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NURS 3304PHARMACOTHERAPEUTICS

Adrianne Linton PhD RN

Jennie Shaw MSN RN

Blackboard Assistance byMaryShannon Williams

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Course Objectives

CourseObjectives

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Examinetheroleofdrugtherapyinrelationtohealthpromotion, diseasepreventionand managementacrossthelifespan. (Essential VII, IX)

Incorporateunderstandingofdrug

classificationsand actions. (Essential VII,IX)

Identifyrelevantassessment data,

appropriatenursinggoalsandintervention,and evaluation datarelatedto drugtherapy. (Essential IX)

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Identifytheneed forcustomizationofdrug

therapy based onindividualpatientvariablesincludingphysiologic,psychosocial,genetic,cultural,patientbeliefsystem, knowledge baseandresources. (Essential VII, IX)

Integrate knowledgeofphysicalandbehavioralscienceswithlegaland ethical

guidelinestoplanforsafeand effectiveimplementationofpharmacotherapeutics.(Essential I, II, V, IX)

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Identifystrategiestoemployintraprofessionalcommunicationrelated to

patients drugtherapy. (Essential VI, IX)Describehowthenursepreparespatientsand theirfamiliestomanageself-pharmacotherapeutics. (Essential VI, IX)

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Identifyinformationtechnologysourcesfortheacquisitionand applicationofevidence-based guidelinestopractice.

(Essential III. IV, IX)

Usecriticalthinkingprocesstoapplyknowledgeofpharmacologytoplansafe

and effective drugtherapy. (Essential I, IX)

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DrugCalculations.

The SchoolofNursinghasadoptedDimensional Analysisasthemethod of

performingmath/

drug

calculations.

Itisexpected thatyoualready know basicmathand youwillhaveanopportunitytoreviewthisskill.

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Criteria for Evaluation

Grade Percentages:

25%- Exam 125%- Exam230%- FinalExam10%- CurrentEvent Written Assignment10%- Blackboard Activitiesand

Participation100% - Total

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TextbooksRequired Lehne, R. A. (2010) Pharmacology for Nursing Care

(7thed.)

Mulholland, JoyceM. (2007) The Nurse, The Math,The Meds: Drug Calculations using Dimensional

Analysis

Recommended

Basch & Ulbright:Natural Standard Herb andSupplement Handbook(2005)

Publication Manual of the American PsychologicalAssociation (2009)

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Equivalencies

1 liter (L) = 1000 milliliters

(mL)

1 kilogram (kg) = 1000 grams 1 gram (g) = 1000 milligrams

(mg)

1 milligram (mg) = 1000micrograms (mcg)

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Equivalencies 1 tsp = 5 mL

1 Tbsp = 15 mL

1 ounce = 30 mL

1 glass = 240 mL

1 gr = 60, 64, or 65

mg

15 gr = 1 Gm 1 kg = 2.2 lbs

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Abbreviations

cc oz IV

g,gm, Gm ss OD

gr T.O. OS

gtt Unit OU

kg V.O. PO

L,l x (times) PR

mcg, g < SC,subc,scmEq > Sl,sl

Mg,mg ID Vag

ml IM

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AbbreviationsAC PC STAT

Ad lib PRN TID

c Q,q

H,h Q AM

hs,HS QIDNPO s

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Do Not Use Abbreviations

The JointCommission

http://www.jointcommission.org

Patient SafetyDo Not Use List

National Patient Safety Goals

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PharmacologyPharmacology

A sciencethat drawsoninformationfromA sciencethat drawsoninformationfrommultiple disciplines,including:multiple disciplines,including:AnatomyAnatomyPhysiologyPhysiologyPsychologyPsychologyChemistryChemistry

MicrobiologyMicrobiology

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BasicTermsBasicTerms

ClinicalpharmacologyClinicalpharmacologyStudyofdrugsinhumansStudyofdrugsinhumans

TherapeuticsTherapeutics

Theuseofdrugsto diagnose,prevent,Theuseofdrugsto diagnose,prevent,ortreat diseaseortopreventortreat diseaseortopreventpregnancy,ormoresimply: themedicalpregnancy,ormoresimply: themedical

useofdrugsuseofdrugs

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Conventional Drugs

Used in Westernmedicine

Productionregulated

Meetstandardsforsafetyand efficacy Includeprescriptionand OTCs

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Non-allopathic Agents Folk remedies

Herbalsupplements

Limited evidenceofsafetyandefficacy (butgrowing)

Promoteconsumerchoiceand

selftreatment

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USES OF DRUG THERAPYDrugs modify existing functions on a tissue orbody organ

Drugs do not create new functions important to

know this.

Restorenormallevelofdeficientsubstances

Block harmfulphysiologicprocesses

Stimulatehealthyphysiologicprocesses

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USES (cont.)

Destroypathogens

Destroyabnormaltissue

Protectvulnerabletissue-sunscreenex,creams

toprotecttheskin Eliminateexcessorharmfulsubstances-

direutics,

Reducesymptoms-exTylenol.

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FUNDAMENTAL PRINCIPLES

All drugs are potential poisons when

taken in sufficiently high doses

No drug produces one, and only one,effect

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Orientationto PharmacologyOrientationto Pharmacology

Propertiesofanideal drugThetherapeuticobjectiveFactorsthat determinetheintensityof

drugresponsesTherapeutics

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ThreeMost ImportantThreeMost ImportantPropertiesofan Ideal DrugPropertiesofan Ideal Drug

1.1.EffectivenessEffectiveness--doeswhatissupposeto dodoeswhatissupposeto do2.2. SafetySafety--thereisnosuchthingasasafethereisnosuchthingasasafe

drugdrug3.3. SelectivitySelectivity--meaningthatit doesnt ONLYmeaningthatit doesnt ONLY

whatitsmeantto do,BUT NO SUCHwhatitsmeantto do,BUT NO SUCHDRUG EXISTS.DRUG EXISTS.

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Additional Propertiesofan Ideal DrugAdditional Propertiesofan Ideal Drug

Reversibleaction-ex. Anethesia,morphinePredictability-cant betotallypredicted,

everyoneis different.Easeofadministration-expill,insulin by

injection,Freedomfrom druginteractions-

Lowcost-Chemicalstability-Simplegenericname-

But becauseno drugisideal

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Therapeutic ObjectiveofTherapeutic ObjectiveofDrugTherapyDrugTherapy

Providemaximum benefitwithProvidemaximum benefitwithminimumharmminimumharm

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FactorsThat Determinethe IntensityofFactorsThat Determinethe IntensityofDrug ResponsesDrug Responses

AdministrationAdministration--PharmacokineticsPharmacokinetics--how drugsmovehow drugsmove

throughyourbodythroughyourbodyPharmacodynamicsPharmacodynamics--how dotheyworkhow dotheyworkSourcesofindividualvariationSourcesofindividualvariation

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Fig. 1-1.The four basic pharmacokinetic processes.Dotted linesrepresentmembranesthatmust becrossed as drugsmovethroughoutthe body.

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AdministrationAdministration

Important determinantsofdrugresponses:Important determinantsofdrugresponses:dosagesize,route,timingdosagesize,route,timing

MedicationerrorsMedicationerrorsPatientadherencePatientadherence

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PharmacokineticsPharmacokinetics

DetermininghowmuchofadministeredDetermininghowmuchofadministereddosegetstoitssitesofactiondosegetstoitssitesofaction

Impactofthe bodyon drugsImpactofthe bodyon drugsFourmajorpharmacokineticprocesses:Fourmajorpharmacokineticprocesses:DrugabsorptionDrugabsorptionDrug distributionDrug distributionDrugmetabolismDrugmetabolismDrugexcretionDrugexcretion

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PharmacodynamicsPharmacodynamics

Impactofdrugsonthe bodyImpactofdrugsonthe bodyDrugDrug--receptorinteractionreceptorinteractionBindingofthe drugtoitsreceptorBindingofthe drugtoitsreceptor

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Sourcesof Individual VariationSourcesof Individual Variation

PhysiologicvariablesPhysiologicvariablesAge,gender,weightAge,gender,weight

PathologicvariablesPathologicvariablesDiminished functionofkidneysand liverDiminished functionofkidneysand liver

GeneticvariablesGeneticvariablesCanaltermetabolismofdrugsand predisposeCanaltermetabolismofdrugsand predisposepatienttouniqueinteractionspatienttouniqueinteractions

DruginteractionsDruginteractions

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Key PointsKey Points

Thereisnosuchthingasasafe drug;allThereisnosuchthingasasafe drug;alldrugscancauseharm.drugscancauseharm.

Thereisnosuchthingasaselective drug;Thereisnosuchthingasaselective drug;all drugscancausesideeffects.all drugscancausesideeffects.

TheobjectiveofdrugtherapyistoprovideTheobjectiveofdrugtherapyistoprovidemaximum benefitwithminimumharm.maximum benefitwithminimumharm.

Becauseallpatientsareunique, drugBecauseallpatientsareunique, drugtherapymust betailored toeachtherapymust betailored toeachindividual.individual.

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Chapter2Chapter2

ApplicationofPharmacologyinApplicationofPharmacologyinNursing PracticeNursing Practice

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Nursing Responsibilities Regarding DrugsNursing Responsibilities Regarding Drugs

Thenursemust knowThenursemust knowWhatmedicationsareappropriateforWhatmedicationsareappropriatefor

thepatientthepatientWhat drugsarecontraindicated fortheWhat drugsarecontraindicated forthepatientpatient

TheprobableconsequencesoftheTheprobableconsequencesofthe

interaction between drugand patientinteraction between drugand patient

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zz Correctadministration,withoutCorrectadministration,withoutadditionalinterventions,cannotensureadditionalinterventions,cannotensure

thattreatmentwillresultinthethattreatmentwillresultinthetherapeuticobjective.therapeuticobjective.--zz TherapeuticobjectiveistoprovideTherapeuticobjectiveistoprovidemaximum benefitwithminimalharm.maximum benefitwithminimalharm.

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ThenursesroleasadvocateThenursesroleasadvocateFollowsthepatientsstatusmostcloselyFollowsthepatientsstatusmostcloselyFirstmemberofthehealthcareteamtoFirstmemberofthehealthcareteamto

observeand evaluate drugresponsesandobserveand evaluate drugresponsesandinterveneifrequiredinterveneifrequiredMust knowtheresponsethatamedicationisMust knowtheresponsethatamedicationis

likelytoelicitlikelytoelicit

LastlineofdefenseforthepatientLastlineofdefenseforthepatient--lastpersonlastpersonthepatientcancountonthepatientcancounton

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Pharmacologyin PatientCare

Nurseresponsibilityand

accountability

Patienthasacardiacarrestafterreceivingarapid infusionofpotassium.-

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Nurse Responsibilityand Accountability

Pregnantwomanhasapreservativeinstead

ofananesthetic druginjected intoherspinalcolumn. Sheistotallyparalyzed and

diesseveralmonthslater.

NICU babies die

afteroverdoseofheparin.

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As a nurse you are responsible for

every drug that you administer.

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The Nursing Processguidesthenurseinadministering drugssafely.

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The Nursing Process

Assessment

Nursing Diagnosis

Planning/GoalsInterventions

Evaluation

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Assessment: Patient- this always

happens FIRST

Currentstatus-levelofconscious

Past (health) history

Medicationhistory

Allergies

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Assessment: Patient

Identifyinghigh-risk patientsLiverand kidneyimpairmentGeneticfactorsDrugallergiesPregnancyElderlyand pediatrics

Tools:patienthistory,physicalexam,and lab results

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Assessment: Delivery systemDrugadministrationand security

Drughandling

Dosagemeasuring

Obtainingthe drug

Systemsused to dispensethe drug

Howto document drugtherapyontheMAR (medicationadministrationrecord)

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Nursing DiagnosesAcute pain related totissue

traumaand reflexmusclespasms

secondarytosurgeryasevidencedbygrimacing,reluctancetogetoutofbed,and apainscoreof8.

Risk for injury related tosedatingeffectsofopioid analgesics

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Planning/Setting Goals

Patientwillhavepainlevelof3 orlesswithin 30 minutesofadministrationofmorphine

Patientwillremainsafeafterpainmedicationisadministered asevidenced bynofallsorinjuriestoday

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Interventions:Drug Administration

Six rights

Patient 2identifiers!

Drug

Dose

Route

Time

Right documentationrighttorefuse

Isthisenoughtomeetthe

therapeuticobjective?

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Keepmedicationsecure-Be knowledgeableaboutinstitutionspoliciesand procedures

Neveradministermedicationprepared byanothernurse-

Nursemustobservepatienttaking

medication-

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Certain drugshavemorethanoneindication. Dosagemay differdependingonwhichindicationthe drugisused for.

Many drugscan beadministered bymorethanoneroute. Dosagemay differdependingontherouteselected.

Certain IV agentscancauseseverelocalinjuryif IV extravasates.

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Interventions:

DocumentationWhentochart-doitimmediatelyafteryougivemeds.

Wheretochart-

Whattochart

Whygivenornot (PRN vsroutine)

Effects

Otherrelevant data

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Interventions:

Teaching

Considerations

KnowledgeReadinessto

learn

Environment

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TeachingMay Include

Drug

Schedule

TherapeuticeffectsAdverseeffects

Interactions

Handling/storage

Effectsofsuddenlydiscontinuing

Whatifdosemissed

Safetyconsiderations

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Evaluation

OfDrugEffects

Therapeuticresponse

Adverseeffect (includessideeffects)

Interactiveeffects

Furtherteachingneeds

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PromotingTherapeuticEffectsPromotingTherapeuticEffects

PromotingpatientadherencePromotingpatientadherenceAlso knownascomplianceorconcordanceAlso knownascomplianceorconcordanceExtenttowhichapatients behaviorcoincidesExtenttowhichapatients behaviorcoincides

withmedicaladvicewithmedicaladvice ImplementingnondrugmeasuresImplementingnondrugmeasuresDrugtherapycanoften beenhanced byDrugtherapycanoften beenhanced by

nondrugmeasures.nondrugmeasures.

Biofeedback,emotionalsupport,weightBiofeedback,emotionalsupport,weightreduction,smokingcessation,sodiumreduction,smokingcessation,sodiumrestriction,etc.restriction,etc.

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Minimizing AdverseEffectsMinimizing AdverseEffects

All drugshavethepotentialtoproduceAll drugshavethepotentialtoproduceundesired effects.undesired effects.

Always knowthefollowing:Always knowthefollowing:Themajoradverseeffectsthe drugcanThemajoradverseeffectsthe drugcanproduceproduce

ThetimewhenthesereactionsarelikelytoThetimewhenthesereactionsarelikelytooccuroccur

EarlysignsthatanadversereactionisEarlysignsthatanadversereactionisdevelopingdeveloping

Interventionsthatcanminimize discomfortandInterventionsthatcanminimize discomfortandharmharm

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Minimizing Adverse InteractionsMinimizing Adverse Interactions

Takeathorough drughistory.Takeathorough drughistory.Advisethepatienttoavoid OTC drugsthatAdvisethepatienttoavoid OTC drugsthat

caninteractwiththeprescribedcaninteractwiththeprescribedmedication.medication.

MonitorforadverseinteractionsMonitorforadverseinteractionsknownknown totooccur.occur.

BealertforasBealertforas--yetyetunknownunknown interactions.interactions.

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Making PRN DecisionsMaking PRN Decisions

PRNPRN pprorenata,meaningasneededrorenata,meaningasneededKnowthereasonfordruguse.Knowthereasonfordruguse.BeabletoassessthepatientsmedicationBeabletoassessthepatientsmedication

needs.needs.

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ManagingToxicityManagingToxicity

EarlyidentificationmakesearlyEarlyidentificationmakesearlyinterventionpossible.interventionpossible.

Knowtheearlysignsoftoxicity.Knowtheearlysignsoftoxicity.KnowtheprocedurefortoxicityKnowtheprocedurefortoxicitymanagement.management.

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OverviewofChapter3OverviewofChapter3

Landmark druglegislationNew drug developmentDrugnamesOver-the-counterdrugsSourcesofdruginformation

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Food Drugand Cosmetic Act (1938) Targeted safetyand efficacy

Regulated manufacture, distribution,advertising,labeling

Made USP officialstandard forstrengthand purity

www.usp.org

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Food Drugand Cosmetic Act (1938)

Designated FDA toenforce

RoleoftheFDA

http://www.fda.gov/

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HarrisKefauverAmendment

Firstlawto demand that drugsactuallyoffersome benefit

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Comprehensive Drug AbusePreventionand Control Act (1970)

Classified and regulated drugswithpotentialforabuse

Established drugabuseeducationandtreatmentprograms

Reallyfocusonthis ACT ***

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Schedule 1: highabusepotential,noapproved medicaluse

Schedule2: highabusepotential,accepted medicaluse-codeine,anabolicsteroids

Schedule 3:lessabusepotential,accepted medicaluse

Schedule 4:someabusepotential,

accepted medicaluseSchedule5:lessabusepotentialthan

schedule 4,accepted medicaluse

Good ideato knowtheseschedules ***

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1992 Rx Drug UserFee Act

Shortened review process

1997 FDA Modernization Act

Permitted drug companies to provide

information about non-FDA approveduses ( off-label uses)-you CANT market a drug

for a USE that is not approved by the FDA. You canshare the information, thats all.

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New Drug DevelopmentNew Drug Development

Therandomized controlled trialTherandomized controlled trialControluseControluseRandomizationRandomization

BlindingBlinding

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StagesofNew Drug DevelopmentStagesofNew Drug Development

PreclinicaltestingPreclinicaltestingClinicaltestingClinicaltesting

Phase 1: healthysubjects

Phase2: targetgroupPhase 3: largertargetgroup

Phase 4: FDA evaluationand

postmarketing surveillance***Knowthesesteps. *** usuallyan 8 yearprocess.***Knowthesesteps. *** usuallyan 8 yearprocess.

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LimitationsoftheTesting ProcedureLimitationsoftheTesting Procedure

Limited informationforwomenandLimited informationforwomenandchildrenchildrenWomenWomen

ChildrenChildrenFailureto detectalladverseeffectsFailureto detectalladverseeffects

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Exercising Discretion RegardingExercising Discretion RegardingNew DrugsNew Drugs

BeneitherthefirsttoadoptthenewnorBeneitherthefirsttoadoptthenewnorthelasttoabandontheold.thelasttoabandontheold.

Balancepotential benefitsagainstinherentBalancepotential benefitsagainstinherent

risks.risks.New drugsgenerallypresentgreaterrisksNew drugsgenerallypresentgreaterrisks

thantheold ones.thantheold ones.

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Which Nameto UseWhich Nameto UseGenericorTrade?GenericorTrade?

ThelittleproblemswithgenericnamesThelittleproblemswithgenericnamesMorecomplicated thantradenamesMorecomplicated thantradenames

The bigproblemswithtradenamesThe bigproblemswithtradenames

Single drugcanhavemultipletradenames.Single drugcanhavemultipletradenames.U.S. drugsand drugsoutsidethe U.S.mayU.S. drugsand drugsoutsidethe U.S.may

have differentactiveingredients.have differentactiveingredients.ProductswiththesametradenamemayhaveProductswiththesametradenamemayhave

differentactiveingredients.differentactiveingredients.Monistatand KaopectateMonistatand Kaopectate

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Which Nameto UseWhich Nameto UseGenericorTrade?GenericorTrade?

Genericproductsversus brandGenericproductsversus brand--namenameproductsproductsAregenericproductsand brandAregenericproductsand brand--nameproductsnameproducts

therapeuticallyequivalent?therapeuticallyequivalent?Would a difference between brandWould a difference between brand--nameandnameand

genericproducts justifytheuseoftradenames?genericproducts justifytheuseoftradenames?

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OverOver--thethe--CounterDrugsCounterDrugs

Americansspend about $20 billionAmericansspend about $20 billionannuallyon OTC drugs.annuallyon OTC drugs.

OTC drugsaccountfor60%ofall dosesOTC drugsaccountfor60%ofall doses

administered.administered.40%ofAmericanstakeatleastone OTC40%ofAmericanstakeatleastone OTC

drugevery2 days.drugevery2 days.

FourtimesasmanyillnessesaretreatedFourtimesasmanyillnessesaretreatedbyaconsumerusingan OTC drugas byabyaconsumerusingan OTC drugas byaconsumervisitingaphysician.consumervisitingaphysician.

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OverOver--thethe--CounterDrugsCounterDrugs

Withmostillnesses (60%to 95%),initialWithmostillnesses (60%to 95%),initialtherapyconsistsofselftherapyconsistsofself--care,includingcare,includingselfself--medicationwithan OTC drug.medicationwithan OTC drug.

TheaveragehomemedicinecabinetTheaveragehomemedicinecabinetcontains24 OTCpreparations.contains24 OTCpreparations.

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SourcesofDrug InformationSourcesofDrug Information

PeoplePeopleCliniciansand pharmacistsCliniciansand pharmacistsPoisoncontrolcentersPoisoncontrolcenters

PharmaceuticalsalesrepresentativesPharmaceuticalsalesrepresentatives

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Published InformationPublished Information

TextText--like bookslike booksGoodman & Gilmans,The PharmacologicalGoodman & Gilmans,The Pharmacological

BasisofTherapeuticsBasisofTherapeutics

Pharmacotherapy: A PathophysiologicPharmacotherapy: A PathophysiologicApproachApproachApplied Therapeutics:TheClinical UseofApplied Therapeutics:TheClinical Useof

DrugsDrugs

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Published InformationPublished Information

NewslettersNewslettersTheMedical Letteron Drugsand TherapeuticsTheMedical Letteron Drugsand TherapeuticsPrescribers LetterPrescribers Letter

Reference booksReference booksPhysicians Desk ReferencePhysicians Desk ReferenceDrugFactsand ComparisonsDrugFactsand ComparisonsNursing drugreferencesNursing drugreferences

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3304-module 1-

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