Syringes are calibrated in minims milliliters



Slide 268

p Syringes are calibrated in minims, milliliters,

or cubic centimeters

Tuberculin syringes are used to measure

small volumes of medication accurately

Equipment Used inEquipment Used in ParenteralParenteralAdministration (cont¶d)Administration (cont¶d)

The insulin syringe has a special scale for

measuring insulin



Slide 269

g In the United States, insulin is manufactured

in U-100 concentration

The U-100 syringe holds 100 units of insulin

per milliliter Low-dose insulin syringes are used for

patients receiving 50 units or less of U-100insulin


Prefilled syringes are disposable and have apremeasured amount of medication



Slide 270

y g ppremeasured amount of medication

Advantages: time saved in preparation, lesschance of contamination

Disadvantages: additional expense, differentholders for different cartridges, volume of second medication limited


The needle has three parts:

Hub



Slide 271

Shaft

Beveled tip

The needle gauge is the diameter of the holethrough the needle

Needle selection depends on age of patient,and site (subcutaneous, IM, or IV)²seeTable 10-1


Major safety development: needleless

systems



Slide 272

y Provide an alternative to needles for routine

procedures, reducing the risk of needlestickswith contaminated sharps



ParenteralParenteral Dose FormsDose Forms

Ampules

Glass containers usually containing a singledose



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dose

Vials

Glass containers that contain one or more

doses Mix-O-Vials

Glass containers with one dose, twocompartments

Preparation of Preparation of ParenteralParenteralMedicationMedication

Equipment needed for preparation of

parenteral medications Drug in sterile sealed container



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p Drug in sterile, sealed container

Syringe of the correct volume

Needles of the correct gauge and length

Needleless access device Antiseptic swab

M AR or medication profile

Preparation of Preparation of ParenteralParenteralMedication (cont¶d)Medication (cont¶d)

Techniques for preparing all parenteralmedications



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gmedications

Use the five RIGHTS: Right Patient, RightDrug, Right Route of Administration, RightDose (Amount and Concentration), Right Timeof Administration

Check the drug dose form ordered against thesource you are holding

Preparing a Medication fromPreparing a Medication fromanan AmpuleAmpule

Move solution to the bottom of the ampule

Cover the ampule neck with a sterile gauzepledget or antiseptic swab while breaking off



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pledget or antiseptic swab while breaking off top

Using an aspiration needle, withdraw

medication from ampule

Preparing a Medication fromPreparing a Medication fromanan AmpuleAmpule (cont¶d)(cont¶d)

Remove the needle from the ampule and

point the needle vertically



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Pull back the plunger. Replace the aspirationneedle with a new sterile needle

Push plunger until medication is at tip of

needle

Preparing a Medication from aPreparing a Medication from aVialVial

Cleanse the top of the vial of diluent

Pull plunger of syringe to fill with an amountof air equal to the volume of the solution to be



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of air equal to the volume of the solution to bewithdrawn

Insert the needle or needleless access device

through the diaphragm, inject air Withdraw the measured volume of diluent

required to reconstitute the powdered drug

Preparing a Medication from aPreparing a Medication from aVial (cont¶d)Vial (cont¶d)

Tap the vial of powdered drug to break upcaked powder; cleanse the rubber diaphragm



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caked powder; cleanse the rubber diaphragmwith swab

Insert the needle or needleless access device

in the diaphragm and inject the diluent in thepowder

Mix thoroughly to dissolve powder

Change needle to correct gauge and length

to administer the medication to the patient

Preparing a Medication from aPreparing a Medication from aMixMix--OO--VialVial

Tap the container a few times to break up the

caked powder Remove the plastic lid protector



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Remove the plastic lid protector

Push firmly on the diaphragm-plunger

Mix thoroughly

Cleanse the rubber diaphragm and removedrug using syringe to administer to patient

Special PreparationsSpecial Preparations

Occasionally two medications may be drawn

into the same syringe for a single injection Medications need to be prepared for use in



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Medications need to be prepared for use inthe sterile field during a surgical procedure




Types of parenteral routes

Intravenous

Intramuscular



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Intramuscular

Intra-arterial

Intraperitoneal

Intrathecal Intracardiac

Intrasternal

Subcutaneous RouteSubcutaneous Route

Medication is deposited in the loose

connective tissue between the dermis andmuscle layer



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Equipment; needle length and gauge

Sites

Route: SubcutaneousRoute: Subcutaneous

Action

Sites



Equipment

Route:Route: IntradermalIntradermal

Action

Sites



Equipment

Intramuscular RouteIntramuscular Route

Injection deep into muscle mass

Equipment: syringe size, needle length andgauge



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g g

Sites

Age and muscle mass


Intramuscular administration

0.5 to 2 mL of a drug is typically used

20- to 22-gauge needles 1 to 1½ inches long



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g g ½ g

Route: Intramuscular Route: Intramuscular

Action, sites, equipment, techniques

Ventrogluteal:



Route Intramuscular (cont¶d)Route Intramuscular (cont¶d)

Dorsogluteal:




Deltoid:




Vastus lateralis:




Z-track:



IV TherapyIV Therapy

IV therapy is the injection of a solution intothe vein

A large volume of fluid is quickly administered



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to the vein with minimal irritation

Faster absorption occurs through the IV route

than with other parenteral routes

IV Therapy (cont¶d)IV Therapy (cont¶d)

Comfortable access for the patient when

multiple doses of medications are required Drugs can be administered directly to the vein



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Drugs can be administered directly to the veinby syringe injection

Drugs can be administered intermittently or

by continuous infusion through a peripheral or central IV line


Requires extended time to administer

Requires a skilled health care provider toperform



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perform

Patient is less mobile

Increased odds of infection

Increased possibility for severe adverse drugreaction


IV therapy requires a written order from the

physician The physician¶s order must include the date



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The physician s order must include the date,type of solution or medication, dosage, rate,and frequency

Equipment Used for IVEquipment Used for IVTherapyTherapy

IV administration sets connect a large volumeparenteral solution with the intravenousaccess device in the patient¶s vein

M d i



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Macrodrip

Microdrip

Types of Infusion ControlTypes of Infusion ControlDevicesDevices

Controllers

Pumps Syringe pumps



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y g p p

IV Dose FormsIV Dose Forms

IV solutions consist of water containing one or more dissolved particles (solutes)

Osmolality



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Isotonic

IV solution and blood have similar osmolality

Hypotonic Solution has fewer dissolved particles thanblood

Hypertonic

Solution has higher concentration of dissolved

particles than blood

Administration of MedicationsAdministration of Medicationsby the IV Routeby the IV Route

Preparing an IV solution for infusion

Dose forms: ampules, vials, prefilled syringes,large volume IV solution bags

E i t



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Equipment

Sites

Peripheral IV access

Central IV access: for large volume, highconcentration, or hypertonic solutions

Basic Guidelines of IVBasic Guidelines of IVAdministration of MedicinesAdministration of Medicines

Premedication assessment

Equipment Technique



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Venipuncture

Selection of catheter or butterfly needle:

select smallest size feasible to administer thespecific type of fluid

Documentation

Patient teaching

Administration of MedicationAdministration of Medication

Care of sites and implanted ports

Dressing changes

Flushing catheters



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Discontinuing IV infusion

Administration of MedicationAdministration of Medication(cont¶d)(cont¶d)

By a heparin/saline/medlock

Into established IV line (IV bolus)

Through implanted venous access device



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Adding medication

Changing to the next container

EquipmentEquipment

Midline access catheters

Flexible Inserted into the cephalic or basilic vein at the

t bit l f l d th l d i th di t l



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antecubital fossal and then placed in the distalsubclavian vein

Lower rates of phlebitis with the use of midline

access catheters

Cheaper than central venous catheters

Equipment (cont¶d)Equipment (cont¶d)

Peripherally inserted central venous catheters

(PICC) Inserted into the superior vena cava



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Inserted into the superior vena cava

Appropriate for pediatric use

Lower incidences of mechanical complications

Cheaper than other central venous catheters

Requires infrequent site rotation

Monitoring IV TherapyMonitoring IV Therapy

Assessments

Procedures

Nursing interventions



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Complications of IV TherapyComplications of IV Therapy

Phlebitis, thrombophlebitis, infection

Septicemia

Infiltration and extravasation



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Air in tubing/air embolus

Circulatory overload, pulmonary edema

Pulmonary embolism ³Speed shock´

Route: IntravenousRoute: Intravenous

Action

Site

Equipment



Equipment

Technique

Nursing Implications for Administration of Nursing Implications for Administration of ParenteralParenteral MedicationsMedications



Sites

Equipment

Technique Developmental needs of pediatric clients

Nursing Process: Overview of Nursing Process: Overview of Medication AdministrationMedication Administration

Assessment

Nursing diagnosis

Planning



Planning

Interventions

Client teaching

Evaluation

GUIDELINES FOR CORRECTGUIDELINES FOR CORRECTADMINISTRATION OF MEDICATIONADMINISTRATION OF MEDICATION

Preparation

Wash hands

Check for drug allergies, check assessment andK ARDEX



Check label

Check expiration

Recheck drug calculation with another nurse Verify doses that are potentially toxic

Pour tablet or capsule in the cap or open packet atbedside after identifying the client¶s ID

Pour liquid at eye level ± lower meniscus Dilute drugs that irritate GIT or give with meals




Administration

When administering drugs to a group clients,give drug last to the client who needs extraassistance



assistance

Discard needles and syringes in appropriatecontainer

Discard unused solution from ampoules Appropriately store unused

Write date and time opened and your initialson label


Administration

Keep narcotics in a double locked drawer

Keys to the narcotic drawer ,must be kept bythe nurse



the nurse

Keep narcotics in safe place

Avoid contamination of one¶s own skin or inhalation


Recording

Report drug error immediately; completeincident report

Charting: record drug given dose time route



Charting: record drug given, dose, time, routeand your initials

Record drugs promptly after given, especially

ST AT dose Record effectiveness and results of

medications especially PRN medications

Report to health provider and record drugs

that were refused Record amount of fluid taken with medication

on I/O chart

Behaviors to avoid duringBehaviors to avoid duringdrug administrationdrug administration

Do not be distracted when preparing meds

Do not give drugs poured by others

Do not pour drugs from containers with labelsthat are difficult to read



that are difficult to read

Do not transfer drugs from one container to

another Do not pour drugs into the hand

Do not give medications for which theexpiration date has passed

Behaviors to avoid duringBehaviors to avoid duringdrug administrationdrug administration

Do not call the client¶s name as the solemean of identification

Do not give drug if the client sates that thedrug is different from the other drug that he or



drug is different from the other drug that he or she is receiving

Do not recap needles

Do not mix with large amount of food or beverage or foods that is contraindicated

Technologic AdvancesTechnologic Advances

Enhance safety

Increase accessibility to sites Promote client mobility

I li t dh



Improve client adherence



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