pharm 1301

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pharm 1301
2012-10-01 16:45:49

basic, ANS, and CNS
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  1. Classification of Drugs
    • –Therapeutic  Classification: describes what is being
    • treated by the drug

    • –Pharmacologic
    • Classification: describes how the drug acts
  2. 1906  Federal Food & Drug Act 
      Label must declare presence of dangerous and possibly addicting drugs and designated designated The United States Pharmacopeia (USP) and National Formulary (NF) as    official standards for therapeutic use, patient safety, quality, purity, strength, package    safety, and dosage form.
  3. Sherley Amendment to Food and Drug Act 
    prohibits fraudulent therapeutic claims
  4. Harrison Narcotic Act
    established legal term “narcotic”
  5. 1938 Revision of Food and Drug Act 
    significant as established mandatory testing for safety prior to marketing
  6. 1951 Durham-Humphrey
    Amendment of Food & Drug Act
    • established “legend” drugs ( must be prescribed) versus  OTC and 
    • also specified that narcotics, etc 
    • not be refilled without a new prescription.
  7. 1962  Kefauver-Harris Amendment 
    •  required that both safety & efficacy be proved prior to marketing
    • new drug
  8. 1970 Controlled
    Substance Act 
    • established schedules
    • of drugs according to abuse potential (C-1 
    • high; C-V low)
  9. drug schedules
    –Patient name

    –Date order is written

    –Name of medication

    • –Dosage (size, frequency, &
    • duration of order)

    –Route (p.o., IM, IV, etc)

    –Signature of prescriber
  11. documenting drug administration
    –Pain medication requires documentation 1-2 hours after the dose. 
  12. ¨NONPARENTERAL drug routes
    • – Tablets and
    • Capsules

    • –Sublingual
    • and Buccal

    –Nasogastric and gastrostomy

    • –Topical
    • medications-skin




  13. PARENTERAL drug routes



  14. Pharmaceutics
    •  study of how various dosage “forms” influence
    • pharmacokinetic and pharmacodynamics properties of drugs
  15. Pharmacokinetics
    • : study of what the
    • body does to the drug
  16. Pharmacodynamics: 
     study of what the drug does to the body 
  17. ¨PHARMACOKINETICS: (four phases)



  18. :  “Onset” 
    when does drug start to work
  19. “Peak” 
    when is drugmost effective
  20. “Duration” 
    how longdoes drug effect last
  21. Simplediffusion or passive transport
    •  the movement of a chemical from an area of
    • higher concentration to an area of lower concentration.
  22. –Active
     drugs cross membranes against their gradient, from low concentrationto high concentration, and this requires energy on the part of the cell and acarrier protein (pumps).
    • rate drug is absorbed form site of administration and extent to which it occurs
    • –Routes of administration
    • –Drug concentration and dose
    • •Bioavailibility expresses the “quantity” extent
    • of drug absorption.
    • –GI tract environment
    • –Blood flow to the absopriton site
    • –Drug ionization
    • –Drug interctions 
    • –Surface area
  24. phases of drug activity
  25.  the “first-pass effect
    • –Metabolism in the liver and
    • return to circulation 
    • ¨Absorption occurs through gastric mucosa, small
    • intestine, or rectum, and passes through the portal circulation into the liver
  26. absoprtion routes


    • –Sublingual, buccal, vaginal and IV routes BYPASS
    • the LIVER and go directly to site of action (NO FIRST-PASS EFFECT)

    • –Parenteral IM< IV SUBQ-IV fastest then
    • IM and finally subq; depends upon blood flow (heat
    • will increase) Suspensions are slower to absorb (Bicillin)
  27. Percutaneous-
    ¨ application to body surfaces;

    –Skin eyes, ears, nose and Lungs

    Gels, creams inhalers, drops ect.

    • Bypasses the “first-pass” effect
    • by direct target effect

    • Transdermal –examples: estrogen,
    • nitroglycerin

    • Inhalation- respiratory drugs,
    • includes steroids
     transportation of drug by bloodstream.

    –Blood flow to tissues:

    • •Drugs distribute to highly
    • vascular areas first: heart, liver, kidneys, and brain and muscle, skin and fat
    • last

    • •Bone has poor blood supply and
    • the brain has a barrier that prevents distribution this meningitis and osteomyelitis are difficult to treat

    –Drug solubility

    –Tissue storage

    –Special barriers to drug distribution

    –Drug-protein binding
  29. ¨METABOLISM(biotransformation): 
    results in transformation of drug into:–Inactive metabolite–More soluble compound–Or more potent metabolite¨Liver is the organ most responsible forbiotransformation, but skeletal muscle, kidney, lungs, blood plasma &intestinal mucosa also cause biotransformation
  30. ¨ EXCRETION:
    –Elimination of drug from the body–Kidney is primary organ ofexcretion–Two other organs playing animportant role in excretion are:  liver  & bowel (fecal & biliary)–Pulmonaryexcretion–Glandularsecretion: breast milk
  31. –Therapeutic range:
    • in this range, the drug produces a therapeutic effect
    • –Toxic concentration: a higher
    • dose level of drug that results in serious adverse effects.
  32. –Side Effects:  
    predictable, adverse drug reactions
  33. ¨Half-life: 
    time it takes for one half of the original amount of drug taken to beremoved from body.–Shorthalf-life–Longhalf-life¨Rule of Thumb: when a drug isdiscontinued it takes approximately four half-levels before the agent isconsidered ‘Functionally” eliminated. (94% is eliminated)
  34. ¨Steady state: 
    with regard to bloodlevels of a drug refers to the physiologic state in which the amount of drugremoved via elimination is equal to the amount of drug absorbed with each dose
  35. ¨Loading
    is a higher amount of drug, often given only once or twice to “prime” thebloodstream with a level sufficient to quickly induce a therapeutic response.
  36. ¨Maintenance
    before plasma levels drop back toward zero, intermittent doses are given tokeep the plasma drug concentration in the therapeutic range
    mechanism ofdrug action in living tissue
  38. therapeutic effect of drug
    –Drug-induced change in normalphysiologic function.  A positive changein faulty physiologic system

    • Mechanism of
    • Action”:  (therapeutic effect) produced
    • in several ways:  Receptor Interaction,
    • Enzyme Interaction,  Nonspecific
    • Interaction
  39. –Therapeutic index: 
    describes adrug’s margin of safety. TherapeuticIndex: the ratioof a drug’s toxic level to the level that provides therapeutic effects.
  40. –Mechanism of action:              

    selective joining of drugmolecule with reactive site on cell surface- “affinity”–Agonists–Antagonists–Agonist-antagonists
  41. –Peak level:
     the  highest blood level of a drug
  42. –Trough level:
     thelowest blood level of a drug
  43. ¨Side effects:
    –Arepredictable and which may occur even at therapeutic doses–Side effectsare less serious than adverse effects–Differencebetween side effect and adverse effect? Severity of symptoms (HA)
  44. Prevent an adverse event? (the nurse would check/do) 
    • –Medical
    • history

    • –Assess the
    • patient and lab data

    • –Prevent med
    • error

    • –Monitor
    • pharmacotherapy carefully

    • –Know the
    • drugs

    • –Be prepared
    • for the unusual

    • –Question
    • unusual orders

    • –Teach
    • patients about adverse effects
  45. ¨Idiosyncratic reactions:
     not a result of a know pharmacologic property ofdrug (G6PD deficiency)
  46. ¨Teratogenic Effect: 
    causes structural defects in unborn fetus
  47. ¨Mutagenic Effect: 
    permanent changes in genetic composition ofliving organism
  48. ¨Carcinogenic Effect: 
    can cause cancer particularly when taken overextended period of time. 
  49. –Nephrotoxicity: 
    patientswith serious renal impairment should not receive nephrotoxic drugs
  50. –Neurotoxicity:
    S/S of neurotoxicity include depression, mania, sedation, behavioral changes,hallucinations, and seizures
  51. –Muscle
    the incidence of drug-induced myopathy is low butmay be serious when it does occur
  52. ¨Hepatotoxicity: 
    liver detoxify foreignchemicals that enter the body and the effects can be minor to major. It isimportant to check the liver enzymes and monitor the patient for s/s of liverproblems
  53. ¨Dermatologic toxicity:
     druginduced rash urticaria, angioedema Steven Johnson syndrome
  54. ¨Bone marrow toxicity:
     these canbe serious and fatal outcomes
  55. ¨Drug Interactions:
    • –When action of one drug is altered by a second drug
    • •Incompatibility 
  56. •ADDITIVE:  
    two drugs with similar effect given togetherso each can be given in smaller doses.
    effect greater than that of each given individually 
     effect is less than that drug would achieveseparately
  59. Drug Interactions
    ¨Food, nutrients and dietary supplements may interact with medications and affect their actions

    ¨Grapefruit juice and enzyme CYP3A4: can last up to 3 days after drinking the juice.

    ¨In most cases with other food-drug interactions there should be a 2-hour time gap between ingestion of the food and drug.

    • ¨Dietary Supplements:
    • –St.John’s wort 
    • –Ginkgo Biloba
  60. ¨Factors that contribute to
    medication errors- the 5 rights
    –Right dose

    • –Right
    • medication

    –Right patient

    • –Right route
    • of administration

    • –Right time of
    • delivery
  61. nursing process: remember AD PIE
    • Assessment
    • nursing Diagnosis- (never use a medical Dx)
    • Planning
    • Implementation
    • Evaluation
    collection of subjective and objectivedata on the patient & environment.–Tools used to collect: drughistory, physical assessment, review of chart, patient & family interview.•Must include use ofover-the-counter (OTC) medications, alcohol, past & present health history,& family history, health beliefs, socioeconomic status, educationlevel/cog- nitive ability, religious belief. 
  63. examples of nursing Dx
    • ¨From your assessment you develop a Nursing Diagnosis. 
    • Common ones for drug therapy would include:
    • –Knowledge deficit ( need to learn)
    • –Ineffective management of therapeutic regimen (why? Financial, knowledge, forgetful, etc)
    • –Impaired memory (elderly, or very ill)
  64. ¨PLANNING: 
    –Prioritize nursing diagnoses–Gather information (teaching specifics, etc)–Identification and statement of goals and outcomecriteria.•Goal Ex.: Prior to discharge patient willdemonstrate ability to take prescribed medication in a safe manner.• Outcome Ex.: Prior to discharge patient will be able to identify which medicationshould not be taken with food.
  65. –Administer Medication Using 5 Rights:
    what is the 6th right?
    • •Right drug
    • •Right dose
    • •Right time
    • •Right route
    • •Right patient
    • •Most include “6th Right –“Documentation”
    • –Patient DrugTherapy Education –First determine you patients“readiness” to learn–Second determine “learning needs”–Third determine “what can theylearn”–To do this you need a thoroughassessment of the patient.
    • –Set goals with client/family

    • –Implement according to assessment
    • findings (cognitive/sensory ability)

    • •Involve family in teaching for
    • reinforcement

    •Use A/V aids when able

    • •Document all teaching and
    • evaluation of the session

    • –Much teaching takes place at
    • discharge but should begin on admission.
    –Monitoring patient response (expected andunexpected) to implemented plan of care.–Has the therapeutic effects of the drug beenprevented or kept to acceptable levels?–Was there an improvement over the baseline data?–Determines degree of attainment of Goals andOutcome Criteria.
  68. ¨Age groups with special consideration are:  
    pediatrics (birth to @ 13 yrs) and geriatrics( post 65 yrs) 
  69. ¨Pregnancy Drug Safety Categories
    – A     Studies indicate no risk to human fetus– B     Studies indicate no risk ot “animal” fetus– C     Adverse effects in animal fetus reported                (no information available onhuman)– D    Possible human fetal risk reported  (consider benefit to risk before use)– X   Fetal abnormalities reported; positive risk   to human fetus is available.   Should not   beused in pregnant women. 
  70. ¨Neonatal &
    Pediatric considerations
    • –Neonate:  less than 1 month old
    • –Infant:     1 month to 1 year
    • –Child:      1 year to 12 years
  71. ¨Geriatric Considerations
    • –Experience decline in organfunction (GI, Liver, Kidney, Heart) ( note similarity to peds)–Polypharmacy: (13% of population consumes 30% of prescription & > 40% ofOver-the-counter (OTC) drugs    (Greaterrisk of drug to drug interaction)
    • –Important to monitor lab values
    • (liver enzymes, kidney function most important)

    –Decreased protein binding sites

    • –Increase in body Fat content
    • mainly due to decrease in body muscle mass.

    • –Total Body Water is significantly
    • decreased

    • –Fat soluble drug will have
    • prolonged effect
  72. physiologic changes in the geriatric Pt.
  73. the parts of the brain that control body functions
  74. the nervous system
  75. •Efferent Nerves
     (control contractions of smooth &skeletal muscle, and some glandular secretions)
  76. •Motor/Somatic Nervous system
     (skeletal muscle)
  77. •Autonomic nervous system
  78. parasympathetic and sympathetic division
  79. types of receptors
  80. •Nerve
    the A&P 
  81. •Autonomic Nervous System
    –Controls the functionof most tissues, except skeletal muscle–Maintains a constant,internal/environment (homeostasis)–Responds to emergencysituations
  82. ANS
    •Norepinephrine: (NE, epinephrine, dopamine

    • •Neurotransmitter secreted by adrenergic fibers (inc
    • heart rate: pupillary dilation);

    • •Adrenergic or sympathomimetic drugs produce same effect
    • in body;

    • •Adrenergic-blocking agents- block or inhibit adrenergic
    • system/activity
  83. ANS: •Acetycholine: (Ach)
    • –Neurotransmitter s/b
    • cholinergic fibers (dec. heart rate;
    • pupillary constriction);

    • –Cholinergic or
    • parasympathomimetic drugs produce same effect;

    • –Anticholinergic
    • agents- BLOCK or INHIBIT cholinergic activity
  84. ANS: adrenergic drugs 
    • •Mechanism of action (MOA):
    • •3 types of adrenergic receptors

    • –Alpha:
    • –Alpha 1 : causes vasoconstriction of blood vessels
    • –Alpha 2: negative feedback preventing release of Norepinephrine

    • –Beta: –Beta 1: increase in heart rate
    • –Beta 2: relax smooth muscle in bronchi (bronchodilation): relax uterus: vasodilation

    • –Dopaminergic:
    • –Vasodilation (cerebral, coronary, mesenteric, & renal perfusion
    • –Improves symptoms associated with Parkinson’s disease
  85. ANS: adrenergic drug uses
    • –Many drugs acts on

    • –Each drug acts to
    • varying degrees

    • –Asthma, hypotension,
    • shock, nasal decongestant

  86. ANS: adrenergic agonists
  87. ANS: adrenergic agonists cont.
  88. precaution for administering epinephrine
  89. proper use of the epipen
  90. ANS: adrenergic drugs
    • •AVAILABILITY: IV/IM/SQ/PO aerosol; usuallyimmediate-effect; EX: albuterol, epinephrine, isoproterenol, pseudoephedrine,dopamine, dobutamine
    • •Side effects (S/E): palpitations; tachycardia; skin
    • flushing ; dizziness; tremors; orthostatic hypotension
    • •ADVERSE EFFECTS (A/E): arrhythmias; chest pain; severe hypotension; hypertension, anginal pain; n/v
    • •Drug Interactions:

    • –Increase effect:
    • Monoamine Oxidase inhibitors
    • (metabolized by monoamine oxidase); tricyclic antidepressants (vasopressor effects); atropine

    • –Decrease effect:
    • beta-adrenergic blocking agents/alpha-adrenergic blocking agents (antihypertensives)
  91. ANS: adrenergic drugs cont.
    • •Nursing implications: baseline vitals- HR/ BP ( take BP
    • supine, sitting, standing), arise slowly

    •S/E dose related- decease dose or d/c meds by physician

    • •Assess for hepatic function, thyroid disease,
    • hypertension, heart disease, DM

    •Consult physician prior to d/c

    • •Use nasal decongestants as ordered;  with increase/ inappropriate use- rebound
    • effect
    • •Mechanism of action (MOA): work opposite of adrenergic agents: INHIBIT/BLOCK stimulation
    • •Uses: ALPHA BLOCKING: vasoconstrictive type of disorders (Raynaud’s phenomenon)
    • –BETA BLOCKING: hypertension; angina, cardiac arrhythmias
    • •Available: PO/IV/IM: increase dose slowly: decrease dose
    • to adjust
    • •A/E: bradycardia, peripheral vasoconstriction, bronchospasm; DM- hypoglycemia; heart failure
    • •Drug Interactions:
    • –Increase effect- anthihypertensive meds: lidocaine/ digitalis
    • –Decrease effect= beta adrenergic agents; enzyme-inducing agent; indomethqacin/salicylates
    • •Nursing Implications: beta-blockers used with caution in
    • patients with respiratory conditions, DM, heart failure;
    • •Monitor Heart rate and blood pressure
    • •DO NOT STOP ABRUPTLY; gradually reduce the dose
    • •Mechanism of action: actions of acetylcholine (decrease
    • heart rate; increases GI motility & secretions)
    • –Direct-acting-stimulate parasympathetic NS
    • –Indirect-acting-inhibit acetylcholinesterate 
    • –Nicontinic/muscarinic receptors: 
    • •“REST & DIGESTS”
    •  •SLUDGE
  94. types of cholinergic receptors and their actions
    • •Uses: mysathenia gravis: reverse muscle relaxants; reverse toxicity of
    • anticholinergic agents; disorders of the eye ( decrease intraocular pressure)

    •Avaiable: PO/ INJ/ DROPS:

    • –Bethanechol, pilocarpine, neostigmine
    • •Side effects: dose –related; N/V/D abdominal cramps;
    • dizziness;  hypotension

    • •Adverse effects: BRONCHOSPASM, wheezing,
    • bradycardia—STOP MEDS!!!

    • •Drug Interactions: atropine/antihistamines- antagonizing
    • effect

    • •Nursing Implications: cholinergic fibers innervate
    • entire body; monitor HR, BP; rise slowly; leg exercises
    • •Mechanism of action: block action of acetylcholine:
    • increase IOP of eye; tachycardia; decrease secretions

    • •Uses: GI/ ophthalmic disorders; bradycardia; Parkinson’s
    • disease; GU disorders; Preop drying agent;
    • placing endotracheal tube

    •Available: INJ/PO

    • •Atropine, scopolamine, Ipratropium, Robinul
    • •Side Effects: blurred vision; constipation, urinary
    • retention: dryness of mucus membranes

    • •Adverse effects: confusion, depression; nightmares;
    • hallucination; orthostatic hypotension- decrease dose; palpitations;
    • arrhythmias, glaucoma— STOP MEDS
    • •Drug Interactions: increase effect- amantadine (Symmetrel); tricyclic antidepressants; phenothiazines

    •Nursing Implications:

    • –Not used with
    • closed-angle glaucoma; enlarged prostate;

    –Assess neuro/ cognitive status
  97. indications for autonomic agents
  98. beneficial effects of  CNS drugs are:
    • -reduction in anxiety
    • -improved sleep patterns
    • -elevated mood
    • -management of psychotic symptoms
    • -slowing the progression of chronic degenerative diseases of the brain
    • -termination and prevention of seizures
    • -reduction in muscle spasms and spasticity
    • -reduction of hyperactivity and mania
    • -reduction of pain
    • -induction of anesthesia
  99. CNS: cerebrum
    • the "thinking" part of the brain
    • for perception, speech, conscious motor movement, movement of skeletal muscles, memory, and smell

    • occipital lobe- vision
    • frontal- reasoning and planning
    • others- language, hearing, motor or sensory functions
  100. CNS: thalamus
    sensory information: sounds, sights, pain, touch, and temperature to cerebral cortex

    disorders of thalamus: OCD, bipolar, anxiety, and panic disorder
  101. CNS: hypothalamus
    • -regulation of hunger, thirst, water, balance, and body temperature
    • -also limbic system: emotional expression, learning, and memory
    • - connect to brain stem: heart rate, respiratory rate, blood pressure, and pupil size(ANS response)
  102. CNS: cerebellum
    muscle movement, balance, posture, tone
  103. CNS: brainstem
    • -consist of medulla oblongata, pons, and midbrain
    • - breathing, heart rate, vision, swallowing, coughing, and vomiting
  104. CNS: spinal cord
    sensory and motor function
  105. CNS: blood-brain barrier
    oxygen and glucose to brain
  106. CNS: reticular activating system
    • -from the brainstem to thalamus
    • -sleeping and wakefulness and performs an alerting function
  107. CNS: basal nuclei (basal ganglia) 
    skeletal muscle movement
  108. CNS: extrapyramidal system
    -controls locomotion, complex muscular movements, and posture