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Pharm Final Ch 1 The Rights of Medical Administration ● Right drug ● Right dose ● Right time ● Right route and form ● Right patient ● Right documentation Current practice standards suggest these additional “Rights”: ● Right reason or indication ● Right to refuse ● Right Response Ch 2 Drug Names Chemical name: Describes the drug’s chemical composition and molecular structure Brand Name Generic name (nonproprietary name): Name given by the United States Adopted Names Council Trade name (proprietary name): The drug has a registered trademark; use of the name is restricted by the drug’s patent owner (usually the manufacturer) Pharmacologic Principles Pharmaceutics- the study of how various drugs forms influence the way in which the drug affects the body Pharmacokinetics- the study of what the body does to the drug ● Absorption ● Distribution-transport of a drug by the bloodstream to its site of action Albumin is the most common blood protein & carries majority of protein-bound drug molecules ● Metabolism-liver (biotransformation) ● Excretion-kidney Pharmacodynamics- the study of what the drug does to the body
Pharmacotherapeutics- the clinical use of drugs to prevent and treat diseases; drugs are organized into pharmacologic classes ● Tolerance: decreasing response to repeated drug doses ● Dependence: physiologic or psychological need for a drug ● Physical dependence: physiologic need for a drug to avoid physical withdrawal symptoms ● Psychological dependence: also known as addiction and is the obsessive desire for the euphoric effects of a drug Pharmacokinetics ● Absorption ● Bioavailability:extent and rate at which the drug enters the systemic circulation ● First pass effect (concentration reduced before reaching the systemic circulation) ● Parenteral route: subcutaneous, intradermal & intramuscular ● Half Life: time required for half (50%) of a given drug to be removed from the body ● Steady state: when the rate of drug input is equal to the rate of drug elimination ● Peak Level: highest blood level of a drug ● Trough level: lowest blood level of a drug ● Toxicity: occurs if the peak blood level of the drug is too high Topical route: ● Skin; transdermal route (patches), Lungs; inhaled route, Eyes, Ears, Nose, Vagina, Rectum Enteral Route ● Oral ● sublingual ● buccal ● rectal (can also be topical) Ch 3: Life Span: Drug Therapy During Pregnancy Drug Therapy During Breastfeeding Drug levels in breast milk are usually lower than those in the maternal circulation Neonatal & Pediatric Considerations: Pharmacokinetics
● Class II ( less serious, temporary or medically reversible effects) ● Class III ( least serious, use of the drug is not likely to result in health problems) Legend drugs: Prescription drugs Orphan drugs: Nonprescription drugs Ethical Terms Related to Nursing Practice (Important) ● Autonomy (self determination and the ability on one’s own ) ● Beneficence ( ethical principle of doing) ● Confidentiality ● Justice (fairness) ● Nonmaleficence ( the duty to do no harm to a patient) ● Veracity ( the duty to tell the truth) Elements of liability for nursing Malpractice ● Duty: Being responsible for accurate assessment of patient’s intravenous and site of I.V., during caustic drug infusion and the timely reporting of changes in the patient’s condition. ● Breach of Duty:Nurses does not notice that the IV site is swollen, red, painful and warm in touch or that the IV has quit infusing properly. ● Causation:Nurses fail to note the signs and symptoms of extravasation at IV site ( e.g. with chemotherapy drug or other caustic drug ) that results in the need of skin graft. ● Damage: extensive skin and nerve damage with several surgical skin grafts resulting in limited use of the arm. Ch 5 QSEN initiatives ( quality and safety education for nurses) Medication errors: Broad term used to refer to any errors at any point in patient care, or could cause a patient harm Adverse drug reactions (ADRs) unexpected , unintended ● Allergic reaction ● Idiosyncratic reaction (a painful reaction that appears in certain persons to irritants that do not produce similar phenomena in the majority of others.)
Drugs commonly involved in severe medication errors: central nervous system drugs, anticoagulants, and chemotherapeutic drugs More potential for harm with “ high-alert” medications ( potentially toxic, requires a special care) SALAD (sound-alike, look-alike drugs) LASA (look-alike, sound-alike) Example: buspirone and bupropion prednisone and prednisolone Errors can occur during any step of medication process ● Prescribing ● Transcribing ● Dispensing ● Administering ● Monitoring Nurses need to always check the medication order three times before giving the drug. Preventing Med Errors ● NEVER use a “trailing zero” with medication orders. ● Do not use 1.0 mg; use 1 mg. ● 1.0 mg could be misread as 10 mg, resulting in a 10-fold dose increase ● In pediatric patients most common errors are dosage errors ● ALWAYS use a “leading zero” for decimal dosages. ● Do not use .25 mg; use 0.25 mg. ● .25 mg may be misread as 25 mg. ANY dosage problem ASK the prescriber CH 7 Over The Counter Drugs and Herbal Supplements *USE of Over the counter Drugs ● May postpone effective treatment of more chronic disease states ● May delay treatment of serious or life-threatening disorders ● May relieve symptoms of a disorder but not the cause
Oral disintegrating medications ● Tablet or medicated strip form ● Dissolve in the mouth without water within 60 seconds. ● Medications are placed on the tongue , not under the tongue, as in the sublingual route. ● Wear gloves if placing medication. ● Instruct the patient to allow the medication to dissolve on the tongue and not to chew or swallow the medication.
● Make sure the patient has not eaten or had anything to drink for 5
minutes before and after taking these medications.
Administering Enteral Drugs ● Liquid form of medications if possible ● If not ,…. crush those medications that are crushable into a fine powder then dissolve in 15 to 30 ml of water ● Administer each med separately, flushing in-between ● Flush with 30 ml after the last med. ● Document including fluid intake ● Assess if fluid restriction or overload concerns apply Administering rectal drugs ● Hand hygiene, standard precautions, gloves ● Assess patients for active rectal bleeding or diarrhea. ● Position patient on left side unless contraindicated (Sims’ position). ● Do not insert suppository into stool. ● Follow insertion procedure. ● Have the patient remain lying on his or her left side for 15 to 20 minutes to allow absorption of the medication. ● Age-related considerations Administering Topical Drugs ● Eye medications ● Cleanse eye before instilling medications ● Inhaled drugs ● Metered-dose inhalers ● Dry powder inhalers ● Small-volume nebulizers
Ch 10 Classification of Pain ● Somatic ( skeletal system) ● Visceral (organs and smooth muscles) ● Superficial ● Deep ● Vascular ● Referred (nerves of a specific area are close to nerves of spinal cord) ● Neuropathic (damage of nerves) ● Phantom ● Cancer ● Central(damage in CNS ) Treatment of Pain in Special Situations ● PCA ( patient controlled anesthesia) and “PCA by proxy” ● Patient comfort vs. fear of drug addiction ● Opioid tolerance ● Use of placebos ● Recognizing patients who are opioid tolerant ● Breakthrough pain (severe pain that erupts while a patient is already medicated with a long-acting painkiller). ● Synergistic effect Opioid Drug: Synthetic drugs that bind to the opiate receptors to relieve pain ● Mild agonists: codeine, hydrocodone ● Strong agonists : morphine, hydromorphone, oxycodone, oxymorphone, meperidine, fentanyl, and methadone ● Meperidine : not recommended for long-term use because of the accumulation of a neurotoxic metabolite, normeperidine, which can cause seizures Equianalgesic ● Ability to provide equivalent pain relief by calculating dosages of different drugs or routes of administration that provide comparable analgesia ● Hydromorphone (Dilaudid ): seven times more potent than morphine
● Failure of the drug to significantly reverse the effects of the presumed opioid overdose indicates that the condition may not be related to opioid overdose. Acetaminophen: Indications ● Mild to moderate pain ● Fever ● Alternative for those who cannot take aspirin products Acetaminophen Dosage ● Maximum daily dose for healthy adults is being lowered to 3000 mg/day. ● 2000 mg for older adults and those with liver disease
Recommended antidote: acetylcysteine regimen
Ch 11 General and Local Anesthetics Adverse Effects ● Vary according to dosage and drug used ● Sites primarily affected ● Heart, peripheral circulation, liver, kidneys, respiratory tract ● Myocardial depression is commonly seen Malignant hyperthermia ● Occurs during or after volatile inhaled general anesthesia or use of the neuromuscular blocking drug (NMBD) succinylcholine ● Sudden elevation in body temperature (greater than 104° F) ● Tachypnea, tachycardia, muscle rigidity ● Life-threatening emergency ● Treated with cardiorespiratory supportive care and dantrolene (skeletal muscle relaxant)
Local Anesthetics
● Also called regional anesthetics
● Do not cause loss of consciousness
Drug Effects: Paralysis
● First, autonomic activity is lost.
● Then pain and other sensory functions are lost.
● Last, motor activity is lost.
● As local drugs wear off, recovery occurs in reverse order (motor, sensory,
then autonomic activity are restored).
“Spinal headache”
● 70% of patients who either experience inadvertent dural puncture during
epidural anesthesia or undergo intrathecal anesthesia.
● Usually self-limiting it takes maximum 7 to 10 days
● Treatment : bed rest, analgesics, caffeine, blood patch and IV fluids
Respiratory muscle paralysis occurs with these drugs.
Emergency ventilation equipment must be immediately available.
Ch 12
Benzodiazepines: Adverse Effects
Mild and infrequent:
● Headache
● Drowsiness
● Dizziness
● Cognitive impairment
● Vertigo
● Lethargy
● Fall hazard for older adults
● “Hangover” effect or daytime sleepiness
Benzodiazepine Antidote is FLUMAZENIL
Barbiturate Toxicity and overdose
● Overdose frequently leads to respiratory depression and subsequent
respiratory arrest
● Overdose produces CNS depression (sleep to coma and death)
● Can be therapeutic
● Carbidopa inhibits peripheral metabolism of levodopa.
● Carbidopa does not cross the blood–brain barrier and prevents levodopa
breakdown in the periphery.
● As a result, more levodopa crosses the blood–brain barrier, where it can be
converted to dopamine.
Levodopa, Carbidopa Therapy
● Contraindicated in cases of angle-closure glaucoma
● Use cautiously in patients with open-angle glaucoma
● Adverse effects : cardiac dysrhythmias, hypotension, chorea, muscle
cramps, and GI distress
● Interactions: pyridoxine and dietary protein
Carbidopa–levodopa: best taken on an empty stomach ; to minimize GI
side effects, it can be taken with food
Anticholinergic Therapy
● Anticholinergics block the effects of ACh
● Used to treat muscle tremors and muscle rigidity associated with PD
● These two symptoms are caused by excessive cholinergic activity.
● Does not relieve bradykinesia ( extremely slow movements)
Nursing Implications; When starting dopaminergic drugs
● assist patient with walking because dizziness may occur
● Administer oral doses with food to minimize GI upset
● Encourage patient to force fluids to at least 3000 mL/day (unless
contraindicated)
● Taking levodopa with MAOIs may result in hypertensive crisis
Entacapone ( an inhibitor of catechol-O-methyltransferase)
may darken the patient’s urine and sweat.
Ch 16
Lithium
● Drug of choice for the treatment of Mania and Bipolar Disorder
● It is thought to potentiate serotonergic neurotransmission
● Narrow therapeutic range : acute mania—lithium serum level of 1 to 1.
mEq/L; maintenance serum levels should range between 0.6 and 1.2 mEq/L
● Levels exceeding 1.5 to 2.5 mEq/L begin to produce toxicity, including
gastrointestinal (GI) discomfort, tremor, confusion, somnolence, seizures,
and possibly death.
● Keeping the sodium level in the normal range (135 to 145 mEq/L) helps to
maintain therapeutic lithium levels.
Adverse Effects of Lithium
● Most serious adverse effect is cardiac dysrhythmia
● Other effects: drowsiness, slurred speech, epilepsy-type seizures,
choreoathetotic movements ( involuntary wavelike movements of the
extremities),
● ataxia (generalized disturbance of muscular coordination), and hypotension
● Long-term treatment may cause hypothyroidism.
Tricyclic Antidepressants:Overdose
● Lethal: 70% to 80% die before reaching the hospital
● CNS and cardiovascular systems are mainly affected.
● Death results from seizures or dysrhythmias.
No specific antidote ● Decrease drug absorption with activated charcoal. ● Speed elimination by alkalinizing urine. ● Manage seizures and dysrhythmias. ● Provide basic life support.
● phenoxybenzamine HCl (Dibenzyline) ● phentolamine (Generic) ● prazosin (Minipress) ● terazosin (Hytrin) ● alfuzosin (UroXatral) ● tamsulosin (Flomax) B.P.H. ● doxazosin (Cardura) Beta Blockers !!! ● Block stimulation of beta receptors in the SNS ● Compete with norepinephrine and epinephrine ● Can be selective or nonselective ● Cardioselective beta blockers or beta 1 -blocking drugs ● Nonselective beta blockers block both beta 1 and beta 2 receptors ● Beta 2 receptors are located primarily on the smooth muscles of the bronchioles and blood vessels. Bata Receptors Beta 1 receptors ● Located primarily on the heart ● Beta blockers selective for these receptors ● are called cardioselective beta blockers Beta 2 receptors ● Located primarily on smooth muscle of bronchioles and blood vessels Mechanism of Action ● Cardioselective beta blockers (beta 1 ) ● Reduce SNS stimulation of the heart ● Decrease heart rate ● Prolong sinoatrial (SA) node recovery ● Slow conduction rate through the AV node ● Decrease myocardial contractility, thus reducing myocardial oxygen demand Nonselective beta blockers (beta 1 and beta 2 ) ● Cause same effects on heart as cardioselective beta blockers ● Constrict bronchioles , resulting in narrowing of airways and shortness of breath ● Produce vasoconstriction of blood vessels of the respiratory system ● Other effects
Ch 20 Cholinergic Drugs; Drugs that stimulate the parasympathetic nervous system (PSNS) Bethanechol (Urecholine) Direct-Acting cholinergic AGONIST; or parasympathomimetic ● Contraindications: known drug allergy, hyperthyroidism, peptic ulcer , active bronchial asthma, cardiac disease or coronary artery disease, epilepsy , and parkinsonism ● Adverse effects: syncope, hypotension with reflex tachycardia, headache, seizure, GI upset, and asthma attacks ● Interactions: acetylcholinesterase inhibitors (i.e., indirect-acting cholinergics) ● Uses: treatment of acute postoperative and postpartum nonobstructive urinary retention and for the management of urinary retention associated with neurogenic atony of the bladder Neostigmine, Pyridostigmine (Mestinon), and Physostigmine -These group of medications should be administered 30 min., before meal ● Uses: reversing the effects of nondepolarizing neuromuscular blocking drugs; treating severe overdoses of tricyclic antidepressants; and antidote, after toxic exposure to non drug anticholinergic agents, including those used in chemical warfare Encourage patients with myasthenia gravis to take medication 30 minutes before eating to help improve chewing and swallowing.
Atropine is the antidote for cholinergics
Ch 21 Cholinergic-Blocking Drugs Drugs that block or inhibit the actions of acetylcholine (ACh) in the parasympathetic nervous system (PSNS); Also known as anticholinergics , parasympatholytics , and antimuscarinic drugs Toxicity and overdose; cholinergic blocking drugs ● Symptomatic and supportive therapy ● Continuous electrocardiographic monitoring
Ace inhibitors ● captopril (Capoten)is not a prodrug; therefore, it does not need to be metabolized by the liver to be effective. This is an advantage in patients with liver disease. ● benazepril (Lotensin) ● enalapril (Vasotec) ● fosinopril (Monopril) ● lisinopril (Prinivil) ● moexipril (Univasc) ● perindopril (Aceon) ● quinapril (Accupril) ● ramipril (Altace) ● trandolapril (Mavik) Captopril and lisinopril can be used if a patient has liver dysfunction, unlike other ACE inhibitors that are prodrugs. Captopril has the SHORTEST HALF LIFE!! Adverse effects of ACE inhibitors ● Fatigue ● Dizziness ● Headache ● Mood changes ● Impaired taste ● hyperkalemia ● Dry, nonproductive cough, which reverses when therapy is stopped ● Angioedema: rare but potentially fatal ● Note: First-dose hypotensive effect may occur. Comparison of ACE Inhibitors and Angiotensin II Receptor Blockers ● ACE inhibitors and ARBs appear to be equally effective for the treatment of hypertension. ● Both are well tolerated. ● ARBs do not cause cough. ● Evidence that ARBs are better tolerated and are associated with lower mortality after MI than ACE inhibitors ● Not yet clear whether ARBs are as effective as ACE inhibitors in treating HF (cardioprotective effects) or in protecting the kidneys, as in diabetes
Angiotensin II Receptor Blockers: Indications ● Hypertension ● Adjunctive drugs for the treatment of HF ● May be used alone or with other drugs such as diuretics Angiotensin II Receptor Blockers: Adverse Effects; Most common adverse effects of ARBs ● Chest pain ● Fatigue ● Hypoglycemia ● Diarrhea ● Urinary tract infection ● Anemia ● Weakness ● Hyperkalemia and cough are less likely to occur than with the ACE inhibitors. Vasodilators: Mechanism of Action Directly relax arteriolar or venous smooth muscle (or both) Results in: ● Decreased SVR ● Decreased afterload (the pressure against which the heart must work to eject blood during systole ) ● Peripheral vasodilation Vasodilators: Adverse Effects Sodium nitroprusside : bradycardia, decreased platelet aggregation, rash, hypothyroidism, hypotension in elderly methemoglobinemia in less than 10% of patients (a condition caused by elevated levels of methemoglobin in the blood. Methemoglobin is a form of hemoglobin that contains the ferric [Fe3+] form of iron.) and (rarely) cyanide toxicity Treatment of pulmonary Hypertension Other drugs used to treat pulmonary hypertension ● epoprostenol ● treprostinil ● iloprost ● sildenafil and tadalafil
