Pharmacology for

Nursing
Introduction
Basic Terms—
Pharmacology: the study of drugs and their interactions with living systems

 Chemical properties
 Biochemical and physiological effects
 Absorption, distribution, metabolism and excretion
• Drug: any chemical that can affect living processes

• Clinical Pharmacology: study of drugs in humans

• Therapeutics: use of drugs to diagnose, prevent and treat illness
• Definition of Disease
 Disease occurs when:
• – Enough cells become dysfunctional
• – Enough cells die and organ loses function
Diseases can be due to:
Autoimmune
Bacteria
Viruses:
Chemicals- environment, pollution
Drugs- medicinal or otherwise
• Properties of Ideal Drug
 Effectiveness:
• – A drug that elicits the response it was meant to (FDA approved with appropriate
experiments)
 Safety:
• Safe even at high concentrations and for long periods of administration (no such
thing)
• Reduced by proper administration (iv, im, sc, etc…)
• No habit forming aspects
• No side effects (resp. failure, immune reaction, etc…)
 Selectivity:
• – Selective for specific reaction with no side effects
 Cramps, fever, nausea, depression, anemia, etc…
• Additional Properties of Ideal
Drug (no drug is ideal!)
 Reversible action- removal w/i specific time (1/2 life is short but potent
during that time)
Predictability- know how patient will respond
Ease of Administration- number of doses low and easy to administer (inc.
compliance & decrease errors)
 Freedom from drug interactions- should not augment or decrease action of
other drugs or have adverse combined effects
 Low Cost- easy to afford (especially with chronic illness)
 Chemical Stability- no lose of effectiveness with storage
 Possession of a simple generic name- easy to remember and pronounce
• Therapeutic Objective
• To provide maximum benefit with minimum harm
Factors that determine Intensity of Response
• Administration- dosage size and route (because of errors in
administration routes and dosage and at wrong time there are many
discrepancies in what patient gets and could cause more harm than good)

Pharmacokinetic processes-
1) drug absorption 3) drug metabolism
2) drug distribution 4) drug excretion
• Pharmacodynamics-
• – Once a drug has reached is site of action,
• pharmacodynamic processes determine the type of response and
intensity
• Drug must first bind to its specific target site at (RECEPTOR) that may
be a chemical, a protein on a cell or in blood or tissue spaces, or
on a bacteria or virus.
• Sources of individual variation:
• – Each patient is unique in ability to respond and to how they each
respond, but formation of “IDEAL DRUG” will lessen this variation
• Age- very important factor
• Sex- due to hormonal differences
• Weight- less effective and longer lasting in obese individuals (storage
in fat)
• Kidney & liver functions - elimination of drug
• Genetic variables- tolerance, allergy (though not always genetic)
• : Application of Pharmacology in Nursing Practice
 Nurse’s “Five Rights of Drug Administration”
• – Use the RIGHT drug
• – Give to the RIGHT patient
• – Give the RIGHT dose
• – Give by the RIGHT route
• – Give at the RIGHT time
 Must also be ready to respond to interaction between drug and
patient (i.e., must be aware of drug REACTIONS and SIDE EFFECTS)
 Nurse must have knowledge of…
• Patient history and drug usage
• What medications are appropriate and be aware of drug interactions
(cooperation between doctor, pharmacist and nurse a must)
• Drug actions and look for abnormal effects
• How to be a patient advocate- check for mistakes on part of doctor or
pharmacist!!
 Do NOT blindly follow Dr’s orders-- THINK and respond to errors
[ do not be intimidated]
 Patient Care
 Pre-administration Assessment
• – Collecting baseline data to evaluate therapeutic and adverse
responses (e.g., get blood pressure data and cell counts to use to
determine whether drugs are effective)
• – Identifying high-risk patients (e.g., liver/kidney dysfunction, genetic
factors, allergies, pregnancy, old age and extreme youth)
• – Assessing the patient’s capacity for self-care (can they follow
directions on their own)
 First two assessments are drug specific & last assessment is for any
patient and drug
 Drug and Dosage Administration
 Drugs may have more than one indication,
i.e. each may have more than one action depending upon dosage
• Aspirin given in low doses to relieve pain & high doses to suppress \
inflammation (arthritis)
 Drugs can be administered by different routes and dosage depends
on route given
• Oral doses usually larger than injected doses (sc, im, iv) and may be
fatal if given by incorrect route
• Certain iv drugs can cause local injury if intravenous line becomes
extravasated and Nurse must monitor this
 Guidelines to help ensure correct administration
• Read medication order carefully- verify
• Verify identity of patient with drug order
• Read medication label & verify
Drug itself
Amount of drug (per tablet, per volume
• Verify suitability for administration by intended route
• Verify dosage calculations
• Use special handling if drug requires
 DO NOT ADMINISTER ANY DRUG IF YOU DO NOT UNDERSTAND THE
REASON FOR ITS USE
• Evaluating and Promoting Therapeutic Effects
 Is the drug doing the right thing? Evaluation criteria
– Must know rationale for treatment and the nature and time course of desired
response
• If do not have this then cannot make judgment of progress
 If desired response do not occur then must act quickly
• Give alternative therapy
• Even if patient gains beneficial responses, must be aware of what drug
is supposed to do, because it still might end up badly
• – Nifedipine: given for hypertension & angina pectoris: when given to
treat hypertension should monitor for reduction in blood pressure;
• if used for treatment of angina, need to monitor for reduction in chest pain
 Promote Compliance
 Drugs must be taken correctly without
– Wrong dose
– Wrong route
– Wrong time
 Educate patients to how to self medicate with specific instructions
– If elderly must also give instructions to another responsible party
(elderly might not like this!)
 Implement Non-drug measures to enhance drug effects
• – Breathing exercises, emotional support, exercise, physical therapy, rest,
weight reduction, stop smoking, and sodium restriction (must evaluate
individual patient for specific needs)
 Minimize Adverse Effects
 Know patient history
– Understand disease and treatment and what drug is supposed to do
(again, do not give drug blindly!!!)
– Identify high risk patient
– Educate patient
– Know adverse effects of drug and educate patient to these
 Know drug interactions with other medications
– This is important part of patient history
• Pharmacology and the Nursing Process
 Nursing Process-- 5 steps
1) assessment
2) analysis (nursing diagnosis: you see patient first)
3) planning- individual for each patient
4) implementation- some collaborative with physician and others are
independent
5) evaluation- degree to which drug therapy is successful
 Drug Names
 3 types of drug names
• – Chemical name: chemical make-up of compound: usually too complex
for people to remember
• – Generic name: assigned by the “United States Adopted Names
Council”. Only one generic name/compound (nonproprietary name)
• – Trade name: proprietary (brand) name. Name by which drug is
marketed
 Acetaminophen (generic name) has 31 trade names (different
formulations of proprietary compound)
 Trade names must be approved by FDA
 Trade names CANNOT imply unlikely results/success
• Try to discourage the use of Trade Names and promote the use of
Generic Names for patients!!
Over-The-Counter Drugs (OTC)
 Drugs that can be purchased without prescription
• – Some drugs that were sold as prescription only are now sold as OTC
• Do consumers have the ability & knowledge to self prescribe?
• – Know sources of drug information to pass on to patient
 Routes of drug Administration
– Enteral- gastrointestinal tract absorption (po): oral, sublingual, rectal
– Parenteral- by injection (iv, sc, im)
 Iv has benefits and disadvantages
– No barrier to absorption, rapid onset, use of large fluid volumes,
use of irritant drugs (iv lines dilute irritant)
– High cost, inconvenience, difficult to administer, irreversible (slow
administration), fluid overload can occur, infection (contaminated
needle), embolism (blockage of site distant from administration)-
clot, hypotonic death of RBCs, air
Subcutaneous
• – sc similar to im administration
Oral
• – per os (by way of mouth)= oral
• – Absorbed from stomach or intestine
 Factors that determine rate of absorption
• Solubility and stability (to acid & proteases)
• Gastric and intestinal pH
• Gastric emptying time
• Food in the gut
• Co-administration of other drugs
• Mechanisms of Drug-to-Drug Interactions
 Direct Chemical or Physical
 Most occur when drugs are in solution in IV
– Can form a precipitate (if precipitate seen solution should be discarded!!)
– Not all interactions of drugs leave a precipitate::
• NEVER COMBINE TWO OR MORE DURGS IN THE SAME IV CONTAINER, unless it has
been proven that there is no adverse reaction
 Pharmacokinetic Interactions
Altered absorption- drug interactions affect absorption (enhancement or inhibition)
– Elevation of gastric pH by antacids prevent proper absorption of drugs from stomach
– Laxatives reduce absorption by accelerating passage through intestine
– Induction of vomiting decreases ability to absorb
– Drugs that reduce regional blood flow decrease absorption
 DRUG-FOOD Interactions- depends on food and drug
• – Decreased absorption
• Food decreases rate and extent of drug absorption

• – Calcium containing foods and tetracyclin (bind to calcium and

complex cannot be absorbed)

• – High fiber foods reduce absorption (like digoxin for heart)

 Timing of Drug administration and Meals
• – If food affects absorption then must decide on whether drug will
cause upset stomach if taken without food or have decreased
absorption if taken with food
 Choose alternative drug?
 Increase dose if taken with food?
 Take shortly before or after meal?
 Adverse Drug Reaction (ADR)
• – Any noxious, unintended and undesired effect that occurs at normal
drug doses
 Mild reactions:
• – Drowsiness
• – Nausea, itching
• – Rash
 Severe reactions:
• – Respiratory depression Neutropenia
• – Hepatocellular injury
• – Anaphylaxis Hemorhage
ADRs most common in
 Elderly (>60 years old)
 Very young (1-4 years)
 Patients taking more than one drug
• – Side effect: “nearly unavoidable secondary drug effect produced at
therapeutic doses
• Intensity is dose dependent
• Occur immediately after initially taking drug OR may not appear until
weeks after initiation of drug use
• – Toxicity: “an adverse drug reaction caused by excessive dosing”
• Allergic Reactions
• • Immune response due to sensitization to drug (anaphylaxis to penicillin)
– Aspirin and sulfonamide drugs cause allergic reactions
– Idiosyncratic Effect
• Defined as an “uncommon drug response resulting from a genetic
predisposition
– Iatrogenic Disease
• • “disease produced by physician”/ or by drugs
• – Taking certain anti-psychotic drugs may induce a syndrome whose
symptoms are identical to Parkinson’s Disease. Since this is
(1) drug induced and
(2) essentially identical to a naturally occurring pathology, it is called
iatrogenic disease
 Physical Dependence
• Long-term use of drug may lead to dependence (opioids, alcohol,
barbituates, amphetamines)
• Body adapts to drug so that if drug discontinued then abstinence syndrome
will develop
 Carcinogenic Effect
• Certain medications lead to cancer
 May take >20 years to develop after initial exposure
 Tumor promotion versus tumor initiation
 spontaneous abortion: lead to vaginal and uterine cancers years
 Teratogenic Effect
• • Drug induced birth defect
 Drug therapy during Pregnancy and Breast-Feeding
• 1/3 to ½ of pregnant women take at least one prescription drug and
most take more
– Some used to treat pregnancy side effects
• Nausea . Pre-eclampsia
• Constipation
– Some medications used to treat chronic disorders
• Hypertension Diabetes
• Epilepsy Cancer
• Infectious Diseases
– Drugs of abuse (alcohol, nicotine, cocaine, heroine)
• Must balance risks vs benefits of drugs during Pregnancy
– Affect fetus more than mother?
– Teratogenic effects
– Mother’s health affects fetus—
 Chronic asthma is more dangerous to the fetus than the drugs
• used for treatment (mother’s who do not take medication for asthma the
incidence of stillbirths is doubled!!)
• – Pregnancy alters drug disposition and excretion processes
 By 3rd trimester renal blood flow is doubled with an increase in
glomerular filtration and elimination of drugs increases (therefore will
need an increased dosage of drug to compensate)
 Tone and motility of intestines (peristalsis) decrease in Pregnancy (more time for
drugs to be absorbed)
 All drugs can cross the placenta
 Lipid soluble cross more easily
 Ionized, highly polar or protein bounds cross with difficulty
– Nicotine (smaller babies)
– Alcohol (dependence)
– Cocaine/heroine/morphine (addictive to fetus)t
– Bacterial and viral infections
• – Teratogenesis
• “to produce a monster”-- gross malformations
– Cleft palate
– Clubfoot
– Hydrocephalus
– Spina bifida
– Behavioral and biochemical anomalies
• Teratogenesis
• • Sensitivity of fetus to drug is dependent upon developmental stage and when drug is
given in relation to the developmental stage
– 3 stages of embryonic development
• Pre-implantation (conception ‡ week 20
• Embryogenic period (week 3 ‡ week 8)
• Fetal period (week 9 ‡ term)
• – During pre-implantation and embryonic stages the teratogen acts in an all-or-none
response, i.e. , is dose is high enough the fetus will die, if dose is sublethal fetus will
recover
• – Gross malformations produced by exposure to teratogens during the embryonic
period (1st trimester)
• – Exposure during the 2nd and 3rd trimesters usually results in organ dysfunction
rather than gross malformations
 Drug Therapy during Breast Feeding
• – Drugs get through breast milk and can effect infant
• – Little research done on this aspect because of dangers involved in these
studies
 Concentration of drugs differ in milk
– Lipid soluble drugs are in higher concentration
• Generally most drugs are in too low a concentration to be harmful to infant
 Things That Can Minimize Risk:
– Dose after breast feeding
– Take drugs with short ½ life
– Take drugs that are not found in breast milk
– Avoid drugs known to be hazardous
 Drug Therapy in Pediatric Patients
• • Patients who are young or old respond differently to drugs than do middle aged
people
– Greater variation
– Generally more sensitive (organ immaturity in infants and organ degeneration in
older people)
– Pediatrics- all patients under age 16
 Pre-mature infants (< 36 weeks gestation)
 Full-term infants (36-40 weeks gestational age)
 Neonates (1st 4 weeks post-natal)
 Infants (5-32 weeks postnatal)
 Children (1-12 years)
 Adolescents (12-16 years)
 Drug Therapy in Geriatric Patients
• – Elderly more sensitive to drugs and exhibit more variability in
response
• Altered pharmacokinetics (organ degeneration)
• Multiple and severe illnesses
• Multiple drug therapy and usage
Poor compliance
• “Individualization of treatment is essential: each patient must be
monitored for desired responses and adverse responses, and the
regime must be adjusted accordingly”
• Geriatric patients will vary quite a lot from one patient to another
• Gastric acidity may be increased in aged affecting absorption of
certain drugs
• – Distribution- in aged there is:
 Increased body fat- reduces plasma levels of lipid soluble drugs
 Decreased total body water- increases concentration of water
soluble drugs and intensity of response
• Metabolism: hepatic functions decrease in elderly and drug levels
increase (amount of dysfunction variable)

• – Excretion: decline of renal function in elderly (variable)-therefore

increase drug levels in plasma
• • Determine renal function by creatinine clearance rates
• Adverse Drug Reactions (ADRs)
• – 7 times more common in elderly (due to multiple factors and not
just aging)
Drug accumulation secondary to reduced renal function
Polypharmacy (treatment with multiple drugs)
Greater severity of illness
Presence of multiple pathologies
Increased individual variation
Inadequate supervision of long-term therapy
Poor patient compliance
 ADR’s can be avoidable

 Take thorough drug history (Rx and OTC)

 Account for changes with age
 Start therapy with low doses
 Monitor drug plasma levels
 Monitor for drug-to-drug interactions
 Dispose of old medications