Pharmacology Notes, Exams of Nursing

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PHARMACOLOGY

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Chapter 1 – Nursing Process & Drug Therapy:

The Six Rights of Medication Administration:

1. Right Drug
2. Right Dose
3. Right Time
4. Right Route
5. Right Patient
6. Right Documentation

Chapter 2 – Pharmacologic Principles:

• Drug o Any chemical that affects the physiologic processes of a living organism
• Pharmacology o The study or science of drugs Drug Names
• Chemical Name o Describes the drugs chemical composition and molecular structure
• Generic Name (Non-Proprietary name) o Name given by the United States Adopted Name Council (All drugs have a generic name, even when they are new; Main focus of this course!!)
• Trade Name (Proprietary Name) o The drug name has a registered trademark; Use of the name is restricted by the drugs patent owner (which is usually the manufacturer)
• Pharmaceutics
• Pharmacokinetics
• Pharmacodynamics
• Pharmacotherapeutics
• Pharmacognosy Pharmacology Principle Pharmaceutics

▪ (The % of administered dose of unchanged drug that reaches systemic circulation; Incomplete absorption; First-pass effect. o Bio-equivalency ▪ (Everything is the same but the names are different; like the brand name and the generic name) Factors that Affect Absorption

• Absorption characteristics vary according to the dosage form and route o Food or fluids administered with the drug ▪ (Slows absorption; Decreases the irritation of a drug) o Dosage formulation ▪ (Help it disintegrate and dissolve before absorption) o Status of the absorptive surface ▪ (Absorbed mostly in the intestines because of the increased surface area) o Rate of blood flow to the small intestines o Acidity of the stomach ▪ (Acidic drugs like acidic environments; basic drugs like basic environments) o Solution of GI motility ▪ (Keeping it in the stomach too long and taking it longer for the drug to get to the intestines) Routes
• A drugs route of administration affects the rate and extent of absorption of that drug o Enteral (GI Tract) o Parenteral (FASTEST EX: IVs) o Topical Enteral Route
• The drug is absorbed into the systemic circulation through the oral or gastric mucosa (In the stomach lining) of the small intestine o Oral o Sublingual o Buccal o Rectal First-Pass: Effect
• The metabolism of a drug and its passage from the liver into the circulation

FASTEST ABSORPTION

o A drug given via the oral route may be extensively altered by the liver before reaching the systemic circulation (high first-pass effect) o The same drug given by IV bypasses the liver, preventing the first- pass effect from taking place, and more drug reaches the circulation ▪ (But, when given by IV, it goes directly to the systemic circulation) ▪ (The first-pass effect means that you can get a medication orally but its sent to the liver 1 st^ and the rest of your body (systemic circulation) 2 nd ▪ (Must be taken orally to have the effect) ▪ (Hepatic portal systems sends medication to the liver 1 st) Parenteral Route

• Intravenous (Fastest delivery to blood circulation)
• Intramuscular
• Subcutaneous
• Intradermal
• Intraarterial- artery (given here to go directly to certain organs)
• Intrathecal- spine
• Intraarticular- joint Topical Route
• Skin (Including transdermal patches)
• Eyes
• Ears
• Nose
• Lungs (Inhalation) Inhalers
• Rectum (Can be external as well; you don’t completely bypass the first-pass effect; about 50/50)
• Vagina Distribution
• The transport of a drug in the body by the bloodstream to its site of action o Protein binding ▪ FATS want to go with fats; keeps it in the blood and allows for more drug interactions o Water soluble vs. fat (lipid) soluble ▪ Lipid (fat) soluble drugs penetrate membranes much easier because they prefer to be in fat; Most are fat soluble to get through membranes faster

Excretion

• Definition: The elimination of drugs from the body o Kidneys (Main Organ) o Liver o Bowel ▪ Biliary excretion ▪ Enterohepatic recirculation Half-Life
• The time it takes for one half of the original amount of drug to be removed from the body
• A measure of the rate at which a drug is removed after about 5 half-lives
• Steady state o The longer the half-life, the longer it will take you to get to the steady state o Amount removed= amount absorbed; Use blood plasm serum; not always accurate (Used to determine the concentration of the drug in your body) Onset, Peak, and Duration
• Onset o Definition: The time it takes for the drug to elicit a therapeutic response
• Peak o Definition: The time it takes for a drug to reach its maximum therapeutic response
• Duration o Definition: The time a drug concentration is sufficient to elicit a therapeutic response Therapeutic Drug Monitoring
• Peak level: Highest blood level
• Trough level (nadir): lowest blood level Pharmacodynamics: MoA
• Receptor interactions
• Enzyme interactions General
• Nonselective interactions Pharmacotherapeutics: Typed of Therapies
• Acute therapy (Short-term)
• Maintenance Therapy (Treats symptoms)

• Supplemental/ Replacement therapy (Insulin/Iron)
• Palliative Therapy (Try to make the patient comfortable)
• Supportive Therapy (EX: Fluids and electrolytes)
• Prophylactic Therapy (Preventative)
• Empiric Therapy (Based on an educated guess for treatment) Contraindications
• Definition: Any characteristics of the patient, especially a disease state, that makes the use of a given medication dangerous for the patient.
• It is important to assess for contraindications o Doesn’t mean that the drug won’t work but it causes harm Monitoring
• Therapeutic index o Definition: Ratio of a drug’s toxic level to the level that provides therapeutic benefits ▪ (Toxic dose/ effective dose)
• Tolerance o Definition: Decreasing response to repeated drug doses ▪ Pain medications and opiods
• Dependence o Definition: Physiologic or psychological need for a drug
• Interactions may occur with the other drugs or food o A drug interaction is the alteration of a drug’s action by: ▪ Other prescribed drugs ▪ OTC Medications ▪ Herbal therapies
• Drug Interactions o Additive o Synergistic o Potentiation o Antagonistic o Incompatibility Drug Sources
• Four main sources for drugs o Plants o Animals o Minerals o Laboratory Synthesis

• The skin is thin and permeable
• Stomach lacks acid to kill the bacteria
• Lungs have weaker mucus barriers
• Body temperature is less well regulated and dehydration occurs easily
• Liver and kidneys are immature, impairing drug metabolism and excretion Methods of Dosage, Calculations for Pediatric Patients
• Body surface area method o Using the west nomogram
• Body weight dosage calculations o Using mg/kg The Elderly
• Elderly: Older than 65
• Use of the OTC medications
• Increased incidence of chronic illnesses
• Polypharmacy Physiologic Changes in Elderly Patients
• Cardiovascular
• Gastrointestinal
• Hepatic
• Renal
• Absorption The Elderly: Pharmacokinetics o Gastric pH less acidic o Gastric emptying slowed o Movement therapy GI tract slowed o Blood flow to the GI tract reduced o Use of laxatives may accelerate GI motility
• Distribution o Lower total body water (TBW) percentages o Increased fat content o Decreased production of proteins by the liver, resulting in decreased protein binding of drugs (and increased circulation of free drugs)
• Metabolism o Aging liver produces fewer microsomal enzymes, affecting drug metabolism o Reduced blood flow to the liver
• Excretion o Decreased glomerular filtration rate

o Decreased number of intact nephrons

Chapter 4 – Cultural, Legal, and Ethical Considerations:

Controlled Substances: Schedule Categories Schedule Abuse Potential Medical Use C- 1 High None C-II High Accepted C-III Less than C-II Accepted C-IV Less than C-III Accepted C-V Less than C-IV Accepted

Chapter 5 – Medication Errors: Preventing & Responding:

Medication Errors

• Preventable
• Common cause of adverse health care outcomes
• Effects can range from no significant effect to directly causing disability or death o There are a lot of drugs on the market, which leads to confusion because there are so many that look and sound similar Common Classes of Medications Involved in Serious Errors
• Antibiotics
• Anticoagulants
• Antidiabetic Drugs (Particularly insulin)
• Cardiovascular drugs
• CNS- Active Drugs (Opioids and anesthetic)
• Vaccines
• Antineoplastic (anticancer) drugs Preventing Medication Errors

Capsaicin Capsicum Frutescence Cocaine Erythroxylon Coca Codeine Papaver Somniferum Ipecac Cephaelis Ipecauariha Quinine Cinehana Officinalis Scopolamine Datura Fastuosa Senna Cassia Acutifolia Paclitaxel Taxis Brevifolia Vincristine Catharanthus Roseus Use of OTCs/Herbal Products

• May postpone effective treatment of more chronic disease states
• May delay treatment of serious and/or life-threatening disorders
• May relieve symptoms of a disorder but not the cause Herbal Products
• Dietary Supplement & Health Education Act (DSHEA) of 1994 o Herbal products are considered “dietary supplements” & NOT drugs o No proof of efficacy or safety required o No standards for quality control o May claim effect but cannot promise a specific cure o Supplement manufacturer does not have to provide the FDA with evidence on which it relies to substantiate for safety or effectiveness of a product before or after it makes the products o Other countries (UK, France, Canada, Germany) require manufacturers to meet quality and safety standards Commonly Used Herbal Products
• Aloe:
• Feverfew:
• Ginkgo:
• Goldenseal:

• St. John’s Wort:
• Valerian:
• Kava:
• Echinacea:
• Garlic:
• Ginseng:
• Hawthorn:
• Saw Palmetto:
• Melatonin:

Chapter 10 - Analgesic Drugs:

Analgesics

• Medications that relieve pain without causing loss of consciousness o “Painkillers” o Opiods o Acetaminophen o NSAIDS Classification of Pain by Onset & Duration
• Acute Pain o Sudden in onset o Usually subsides once treated
• Chronic Pain o Persistent or reoccurring o Lasting 3 - 6 months or longer o Often difficult to treat ▪ WILL OFTEN LEAD TO TOLERANCE

• Methadone HCl (Dolophine) (Long half-life; less withdrawal)
• Propoxyphene HCl
• Oxycodone
• Meperidine HCl (Demerol) (Acute use because when metabolized, its toxic)
• Hydromorphone
• Fentanyl (Very potent; even a small dose is lethal) Opioid Analgesics: MoA
• Three classifications based on their actions: o Agonist o Partial agonist o Antagonist Agonists
• Bind to an opioid pain receptor in the brain
• Cause an analgesic response (reduction of pain sensation) o Basically they alter the perception of pain Agonists – Antagonists
• Bind to a pain receptor
• Cause a weaker neurologic response than a full agonist
• ALSO CALLED PARTIAL-AGONIST or mixed agonist o Good for a patient who used to be an opioid addict o Bad for someone who is currently opioid dependent because they cause withdraw

Antagonist

• Reverse the effects of these drugs on pain receptors
• Bind to a pain receptor and exert no response
• Also known as competitive antagonists o These COMPETE with AGONIST Opioid Receptors
• Mu
• Kappa
• Delta
• Sigma
• Epsilon Opioid Analgesics: Indications
• Main Use: To alleviate moderate to severe pain
• Often given with adjuvant analgesic drugs to assist the primary drugs with pain relief o NSAIDs (Help with inflammation) o Acetaminophen o Antidepressants o Anticonvulsants o Corticosteroids
• Opioids are also used for: o Cough center suppression (Works in the medulla; First-pass effect is bypassed with codeine) o Treatment of diarrhea (Most common adverse effect is constipation) o Balanced anesthesia (Used with general anesthesia) Opioid Analgesics: Contraindications
• Known drug allergy
• Severe asthma USE WITH EXTREME CAUTION IF:
  • Respiratory insufficiency
  • Elevated intracranial pressure (Increase in pCO2 which increases vasodilation that causes intracranial pressure)
  • Morbid obesity Primary Receptors

Toxicity and Management of Overdose

• Naloxone (Narcan) Short half-life and works fas*tANTAGONIST
• Naltrexone (Revia) Longer half-life than naloxone o These drugs bind to opiate receptors and prevent a response o Used for the complete or partial reversal of opioid induced respiratory depression
• Regardless of withdraw symptoms, when a patient experience sever respiratory depression, an opioid antagonists should be given GIVEN TO PEOPLE WHO OD
• Opioid withdraw/ opioid abstinence syndrome
• Manifested as: o Anxiety, irritability, chills & hot flashes, joint pain, lacrimation, rhinorrhea, diaphoresis, nausea, vomiting, abdominal cramps, diarrhea, and confusion o Withdraw is the OPPOSITE of what the drug does for you Nonopioid Analgesic: Acetaminophen
• Analgesic and antipyretic effects
• Little to no anti-inflammatory effects
• Available OTC and in combination products with opioids - MoA o Similar to salicylates o Blocks pain impulses peripherally by inhibiting prostaglandin synthesis
• Indications o Mild to moderate pain o Fever o Alternative for those who CANNOT take aspirin products
• Toxicity and Managing Overdose o Even though available OTC, lethal when overdosed o Overdose, whether intentional or due to chronic unintentional misuse, causes hepatic necrosis Destroys liver; acute o Long-term ingestion of large doses also causes nephropathy (Chronic Kidneys) o Recommended ANTIDOTE: Acetylcysteine Regimen Only works if its caught early enough
• Dosage o Maximum daily dosage for adults is 3000 mg per day o Inadvertent excessive doses may occur when different combination drug products are taken together

o Be aware of acetaminophen content of all the medications taken by the patient (OTC & Prescription)

• Interactions o Dangerous interactions may occur when taken with alcohol or other drugs that are hepatotoxic o Should not be taken in the presence of: ▪ Drug allergy ▪ Liver dysfunction ▪ Possible Liver failure ▪ G- 6 - PD deficiency

Chapter 44 – Anti-inflammatory & Anti-gout Drugs:

NSAIDs

• Large and chemically diverse group of drugs with the following properties: o Analgesic (pain) o Anti-inflammatory o Antipyretic (fever) o Antirheumatic (arthritis) NSAIDs: MoA
• Activation of the arachidonic acid pathway causes: o Pain o Headache o Fever o Inflammation
• Analgesia- treatment of headaches, mild to moderate pain & inflammation o Block the chemical activity of either both COX enzymes (prostaglandin [PG] pathway) o Result: limits the undesirable inflammatory effects of PGs
• Antipyretic: reduces fever o Inhibit prostaglandin E2 within the area of the brain that controls temperature Chemical Categories of NSAIDs
• Salicylates
• Acetic acid derivatives
• Cyclooxygenase- 2 (COX-2) inhibitors
• Enolic acid derivatives
• Propionic acid derivatives