Pharmocology NSG 304

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Pharmocology NSG 304
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Nsg 304 Chapter 1,2,3,4,5,6,7,9,12,13,16,17
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  1. definition of a drug
    any substance that is taken to prevent, cure, or reduce symptoms of a medical condition
  2. Pharmacology
    Study of drugs
  3. Pharmocotherapy
    Application of drugs for prevention of disease and treatment or suffering.
  4. Therapeutic drugs
    categorized as those drugs that offer treatment of disease
  5. Pharmacologic Drugs
    Categorized by mechanism of action
  6. Mixed categories of drugs
    Drugs that overlap into different therapeutic and or pharmacological categories.
  7. Prototype drug
    Selecting a single drug in a class and comparing it to all the other drugs in that class.

    Learning the prototype drug in depth allows for predicting the adverse effects of other drugs in that same class
  8. Chemical name
    relates to the chemical and molecular structure
  9. Generic name
    Often derived from the chemical name. Generic name is the common name of the drug.
  10. Trade name
    the propriety name given by the manufacturer
  11. Generic VS Brand Drugs
    Bioavailabilty issues

    switching from brand to generic?

    Why are generic brands becoming so popular?
  12. Bioavailabilty of drug
    the rate and extent to which active ingredients are absorbed from a drug product and beciomes available at the site of drug action to produce its effect.
  13. Switching from Brand to Generic?
    dosages may be identical

    drug formulations not always the same

    may have different inert ingredients

    -tablet form: active ingredients may be more tightly compressed in one of the preparations

    -liquid drugs: may use different solvents such as water or alcohol
  14. Why are generic medications becoming popular?
    Cost half as much as brand name drugs
  15. What nurses need to know:
    -Generic, Brand, and or chemical name

    -indications for drug

    -contraindictations of the drug

    -adverse reactions/side effects

    -administration: Dose, Route (PO,SQ,IV,PR, etc.)

    -Nursing considerations
  16. Patent medications
    legal right to manufacture or sell drugs

    patent medications contain a brand name that clearly identify the product
  17. Drug legislation
    -purpose- to protect the public so that they could receive "safe" medications
  18. Harrison Narcotic Act of 1914
    -requires prescriptions for high doses of narcotic drugs and mandate that pharmacists and physicians keep narcotic records.
  19. Food, Drug, and cosmetic act (1938)
    -corrected certain loop holes in previous laws

    -first law preventing the sale of newly developed drugs that had not been thoroughly tested for safety before marketing

    -drug labels were required to contain instructions for safe use

    -this law was also the first attempt at regulating cosmetics and medical devices

    -law did not clearly define "prescription" or specify which drugs required a prescription allowing many harmful and addictive drugs to be sold by corner druggists
  20. Durham-Humphrey Amendment (1951)
    -Ammendment to the FDCA delineated the difference between safer drugs, which may be sold over the counter, and more dangerous drugs that required prescriptions
  21. Orphan drug act (1983)
    -Drug companies offered developmental grants, tax credits for clinical investigation expenses, and 7 years exclusivity to market an orphan drug.

    - Over 700 medications have been approved as orphan drugs since the passage of this act.

    -Law needed because drug companies were reluctant to develop drugs for these disorders because there would not be enough sales to recoup their research and development costs
  22. Dietary Supplement Health and Education Act (1994)
    -Introduced to control misleading industry claims

    -regulation of these products remains less stringent then other OTC drugs
  23. Medicare Prescription Drug Improvement & Modernization Act (2003)
    -Law provides for a standard benefit that pays 75% of prescription drug spending up to the first $2,250.

    -Those qualifying for the low income criteria may have their premiums and cost subsidized by the government

    -Participants are protected against catastrophic costs at $3,600 per year with most beneficiaries paying a 5% co-pay amount.
  24. U.S. Pharmacopedia-National Formulary (USP)
    -First comprehensive publication of drug standards

    -A medical reference summarizing standards of drug purity, strength, and directions for synthesis

    -All drug products were covered in USP
  25. Food and Drug Administration (FDA)
    -First began in 1862 when president Lincoln appointed chemist to head agency for food and drugs in United States

    -FDA established by PFDA of 1906 and later expanded to carry out the provisions of FDCA of 1938

    -One of the oldest drug regulatory agencies in the world
  26. FDA mission statement
    -Protecting the bublic health by assuring the safety, efficacy, and security of human and veterinary drugs, biological products, medical devices, the nation's food supply, cosmetics, and products that emit radiation

    -Advancing the publ;ic health by helping to speed innovations that make medicines and foods more effective, safer, and more affordable

    -Helping the public get the accurate, science based information they need to use medicines and foods to improve their health
  27. 6 branches of FDA
    1)Center for Biologics Evaluation and research

    2)Center for devices and radiological health

    3)Center for drug evaluation and research

    4)center for food safety and applied nutrition

    5)center for veterinary medicine

    6)National center for toxicological research
  28. Drug Approval process steps
    1) Preclinical Research

    2)Phase 1

    3) Phase 2

    4)Phase 3

    5) NDA Accepted

    6) NDA Approved

    7) Post marketing Surveillance
  29. Investigational New Drug (IND)
    -if a drug appears promising, pharmaceutical company submits IND application to FDA that contains all the animal and cell testing data

    -Scientists at the FDA study the data and must be convinced that the drug is safe enough to allow human testing,

    -Approval from FDA is necessary before the next stage can begin
  30. Clinical Phase Trials
    -second stage of drug testing

    -takes place in 3 stages termed clinical phase trials

    -longest part of drug approval process and occur in sequential stages
  31. Clinical Phase Trial: Stage 1
    -Testing conducted on 20-80 healthy volunteers for several months to determine proper dosage and to assess for adverse effects

    -Focus of phase 1 is on safety

    -If unacceptable levels of toxicity are noted, clinicals are stopped
  32. Clinical Phase Trials: Stage 2
    -Several hundred patients with the disease arte given the drug

    -Primary focus is on effectiveness, although safety and data continue to be recorded

    -usually compared to an inert substance or placebo which serves as a control "nontreatment" group

    -May be compared to a standard drug used for the same condition
  33. Clinical Trials: Phase 3
    -Large number of patients with the disease are given the drug to determine patient variability

    -potential drug-drug interactions are examined

    - Patients with chronic conditions such as cardiac, renal, or hepatic impairment are given the drug to determine safety in these important populations

    -Assessment of effectiveness and safety continues for several years and thousands of patients may be given the new drug during phase 3
  34. New Drug Application (NDA)
    -If drug continues to show promise through the clinical phase trials, a new drug application (NDA) is submitted to the FDA

    -The NDA signals that the pharmaceutical company is ready to sell the new drug

    -During NDA review, the FDA examines all the preclinical and clinical data to assess whether the proposed new drug is safe and effective.

    -By law, the CDER is obligated to act on at least 90% of the NDAs for standard drugs within 10 months of submission. For priotiry drugs, the benchmark is 6 months

    -If the NDA is approved, the manufacturer may begin selling the new drug. If the NDA is rejected, the FDA indicates whether the drug is approvable or not approvable

    -"Approvable" means that the drug will likely be approved if the pharmaceutical company conducts additional testing or addresses specific issues identified by the FDA.

    -"Not Approvable" means that a drug has significant barriers to approval
  35. Post Market Surveillance
    -Stage 4 of drug Approval process

    -Begins after the NDA review has been completed.

    -Purpose of stage 4 is to survey for harmful drug effects in a larger population

    -Some adverse effects are very subtle, take longer to appear, and are not identified until a drug is prescribed for large numbers of people

    -Adverse reactions are reported by manufacturers, health care providers and patients to the adverse event reporting system (AERS), a computerized database designed to support the FDAs postmarketing surveillance program.
  36. Historical Gender Issues
    -Caucasion males were predominantly used in drug research studies
  37. Historical Gender issues
    -Women were excluded due to hormonal changes and pregnancy
  38. Historical gender issues
    Drug study results performed on causcasian males were generalized to females and other races
  39. Prescriptions
    -Written by MD's, Nurse Practitioners, Physician Assistants

    -Prescription rights vary by state

    -Must be written for all drugs considered as RX

    -OTC drugs do not require RX
  40. Former RX drugs that are now OTC
    Zyrtec

    Claritin

    Pepcid

    Prilosec
  41. Scheduled I drugs
    -Highest Addictive

    -The drug or other substance has a currently accepted medical use in treatment in the United states

    -I.E. Heroin, Lsd, Peyote
  42. Scheduled II Drugs
    -Highest Addictive

    -The drug or other substances has a currently accepted medical use in treatment in the United States or a currently accepted medical use with severe restrictions

    -I.E. Opioids (morphine), demerol, Dilaudid
  43. Scheduled III Drugs
    -Less potential for Addiction

    -The drug or other substances has a currently accepted medical use in treatment in the United States

    -I.E. -Codeine, hydrocodone, Immediate-acting Barbituates
  44. Scheduled IV Drugs
    -Lower potential for addiction

    -The drug or other substance has a currently accepted medical use in treatment in the United States

    -I.E.- Benzodiazipines, long acting barbituates
  45. Sceduled V Drugs
    -Lowest potential for addiction

    -The drug or other substance has a currently accepted medical use in treatment in the united states

    -I.E.- Cough medicines with codeine, Lomotil
  46. Goal of Adherence/compliance of drug administration
    -The pt is able to understand the reason for being on a particular medication and is able to take their medications as directed.
  47. Reasons for being non-compliant
    -The pt does not understand what the drug does

    -The pt misunderstands the correct amount of drug to take

    -Poly-Pharmacy

    -Financial Issues

    -Side effects of the drug
  48. The Nurse's Role
    -Pts education

    -Use of Critical Thinking Skills

    -ADPIE

    -Creative Ideas
  49. Drug Storage
    -Expiration date: approximation date of when drugs lose their effectiveness

    -Light: Some medications are degraded by exposure to light, should be stored out of direct light, often housed in amber colored containers, some meds are covered in foil because they are so sensitive to light

    -Moisture and Air: some drugs interact with atmospheric gases or with water vapor, should be stored with tightly capped lids, storage in areas with high humidity will enhance deterioration

    -Narcotic considerations: must be stored in lockers or boxes, access must be restricted from theft or misuse
  50. PO
    By mouth
  51. SQ
    Subcutaneous route
  52. IV
    Intravenous route
  53. GTT
    drop
  54. QD
    Everyday
  55. BID
    Twice per day (0800-2000)
  56. TID
    Three times per day (0800-1600-2400)
  57. QID
    Four times per day (0600-1200-1800-2400)
  58. Metric measurements
    ml

    L

    mg

    g

    kg
  59. Apothecary drug measurements
    minims

    fluid dram

    fluid ounce

    pint

    grains
  60. household drug measurements
    tsp

    tbsp

    cup

    quart

    drops
  61. 1 ml =
    =15-16 minims

    or

    =15-16 drops
  62. 4-5 ml =
    =1 fluid drams

    or

    =1 tsp

    or

    60 drops
  63. Route of drug administration

    "oral"
    tablets and capsules

    liquids

    sublingual
  64. Route of drug administration

    "topical"
    dermatalogic prepartations are drugs applied to skin

    -Include: creams, lotions, ointments, gels, powders, and sprays
  65. route of drug administartion

    "Transdermal"
    -Transdermal patches contain a certain amount of medication

    -rate of dosage may vary

    -drugs given through this route avoid the first-pass effect of the liver and bypass digestive enzymes

    -examples: nitroglycerine; scopolamine (motion sickness); testosterone;
  66. Route of drug administration

    "Instillations"
    eye drops

    ointment

    ear drops

    sprays
  67. more drug administration routes
    inhalations

    nasogastric and gastrostomy tubes

    suppositories: rectal; vaginal
  68. Drug administration by Parenteral Injection
    -intramuscular: ventrogluteal; dorsogluteal; deltoid; vastus lateralis; z track

    -subcutaneus (subq)

    -Intradermal
  69. Drug administration by Parenteral Injection
    Intravenous injection:

    radial vein

    median cubital (just below bicept, antcubical)

    cephalic vein (lateral anterior bicept)

    Basilic vein (medial bicept)
  70. Pharmacokenetics
    -study of drug movement throughout the body

    -what body does with med after administration

    -crossing plasma membranes to reach targtet cells
  71. diffusion/passive transport
    -movement of chemical from an area of higher to lower concentration (IV- blood to tissue)

    -may need a carrier (transport) proteins to cross membrane
  72. Active Transport
    -Movement across membranes vs their gradient from low to high concentration

    -requires expenditure of cell energy and carrier protein (pumps)
  73. 4 Phases of Pharmacokinectics
    1)Absorption

    2)Distribution

    3)Metabolism

    4)Elimination & Secretion
  74. Drug Absorption
    -Drug molecules move from site of administartion to bloodstream

    topicals

    enterals

    parenteral

    IV
  75. Topicals
    -absorbed across skin

    -absorbed across mucous membrane of: vangina ;respiratory tract ; Nasal passages
  76. Enterals
    Absorbed across membranes lining GI tract
  77. Parenteral (ID, IM, SQ)
    Blood vessels in skin
  78. IV
    -Directly into bloodstream (not absorbed)

    -most rapid onset of action
  79. Absorption rates
    IV - most rapid onset of action

    Inhalation- rapid response

    SQ/IM- absorbed rapidly (less than IV/Inhalation)

    Tablets/capsules- slow absorption, must disolve

    liquid formulations faster than tablets

    Topicals- absorb slowly, keratin layer thick
  80. absorption influences
    -drug concentration and dose

    -Higher dose = faster/greater response

    -Creates greater diffusion rate
  81. absorption influences

    "GI tract environment"
    -most absorption in small intestine

    -motility influences

    -blood flow to absorption site
  82. Absorption Influences

    "Drug Ionization +/-"
    -Affects ability to cross plasma membranes & be excreted

    -Acids absorbed in acids because they are non-ionized

    -Bases absorbed in bases because they are non-ionized
  83. Absorption Influences

    "drug interactions"
    -May delay/slow absorption

    -food may delay/ slow absorption

    -high fat meals
  84. absorption influences

    "surface areas"
    -larger increases absorption
  85. medication error
    -any preventable event that may cause or lead to inappropriate medicatio use or lead to inappropriate medication use or patient harm while medication is in control of the health care professional, patient, or consumer
  86. Medication error index
    -National Coordinatig council for medication error reporting and prevention (NCC MERP) classiifes in index

    -Index categorizes errors by evaluating exten of harm error causes
  87. rights of drug administration
    dose

    medication

    patient
  88. Distribution: Transport of meds through body after absorption
    Infuencing Factors:

    blood flow to tissues

    -heart, liver, kidneys= highest exposure to drug

    -skin, adipose tissue= least exposure
  89. drug solubility
    -lipid- soluble =more completely distributed

    -water -soluble= less completely distributed
  90. tissue drug storage
    -high affinity= bone marrow, teeth, eyes, adipose tissue

    Na Pentothan, valium
  91. drug-protein binding
    bind to plasma proteins e.g. albumin

    form drug-protein complexes

    -too large to cross capillary membranes (trapped coumadin)

    -compete with other drugs for plasma protein binding sites (tagment displaces warfin)
  92. Blood Brain Barrier (BBB)
    -endothelial cells sealed and thick basement membrane

    -astrocytes secrete chemicals adjusting capillary permeabiltiy
  93. fetal placental barrier
    protect fetus

    -ineffective for: alcohol, cocaine, caffeine, some prescription drugs
  94. metabolism-biotransformation
    -process used by body to chemically change a drug molecule for excretion (usually)

    -liver primary site

    -kidneys and cells of intestinal tract-high rates

    -changes from lipid-soluble to water soluble (absorption-distribution-excretion)

    -chemical changes create metabolites-usually less active

    -metabolites may be more active (90% inactive-codeine: 10% morphine)
  95. most liver metabolism by hepatic microsoamal enzymes

    P-450 system CYP
    -CYP= an enzyme metabolizes drugs, nutrients, endpgenous substances

    -over 50 isozymes of cytochrome P450

    -Drugs as:

    substrate for enzyme- when drug metabolized by CYP

    enzyme inhibitor-inhibit action of cyp isozyme

    -enzyme inducers- drug increases metabolic activity in the liver/inactivation
  96. first pass of effect of liver for drug
    -completely metabolized to inactive form on first trip through liver before enter general circulation

    -bypass by giving sublingual, rectal, parenteral (still pass through liver)
  97. Elimintaion and excretion of drugs
    kidneys

    lungs

    urine

    glandular
  98. drug excretion
    renal:

    primary site of excretion

    dependent on PH of filtrate in the renal tubule

    impaired kidney function affects
  99. elimination and excretion continued

    "pulmonary"
    dependent on factors afecting gas exchange

    diffusion

    gas solubility

    blood flow to lungs

    excrete most drugs in unmetabolized form
  100. glandular secretion of drugs
    water-soluble drugs secreted into:

    saliva

    sweat

    breast milk
  101. fecal-biliary excretion
    feces- certain oral excreted in feces

    no absorption (worms, meds, barium sulfate)

    -Bile: excreted in bile- "biliary excretion"

    -drug enters duodenum via common bile duct and leaves body in feces

    -enterohepatic recirculation: may be recirculated numerous times with bile back to liver

    -prolongs activity
  102. time response of drugs
    -directly related to concentration in plasma

    -measure serum concentration:

    minimum effective concentration

    therapeutic range

    toxic concentration
  103. duration of action
    -length of time drug concentration remains in therapeutic range
  104. plasma half life
    drugs duration of action

    -length of time required for plasma concentration of drug to decrease by 1/2 after administration

    -long term- higher risk for adverse effects

    -discontinued drug takes 4 half lives un til "functionally" eliminated (94%)
  105. Therapeutic range
    goal to keep drug plasma levels continually

    next dose before plasma level falls
  106. Loading dose
    larger intitial dose

    primes the bloodstream

    quicker therapeutic range
  107. maintenance dose
    keeps plasma levels @ therapeutic level
  108. pharmacodynamics
    -study of drug concentration and its effect on the body in relation to the amount of drug in the plasma
  109. frequency distributive curve
    median effective dose
  110. therapuetic index
    -measures the index/ or range of the drug in relation to being safe or toxic

    -median effective dose

    -median toxicity dose- 50% of group patients
  111. median lethal dose
    50% of lab rats death
  112. therapeutic index
    • median lethal dose
    • ___________________

    median effective dose
  113. dose response curve

    "Phase 1"
    occurs @ lowest doses

    few target cells affected
  114. dose response

    "phase 2"
    -relationship between amoint of drug given and degree of response

    -twice the drug =twice the response
  115. dose response

    "phase 3"
    -increasing drug= no more therapeutic effect

    may produce adverse effects
  116. how actions of drug change with increasing dose
    onset

    -peak= highest plasma drug concentration at a given time (estimated maximum efficacy)

    IV drug=10 mintues

    oral drugs= 3 hours: shows rate of absorption

    -Duration of action

    -trough- lowest plasma concentration od drug (drawn/measued before next dose) shows elimination
  117. potency
    -ability of drug to reach therapeutic effect at lower dose comparted to other drug in same class

    -more potent produces therapeutic effect @ lower dose
  118. efficacy
    -maximal response that can be produced from drug
  119. comparison of both potency and efficacy
    which is most important
  120. receptor
    -a cellular molecule to wich a med binds to produce its effect

    -the drugs specific target

    -response proportional to concentration of receptors bound

    -enhance or inhibit normal cell function
  121. intrinsic activity
    -drugs with ability to bind to a receptor and produce action

    high or low
  122. second messenger
    -once receptor is occupied, second messenger events triggered in cell

    -stimulates or inhibits normal activity of cell
  123. drugs acting independently of cellular receptors
    --change permeabiltiy of cellular membranes

    -depress membrane excitability

    -alter activity of cellular pumps

    -nonspecific mechanisms
  124. agonists
    -drug produces same response as receptor it is bound to

    -enhances the desired effect

    -partial agonist= weaker effect
  125. antagonist
    -drug intentionally responds by blocking action of receptor it attaches to

    -used when body producing too much of a response to endogenous chemical or drug overdose
  126. idiosyncratic response
    unpredictable reaction

    unexplained reaction
  127. adverse effects/events

    "side effects"
    predictable

    may occur @ therapeutic doses

    less serious than adverse reactions

    can be dose related

    common side effects

    nausea, heartburn, diatthea, etc
  128. adverse effects/events

    "serious drug effects"
    FDA defines

    result in patient death, hospitilization or disability

    cause congenital abnormally

    case life threathening event

    require intervention to prevent permanent damage
  129. nurse's role
    -take a thorough medical history

    -thoroughly assess patient/diagnostic data

    -prevent medication errors

    -monitor pharmacotherapy S/S carefully

    -know the drugs adverse effects

    -be prepared for the unusual

    -question unusual orders

    -teach patients about adverse effects
  130. Allerigic reactions (6-10%)
    -due to hypersensitive reaction to drug causing release of mast cells, eosinophil, basophils, or lymphocytes triggering allergic responses

    -may be exposed to class of drugs over period of time and then develop allergic reaction

    -characteristics= occurs with small or normal dosed drug (not proportional to dose)

    -unrelated to the action of drug

    -cross allergy

    -common reactions

    PCN -rash

    radiologic contrast media

    preservatives
  131. teratogenic drugs (cause birth defects)

    CATEGORY A
    -Category A= adequate studies in pregnant women show no risk to fetus
  132. teratogenic drugs (cause birth defects)

    CATEGORY B
    -Animal studies show no harm to fetus but no adequate studies done on pregnant women
  133. Teratogenic drugs (cause birth defects)

    Category C
    Animal studies show adverse effects on fetus but no adequate studies on humans
  134. Teratogenic drugs (cause birth defects)

    Category D
    Positive evidence of human fetal risk but benefits may outweigh the risks (risk-benefit ratio)
  135. Teratogenic drugs (cause birth defects)

    Category X
    Animal or human studies shown fetal abnormalities or toxicity and the risks outweigh the benefits
  136. Nephrotoxicity

    "kidneys"
    Assess dehydration , renal function tests, adjust for renal impairment
  137. neurotoxicity
    -Blood Brain Barrier (BBB) controls access of drugs to brain

    -Assess for change in behavior, seizure, sedation
  138. Muscle toxicity (skeletal/cardiac)
    -Assess for unexplained muscle pain and CK-MB level, EKG
  139. Hepatotoxicity

    "liver"
    -monitor liver enzymes

    -observe for RUQ pain, anorexia, V/V
  140. Dermatalogic Toxicity

    "skin"
    rash

    urticaria

    pruritus

    phototoxicity
  141. Bone marrow toxicity
    Decrease in RBC, WBC, platelets
  142. Drug interactions
    -drug-drug

    -food, nutrients and dietary supplememnts

    -effects:

    drug inhibited

    drug enhanced

    drug actions changed or new response
  143. Pharmacokinetic Variables

    "Absorption"
    presence of food - <

    alterations of PH -variable

    drug-drug binding - <

    Increased peristalsis- variable

    slowed gastric emptying -variable
  144. Pharmacokinetic Variables

    "disribution"
    displacement of drug from plasma protein binding site ->
  145. Pharmacokinetic Variables

    "Metabolism"
    stimulation of cyp: enzyme induction - <

    inhibition of cyp: enzyme inhibition
  146. Pharmacokinetic Variables

    "excretion"
    renal excretion - grf- >

    interferences of other drugs - <

    biliary excretion interferences by other drugs - <
  147. Additive effect
    2 drugs similiar therapeutic class produce combined summation response
  148. synergism effect
    -effects of 2 drugs greater than would be expected from each individual effect
  149. Antagonist effect
    adding a second drug results in diminished response
  150. medication error
    "any preventable event that may cause or lead to inappropriate medication use or patient harm while medication is in the control of the health care profesional, patient, or consumer"
  151. medication error index
    -national coordinating council for medication eror reporting and prevention (NCC MERP) classifies in index

    -index categorizes errors by evaluating extent of harm error causes
  152. rights of administration

    "five rights"
    dose

    medication

    patient

    route (of Admin)

    time (of delivery)

    reason documentation

    education

    evaluation

    right to refuse
  153. reduce medication errors
    -check drugs with a colleague ex. heparin/insulin

    -assessment of patient ex:wt/ht, labs

    -do not accept a telephone/verbal order

    -monitor patient medications for drug-to-drug interactions

    -correct incomplete/illegible orders

    patient issues

    (non compliance, right to refuse, inappropriate use of medication)
  154. Joint Commission on accreditation of healthcare organizations (JCAHO)
    identifies look alike drugs

    identifies sound alike drugs
  155. institute for safe medication practices (ISMP)
    -maintaining error reporting program (MERP)

    -shares info with FDA

    -Provides newsletter: Medication Safety Alert/Safe medicine

    -Education programs for healthcare workers

    -standardize medication error reporting

    -examines causes
  156. FDA
    -safety information and adverse event reporting program

    -medwatch reports safety issues
  157. united states pharmacopeia (USP)
    -medmarx database

    0track adverse events and med errors

    hospital and healthcare systems
  158. Reporting med errors
    facility dictated policies and procedures

    include interventions implemented
  159. The nurse's role

    "assessment"
    allergies

    health concerns

    OTC/herbals

    5-10 rights

    renal/hepatic functions
  160. The nurse's role

    "planning"
    no unacceptable abbreviations

    nu verbal drug orders

    no unclear orders

    patient education
  161. The nurse's role

    "Implementation"
    focus on the task

    identify patient

    correct procedure/technique

    double check high-risk drugs

    calculate the correct dosage

    document on the MAR

    open in front of patient

    confirm pt swallowed

    dont crush SR,EX,XR,LA
  162. The nurse's role

    "Evaluation"
    Assess pt after giving med

    assess for expected outcomes

    assess for adverse effects
  163. medication reconcilitation
    polypharmacy

    reconciliation

    list of all medications
  164. nursing process
    -"a systemic, rational method of planning and providing nursing care"
  165. Assessment
    systematic

    data:

    collection

    organization

    validation

    documentation

    data used to:

    identify current health problems

    develop nursing diagnosis and plan of care

    patient history
  166. Diagnosis
    analysis of assessmnet data

    identification of health problems

    formulation of nursing diagnosis:

    used to set goals

    set interventions- plan of care

    constant flux

    problem/risk for problem "related to" etiology

    north american diagnosis association (NANDA)

    Hierarchy
  167. Nursing DX in Pharmacotherapy
    -acute confusion, related to drug effects

    -Deficient fluid volume, related to drug effects

    -Excess Fluid volume, related to drug effects

    -risk for injury, related to drug effects

    -deficient knowledge, related to new drug therapy

    -ineffective health maintenance, related to knowledge deficit
  168. Planning
    prioritizes diagnosis

    formulates desired outcomes

    selects nursing intervention (evidenced based)

    evaluation criteria

    determine if goal is met
  169. Implementation
    puts plan into action

    achieve goals

    patient achieves optimal wellness
  170. evaluation
    -compare current health status with desired outcome

    -determine if goal/outcome achieved

    -does plan/intertvention require revision
  171. geriatric pharmacology issues
    poly pharmacy

    drug interactions

    multiple medications - comorbidities

    multiple pharmacies

    otc drugs
  172. geriatric pharmacology issues

    "Physiological changes"

    -GI Absorption
    GI absorption:

    slows, usually complete

    decreased GI motility

    decreased blood flow to/from GI tract

    increased gastric PH
  173. geriatric pharmacology issues

    "Physiological changes"

    -Distribution
    decrease in total body water for dilution

    -increased fat storage in elderly lowers plasma/increases tissue levels

    -reduced plasma protein levels + higher plasma levels
  174. geriatric pharmacology issues

    "Physiological changes"

    -Metabolism (decreases)
    reduced hepatic function

    decreased liver mass

    diminished liver blood flow

    altered activity of some hepatic enzymes

    extended duration of action of drugs
  175. geriatric pharmacology issues

    "Physiological changes"

    -excretion (decreases)
    mainly by kidney

    decreased receptors in kidney

    check creatinine/creatinine clearance
  176. Drug adherence issues
    -no more symptoms 36%

    -Financial 35%

    -Belief of non-effective 33%

    -Dont believe needed 33%

    -Side/Adverse effects 23%

    -Prevented from doing other things wanted 25%
  177. Health Teaching with the older adult
    -if needed, make sure patients eyeglasses clean and hearing aids in working order

    -Speak in tone of voice thay can hear

    -use large print and bright colors for teaching aides

    -label with instructions

    -use schedule dosing calendar

    -document new signs of confusion-engage family

    -review all medications on every new encounter with pt

    -follow-up calls

    -report adverse signs
  178. culture
    -"socially transmitted knowledge of values, beliefs, norms, and lifeways of a particular group that guides their thoughts and behaviours"
  179. Transcultural Nursing
    -comparative study of cultures to understand similarities and differences across human groups
  180. cultural competence
    cultural awareness

    cultural knowledge

    cultural skills

    cultural encounters

    cultural desire
  181. Transcultural Considerations
    -racial and genetic -genetic polymorphism

    pharmacokinetics

    efficacy

    adherence

    high risk behaviors
  182. Transcultural Considerations

    "Assessment"
    -ethnocultural and racial background

    -time away from country of origin

    -travel history and language ability

    -travel history and language ability

    -nonverbal communication practices

    -preferred foods and preparation

    -health, illness/disease practices

    -traditional and folk health practices
  183. Transcultural Considerations

    "Nursing Diagnosis"
    -Planning

    -develop culturally congruent dietary plan so client understands dietary practices related to drug interactions

    -interventions

    -involve family in teaching about pharmacotherapeutics

    -provide explanations for all Rx and OTC products at level appropriate to client/family

    -provide written instruction in client's preferred language

    evaluation
  184. Nursing Decision and action modes
    -cultural care preservation maintenance

    -cultural care accomodation or negotiation

    -Cultural care repatterning or restructuring
  185. major subdivisions of the nervous system
    • -CNS- central nervous system
    • Brian
    • Spinal cord

    -Periphreal Nervous System

    nerves that carry messages to and from CNS
  186. Periphreal Nervous System (PNS)
    -carries nerve impulses to the central nervous system to rest of body

    -neuron in PNS are motor and sensory

    -Sensory: recognize changes to environment

    _motor: respond to changes by moving muscles, respond to changes by secreting chemicals
  187. Motor division has two components
    -somatic nervous system

    -autonomic nervous system
  188. somatic component
    nerves that provide voluntary control of skeletal muscle
  189. Autonomic component
    -provide involuntary control of vital functions of systems

    cardiovascular

    digestive

    respiratory

    GU

    -controls vital life activities without our awareness

    -Contraction of smooth muscle of bronchi, blood vessels, GI tract, eye, GU tract

    -contraction of cardiac muscle

    -Secretion of salivary, sweat, and gastric glands
  190. Autonomic nervous ystem
    -divided into two mostly opposing component branches

    sympathetic

    parasympathetic
  191. sympathetic nervous system
    -activated under emergency condition/stress

    -fight or flight response to threat

    -brain increases alertness/readiness

    -heart rate and bp increase

    -renin release from kidneys

    -blood shunted to skeletal muscle for activity

    -liver produces more glucose for energy

    -bronchi dilate, breathing faster/deeper

    -pupils dilate

    -body warms/perspiration increases

    -constriction of arterioles

    -control adrenal medulla and sweat glands

    -release of renin by kidneys (increase bp)

    -mobilizes lipids for energy

    -peristalsis and urine formation temporarily suspended

    -always some degree present- autonomic tone

    -effects last longer than those of parasympathetic
  192. parasympathetic nervous system
    -activated in non-stressful situation

    -produces "rest and digest response

    -promote relaxation/body maintenance activities

    digestion increases

    peristalsis increases promoting defication

    heart rate/bp decline

    bronchi constrict/respirations slow

    pupil constricts

    salivation stimulated constricts breathing

    erection of penis
  193. transmission of information throughout nervous system
    -neurons communicate with each other, muscles, glands

    -autonomic nervous system

    -preganglion neuron originates in CNS

    -connects with nerve outside CNS-ganglia

    -Ganglia- neuron cell body waiting to receive action potential

    -impulse crosses synapse

    -crosses synapse with chemicals- neurotransmitters

    -postganglionic neuron terminates on smooth muscle, gland @ specialized synapse called neuroeffector junction

    -conveys message to muscle/gland
  194. synaptic transmission of impulse
    -preganglionic neuron originates in CNS

    -connects with second nerve outside CNS in ganglia (mass of nerve cell bodies)

    -information communicatd from nerves to muscles or glands

    -message crosses synapse (space between two neurons)

    -message uses neurotransmitters (chemicals) to travel from one cell to the other

    -neurotransmitters enters synaptic cleft so impulse can cross over

    -second neuron (postganglionic) terminates on smooth or cardiac muscle or gland @ neuroeffector junction

    -the more neurotransmitters released into synapse=greater/longer lasting response
  195. many drugs affect autonomic function by altering neurotransmitter activity
    -directly activate a muscle or gland

    -stimulate actions/release of natural neurotransmitters

    -meds act at:

    preganglionic neuron

    ganglia @ synapse

    postganglionic neuron at target tissue

    -block actions/release/binding/storage/re-uptake of natural neurotransmitters
  196. primary neurotransmitters of ANS
    -Acetylcholine (Ach)

    -Norepinephrine (NE)
  197. Acetylcholine
    -neurotransmitters released at cholinergic receptors

    -neurons released ACH called cholinergic nerves

    -located on postganglionic or neuroeffector cell membranes

    -cholinergic receptors bind ACH to continue impulses @ ganglia or cause autonomic action @ neuroeffector tissue

    -2 types of cholinergic receptors that bind ACH

    Nicotinic

    Muscarinic
  198. nicotinic receptors
    -located @ preganglionic neurons ending in ganglia in sympathetic (fight or flight) and parasympathetic nervous systems (rest and digest)

    -actions resmble those of nicotine

    -found in skeletal muscle

    -controlled by somatic nervous system and adrenal medulla

    -produce profound effects on ANS and somatic nervous system

    -Activation of ACH nicotinic receptors causes stimulation

    tachycardia

    HTN

    >tone/motility in digestive tract

    -enhances nerve conduction at ganlia

    -used to promote skeletal muscle relaxation during surgical procedures
  199. muscarinic receptors
    -located postganglionic neurons ending in neuroeffector target tissues in parasympathetic nervous system

    -actions resembles those of poisonous mushroom

    -found in most sweat glands and blood vessels serving skeletal muscles

    -when ach binds to muscarinic receptors=stimulating or inhibiting depending on target tissue

    decreased HR

    Increased peristalsis

    -used to block muscarinic receptors during opthalmic procedures, preanesthetic agents, asthma, bradycardia
  200. termination of acetylcholine Action
    -removed from synaptic cleft after effect produced

    -Acetylcholinesterase (Ach)

    AchE

    found at synaptic cleft

    -pseudocholinesterase (plasma cholinesterase)

    destroys Ach

    found in liver

    may have genetic deficiency-unable to inactivate plasma Ach or succinylcholine
  201. norepinephrine
    -primary neurotransmitter released at adrenergic receptors (postganglionic sympathetic nerves/synaptic =adrenergic *think adrenaline)

    in sympathetic nervous system (fight or flight)

    -its a catecholamine that helps neurotransmission

    -inactivated by reuptake which is slower than

    -endogenous hormone

    -adrenergic receptors are either alpha 1,2 or beta 1,2
  202. Adrenergic receptors
    -stimulation causes:

    -enzymes on inside of plasma membrane to activate

    -changes occur within cell

    -changes due to messenger, G-protein production initiating cascade

    -Alpha 1 receptors stimulation

    -receptors release intrcellular calcium stores, cause excitatory effects

    -smooth muscle contraction

    -sphincter closure

    -used for effects on vascular smooth muscle e.g. tx of HTN
  203. Alpha 2 receptor
    -cause mostly inhibitory actions

    -stimulation causes:

    inhibit norepinephrine (NE) release from sympathetic nerve endings

    -suppress outflow of sympathetic activity from brain

    -used to decrease blood pressure due to effects on CNS vs ANS
  204. beta-adrenergic receptors
    -act by increasing second messenger, cyclic adenosine monophosphate (cAMP) in target cells

    -beta 1 receptors

    primary tissues served = heart, coronary vessels

    stimulation causes "fight or flight reaction"

    increase heart rate

    increases heart strength of contraction

    dilation coronary arteries

    kidney release renin to maintain BP
  205. beta 2 receptors
    -located in smooth muscle in blood vessels, GI tract, lung

    -Stimulation causes:

    inhibit vasoconstriction= vasodilation

    dilate bronchioles

    slow peristalsis

    decreased urine production
  206. Termination of norepinephrine Action
    -50-80% of NE taken back into pregaglionic nerve-reuptake

    -repackaged for future use

    -destroyed portion by monoamine oxidase (MAO) enzyme

    -NE in circulation destroyed by Catechol-O-methyltransferase (COMT) enzyme in kidney/liver cells

    -slower inactivation via reuptake vs enzyme destruction of Ach
  207. Adrenal Medulla
    -specialed type of sympathetic nervous system tissue

    -preganglionic neurons from spinal cord terminate in adrenal medulla

    -neurons secrete epinephrine and norephhrine directly into blood

    effects last longer as directly secreted into blood

    -distributed to most body cells, not just those inervated by ANS

    -Deactivated by liver

    -25-50% of all sympathetic nervous system responses due to adrenal medulla circulation of hormones
  208. cholinergic receptors

    (release ach)
    -located throughout periphreal nervous system

    -in autonomic system

    -at neuroeffector junctions in parasympathetic divisions

    -at ganglia in parasympathetic and sympathetic divisions

    -in somatic nervous system

    -at neuromuscular synapses responsible for skeletal muscle contraction

    -cholinergic synpases present throughout central nervous system
  209. Ach degree of activation
    -dependent an amount of acetylcholine (Ach) interacting with cholinergic receptors
  210. Drugs and chemicals increasing action of Ach @ cholinergic receptors
    cholinergic agonists/parasympathomimetics

    -promote rest and digest responseincrease the action of Ach @ cholinergic receptors

    -mimic the parasympathetic neurotransmitter Ach
  211. cholinergic agonist drugs can be
    -direct acting

    -drug releases more Ach into synapse or binds directly to Ach receptor

    - indirect acting

    -drug blocks destruction of Ach allowing more to remain in synapse
  212. Types of cholinergic receptors
    -muscarine and nicotinic

    -Ach stimulates both types but drugs may be selective for one or the other
  213. Cholinergic Muscarinic Agonists
    -directly stimulate cholinergic receptors @ neuroeffector junctions in parasympathetic nervous system

    -Actions:

    -increase smooth muscle tone and contractions

    -iris contraction producing pupil constriction (miosis)

    -contraction of ciliary muscle- allows fluid to drain from anterior chamber

    -reducing intaocular pressure pre-op for acute angle closure glaucoma

    -pilocarpine to treat open angle glaucoma
  214. Cholinergic Muscarinic Agonists
    -increased GI motility (tone/contractions)

    -stimulate smooth muscle of urinary tract-promote emptying

    -increased gladular secretion (salivary,lacrimal,sweat,digestive) (treat xerostomia0dry mouth) in sjogrens syndrome

    -constriction bronchial smooth muscle (airways narrow) contraindicated with asthma

    -decrease heart rate /BP

    -may cause reflex tachycardia from receptors in cartotid arteries and aortic arch


    -may cause atrial fibrillation in pts with hyperthyroidism

    -contraindicated in serious heart disease

    -poorly absorbed by GI tract, generally dont cross blood brain barrier
  215. Urecholine/Bethanechol Chloride

    "USE"
    -stimulats smooth muscle contraction post general anesthesia- restore peristalsis

    -relaxes sphincter, bladder muscle to contract for urinary retention
  216. Urecholine/BethanecholChloride

    "Action"
    -Parasympathomimetic; Muscarinic agonist (direct acting)
  217. Urecholine/BethanecholChloride

    "adverse reactions"
    -parasympathetic actions

    -increased salivation

    abd cramping

    sweating

    flushing of skin

    miosis (pupil constriction)

    blurred vision

    N/V

    low p/bp

    reflex tachycardia

    complete hearty block

    acute bronchospasm
  218. Urecholine/BethanecholChloride

    "contraindications"
    -suspected bowel obstruction (increased contraction)

    -recent GI surgery (excessive GI Contraction)

    -Active ulcer or inflammatory disease

    -severe bradycardia, hypotension, (slows HR)

    -COPD, asthma (bronchoconstriction)

    -Hyperthyroid (dysrhythmias)

    -Cystitus- force up kidneys if bladder sphincter doesnt open
  219. Urecholine/BethanecholChloride

    "Drug interactions"
    -do not take with AchE inhibitors-overstimulation of muscarinic receptors

    -ganglionic blockers = rapid fall in BP
  220. Urecholine/BethanecholChloride

    "Nursing Considerations"
    -Montior BP and pulse, respirsatory status

    -Assess urine output (renal excretion)

    -obtain thorough PMH
  221. Acetylcholinesterase Inhibitors (indirect-acting)

    "Action"
    -works to inhibit action AchE

    -Allows Ach to remain on cholinergic receptors longer, prolonging its action

    -nonselective- affect all Ach synapses
  222. Acetylcholinesterase Inhibitors (indirect-acting)

    "Indications"
    -Alzheimer's disease (mild/mod)- Improves memory and cognition

    -Glaucoma - contract iris sphincter/ciliary muscle to decrease intraocular pressure

    -Prophylaxis of nerve gas poisoning-cover active site of AchE so toxic agent counldnt bind to enzyme

    -Myasthenina gravis- increase strength of muscular contraction
  223. Cholinergic Crisis

    overdose with acethycholinesterase (AchE) inhibitors

    "signs and symptoms"
    -intense parasympathetic stimulation

    miosis

    Nausea and vomitting

    urinary incontinence

    abdominal cramping

    -Progression= sympathetic and nicotinic stimulation: muscle twittching, progressive muscle weakness, hyperglycemia

    -Antidote: Atropine reverses muscarinic effects
  224. Myasthenia Gravis (MG)

    "description"
    -An autoimmune disorder caused by antibodies attack on nicotinic synapses on skeletal muscle

    -muscular weakness and fatigue

    -respiratory muscle paralysis/double vision

    -ptosis (eyelid drooping) /inability to open eyes

    -difficulty chewing or swallowing
  225. Myasthenia Gravis (MG)

    "Treatment"
    -intensive AchE inhibitor therapy (pyridostigmine)

    -Corticosteroids- reduce AchE receptor antibody levels
  226. Myasthenia Gravis (MG) Crisis
    -Generalized muscle weakness that can involve muscles of respirtation including diaphragm

    -tx with AchE inhibitor therapy (Neostigmine)
  227. Cholinergic Drugs

    "Action"
    -stimulates the parasympathetic nervous system

    -also called parasympathomemetics

    -Agonist that help increase Acetylcholine neurotransmitter
  228. Cholinergic Drugs

    "function"
    -mimic effects of acetylcholine usually at muscarinic receptors

    -stimulates the cell to produce a response-tone, strength, and secretions
  229. Cholinergic Drugs

    "Effects"
    -increases tone and motility of GI

    -Contracts urinary bladder

    -Increases pupillary constriction- myosis

    -Maintain muscle strength and tone
  230. Cholinergic Nicotinic Agonists
    -receptors located in autonomic ganglia

    -synapse with neurons leading to skeletal muscles (nicotinic receptors ) and those leading to effector organs (muscarininc receptors)

    -can produce widespread, nonselective effects on body

    -stimulates parasympathetic and sympathetic responses

    -Actions:

    CNS alertness

    stimulation of emetic center in CNS (nausea)

    increased heart rate

    increased BP
  231. Nicotinic Agonists
    -only drug widespread use is nocotine-replacement therapy (nicorette, NicoDerm)

    -Example: Smoking cessation Products

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