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NUR 326 Week 1 Notes

by: Emily

NUR 326 Week 1 Notes NUR 326


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About this Document

These notes cover Chapters 1, 2, 3, 4, 5, and 9
Amy Beasley
Class Notes
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This 15 page Class Notes was uploaded by Emily on Monday September 12, 2016. The Class Notes belongs to NUR 326 at University of Alabama - Tuscaloosa taught by Amy Beasley in Fall 2016. Since its upload, it has received 2 views. For similar materials see Pharmacology in NURSING at University of Alabama - Tuscaloosa.


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Date Created: 09/12/16
Chapter 1 Learning objectives - Paraphrase the properties of an ideal drug. - Examine the nurse’s role as advocate in regards to pharmacology in nursing practice. - Describe the process for new drug development. - Compare and contrast a drug’s chemical name, generic name, and trade name. - Outline major differences between prescription and over-the-counter (OTC) drugs. - Explain the applications of pharmacokinetics to clinical practice. - Describe the applications of a drug's onset, peak, and plasma half-life to duration of pharmacotherapy. - Apply principles of pharmacodynamics to nursing practice. - Describe drug receptor bindings and interactions. - Discuss the consequences of drug-drug interactions, the basic mechanisms of drug- drug interactions, and the critical steps in minimizing adverse drug-drug interactions. Basic Terms - See Page 5 (Table 1-1 and 1-2) - A drug is defined as any chemical that can affect living processes. - Virtually all chemicals can be considered drugs then, but we only will focus on drugs that have therapeutic applications. - The therapeutic objective is to provide maximum benefit with minimal harm - Pharmacology is the study of drugs and their interactions with living systems. - This encompasses the study of the physical and chemical properties of drugs, as well as their biochemical and physiologic effects. - Includes knowledge of the history, sources, and uses of drugs, as well as knowledge of drug absorption, distribution, metabolism, and excretion. - Clinical pharmacology refers to the study of drugs in humans, which includes the study of drugs in patients as well as healthy volunteers (during new drug development). - Therapeutics (or, also known as pharmacotherapeutics), is the use of drugs to diagnose, prevent, or treat disease, or to prevent pregnancy. - This is also referred to as the medical use of drugs. - Therapeutics is our main concern, and as nurses, we need to understand: - how drugs produce their effects (both therapeutic and adverse) - The reasons for giving a particular drug to a particular patient - The rationale underlying selection of dosage, route, and schedule of administration - Therapeutic classification is one name used in classifying a medication that is based upon the usefulness in treating particular diseases or disorders. - i.e. anticoagulant (influences blood clotting) 1 - Pharmacologic classification refers to the way a drug works at the molecular, tissue, or body system level. - i.e Diuretic (lowers plasma volume) - Mechanism of action identifies how the drug produces it physiological effect. - i.e. lowers plasm a volume (R/T pharmacologic classification) - Prototype drug is a “drug model” that represents a class of drugs. - i.e lorazepam (Ativan) = benzos Properties of an Ideal Drug - The big three - Effectiveness - An effective drug elicits the responses for which it is given. - If the drug isn’t effective, there is no reason to give it. - US law requires that all new drugs be proved effective prior to their release for marketing. - Safety - A safe drug is one that cannot produce harmful effects, even if administered in very high doses and for a very long time. - All drugs have the ability to cause injury, especially with high doses and prolonged use. - The chances of producing adverse effects can be reduced by proper drug selection and drug dosing, however the risk of adverse effects can never truly be eliminated. - Selectivity - A selective drug is one that elicits only the response for which it is given. - There truly is no wholly selective drug because all drugs cause side effects. - Additional properties - Reversible action - Like an antidote: to reverse the action of a drug - Predictability - What the drug will do based on a clinical trial - Ease of administration - Freedom of drug interactions - To prevent adverse reactions - Low cost - Due to insurance payments and benefits - Chemical stability - Able to be transported in a container - Simple generic name - Recognizability 2 Drug Names - Chemical Name: uses the nomenclature of chemistry to describe its physical and chemical properties - A drug has only one chemical name - Can be complicated, difficult to remember and pronounce - Drugs are sometimes classified by a portion of their chemical structure (chemical group name), which can become invaluable to nurses and students! - Examples: Cephalosporins, phenothiazines, benzodiazepines - Generic Name: is assigned by the U.S. Adopted Name Council - A drug has only one generic name - Less complicated and easier to remember - Written in lower case, Example: diazepam - In many cases, the final syllables of the generic name indicate a drug’s pharmacologic class (see Table 3-4 on page 19). - Trade Name: (also called proprietary or brand name) - The names under which a drug is marketed. These names are created by drug companies with the intention that they be easy for consumers to recall and pronounce. - The drug developer has exclusive rights to name and market a new drug for 17 years in the United States. - After 17 years, competing companies may sell a generic equivalent drug, sometimes using a different name, which the FDA must approve. - A drug may have several trade names - Trade name is capitalized; Example: a trade name for diphenhydramine is Benadryl. - Generic vs. Brand-Name Drugs: Problems with Trade Names 1. A single drug can have multiple trade names 2. Over-the-counter (OTC) products with the same trade name may have different active ingredients 3. Trade names can endanger international travelers Over-the-counter (OTC) Drugs - These are drugs that can be purchased without a prescription - The decision to be made OTC is made by the FDA - Just because a drug is considered available OTC does not necessarily mean the drug is considered “safe” - Advantages to Prescription Drugs: - Health care provider examines the patient and orders the proper drug. - Amount and frequency of drug is controlled. - Instructions on use and side effects of drug are discussed. - Disadvantages to Prescription Drugs: - Require a prescription to obtain - Need for health care provider appointment 3 - Advantages to OTC Drugs: - No health care provider appointment required - Often less expensive than prescription drugs - Disadvantages to OTC Drugs: - Patient may choose wrong drug. - Patient may not know reactions or interactions. - Ineffective treatment may result in progression of disease. Trade-name vs. Generic Equivalents - Unclear determinations to blanket all drugs as equal - Drug formulation variations - Bioavailability - How much of the drug is available to be used by the body Chapter 2 Drug Approval and Regulation - Randomized controlled Trial - An expensive an lengthy process that could require 10-15 years for completion - Rigorous procedures for testing have been established so newly released drugs might be both safe and effective. - Although testing can determine effectiveness, it cannot guarantee that a new - drug will be safe Significant adverse effects may evade detection during testing, only to become apparent after a new drug has been released for general use - Stages of new drug development: - 1. Preclinical Investigation involves laboratory research. Tests are done on animals to determine toxicity, pharmacokinetics, and possible useful effects. - When sufficient data has been gathered, the drug developer may apply to the FDA for permission to begin testing in humans. - If approved, the drug is awarded Investigational New Drug status - 2. and 3. Clinical Investigation takes place in three different stages termed clinical phase trials - This is the longest part of approval process (2-10 years), but evaluates human benefits - Tests are done on healthy volunteers first (Phase I), then on patients with the target disease (Phase II and III) - If results of clinical investigation are positive, even if precautions are noted, a New Drug Application is the next step. The average review time 17–24 months. - If the drug is approved: process continues; if drug is rejected: process suspended - 3. Post-marketing Surveillance: The new drug is placed on market and surveyed for harmful effects in larger population 4 - FDA holds annual public meetings, and will withdraw a drug if serious problem found - Nurses participate most in the drug approval process during the post-marketing surveillance period of Phase IV. All nurses administering medications monitor for therapeutic effects and adverse reactions from the drugs, and are responsible for reporting adverse reactions. - Limitations of the testing procedure - Limited information on women and children Medication Guidelines - Commonly referred to as MedGuides - FDA approved documents - Required when the FDA has determined that (1) patient adherence to directions for drug use is essential for efficacy and (2) patients need to know about potentially serious effects when deciding whether to use a drug - Example: - - These were created to educate patients about how to minimize harm from potentially dangerous drugs Black Box Warning - Strongest safety warning a drug can carry and still remain on the market - Purpose of the warning is to alert prescribers to: - Potentially sever side effects (for example, life-threatening dysrhythmias, suicidality, major fetal harm) - Ways to prevent or reduce harm (for example, avoiding a teratogenic drug during pregnancy) Controlled Substances - The Controlled Substances Act of 1970 (also known as Comprehensive Drug Abuse Prevention and Control Act): - Restricts the use of drugs with potential for abuse - Restricted drugs are placed into one of five schedules - Hospitals and pharmacies must maintain complete records of scheduled drugs. - The DEA is the agency responsible -- along with the Board of Medicine and Nursing in each state -- to regulate who, where, and what can be prescribed by independent licensed healthcare providers. - Hospitals and pharmacies must register with DEA, and must use an assigned registration number to purchase scheduled drugs - Anyone convicted of unlawful manufacturing, distributing, and dispensing of controlled substances faces severe penalties. 5 - A medication’s potential for abuse and misuse determines the level of restriction in number and type of providers who may “order” a medication. - Drugs that have a significant potential for abuse are placed into five categories called schedules. - Schedule I drugs have the highest abuse potential, Schedule V the lowest. - The 2009 death of Michael Jackson called for a greater restriction on the use of the anesthesia agent called propofol (Diprovan). - Schedule I Drugs: - Restricted to situations of medical necessity, if allowed at all - Little or no therapeutic value; mostly used for research - Examples include heroin, LSD, methaqualone - Schedule II-V Drugs: - May be dispersed only in cases where therapeutic value has been determined - Some Schedule V drugs may be dispersed without a prescription. - Schedule II Drugs: - High abuse potential and high potential for physical and psychological dependence - May have a therapeutic use with prescription, although some drugs are no longer used - Have more restrictions: - Need special order form to obtain - Orders must be written. - Orders must be signed by health care provider. - Telephone orders to pharmacies are not permitted. - No refills are permitted; patient must see health care provider first. - Examples include Morphine, PCP, Cocaine, Methadone, Methamphetamine - Schedule III Drugs: - Moderate abuse potential; moderate physical dependence; high potential for psychological dependence 6 - Therapeutic use with prescription - Examples include Anabolic steroids, Codeine with aspirin or Tylenol, Hydrocodone with aspirin or Tylenol, Some barbiturates - Schedule IV Drugs: - Lower abuse potential; lower potential for physical and psychological dependence - Therapeutic use with prescription - Examples include: Dextropropoxyphene, Pentazocine, Meprobamate, Diazepam, Alprazolam - Schedule V Drugs: - Lowest abuse potential, lowest physical and psychological dependence - Therapeutic use without prescription - Examples include OTC cough medicines with codeine - Not all drugs with abuse potential are regulated! - Examples include Tobacco, alcohol, and caffeine Teratogenic Drug Classification - FDA classifies medications by their teratogenic effects to the fetus - Birth defects are most probable in the first trimester - Most medicines are Category C - Teratogenic classifications are found on the drug boxes
 7 Chapter 3 Principles of Drug Administration - Nurses are expected to understand pharmocotherapeutic principles for all medications given to each patient - Six right used as the basis of safe delivery of care medications: - Right patient - Right medication - Right dose - Right route of administration - Right time of delivery - Right documentation - Nurse Responsibilities include: - Know classifications, actions, and side effects of drug - Know patient details and why drug was prescribed - Know how drug is acquired and pharmacy procedures - Know how to prepare and administer drug safely - Before drug is administered, the nurse must know all variables of the patient's condition. - Be prepared to recognize and react to adverse effects - Five Most Common Medication Errors: - Incomplete patient information - Unavailable drug information - Miscommunication of drug orders - Lack of appropriate drug labeling - Environmental distractions - Three Checks of Drug Administration: - Checking the drug with the MAR or the medication information system when pulling it from storage - Checking the drug when preparing it, pouring it, taking it out of the unit-dose container, or connecting the IV tubing to the bag - Checking the drug before administering it to the patient - Despite six rights and three checks, mistakes still occur. Nurses are held accountable for correct administration of drugs, but responsibility also rests on other positions like physician and pharmacist. Routes of Administration - There are multiple ways to administer medications. This is one of your psychomotor tasks you will learn in Fundamentals. - Routes - Enteral - Oral 8 - Parenteral - Subcutaneous injection (SubQ, SQ) - Intramuscular injection (IM) - Intravenous injection (IV) - Others - Intrathecal - Epidural - Intracardiac - Into joints or body cavities - Aerosol - Transdermal delivery - Installations - For the purposes of pharmacology, you will need to have a working knowledge of any barriers to absorption for each of the major routes of administration (PO, IV, IM, subQ). Additionally, you will need to know the different types of oral preparations (tablets, enteric-coated, and sustained release). Chapter 4 Pharmacokinetics - To understand pharmacokinetics, you also have to understand: - How the body handles medication - Actions and side effects of drugs - Obstacles that a drug faces to reach target cells. The greatest barrier for many drugs is crossing many membranes. - For example, in the enteral route, drugs are broken down by stomach acids and enzymes. The organs will attempt to excrete medicines. Phagocytes may attempt to remove medicines seen as foreign. - Absorption - Movement from site of administration, across body membranes, to circulating fluids - Primary factor in determining the length of time for the effect of the drug to occur - What are factors affecting drug absorption? - Liquid - Digestive motility - Route of administration - Drug to drug - Distribution - Distribution involves the transport of pharmacologic agents throughout the body. - What are factors affecting drug distribution? - The simplest factor determining distribution is the amount of blood flow to body tissues. 9 - Blood-brain barrier and fetal-placenta barrier: special anatomic barriers that prevent many chemicals and medications from entering - Makes brain tumors difficult to treat - Fetal-placenta barrier protects fetus; no pregnant woman should be given medication without strong consideration of condition. - Metabolism - The process of converting the drug to a form that can be more easily removed or excreted. - The liver is the primary site; kidneys and GI tract are others - What are factors affecting metabolism? - Drinking/alcohol - Genetics - Displaced or absent hepatic enzymes - Excretion - How drugs are removed from the body. - The concentration of a drug in the blood stream depends on the excretion rate. - The primary site of excretion is the kidney - Renal failure diminishes excretion of medications, and drugs are retained for extended times. Dosages must be reduced. - Other sites of excretion: respiratory system, glands, biliary system - Alternate first pass effect routes (see textbook) - Sublingual - Rectal - Parenteral routes 10 Plasma Drug Concentration and Therapeutic Response - Minimum effective concentration—amount of drug required to produce a therapeutic effect - Toxic concentration—level of drug that will result in serious adverse effects - Therapeutic range—plasma drug concentration between the minimum effective concentration and the toxic concentration - To reach/maintain therapeutic range: - Repeated doses of drug are given - Drug accumulates in bloodstream. - Plateau is reached. - Amount administered equals amount eliminated. - Sometimes a loading dose is given: - A higher amount of the drug given to help the plateau be met faster - Quickly produces the therapeutic response - Patient is then given the maintenance dose, which keeps the plasma-drug concentration in therapeutic range. Plasma Half-Life of Drugs - Most common description of a drugs duration - It is the length of time needed to decrease the drug plasm by one half - The greater the half-life, the longer it takes to excrete - Determines frequency and dosages of medications - Onset of drug action represents the amount of time it takes to produce a therapeutic effect after drug administration. - Peak plasma level occurs when the medication reaches its peak. - Duration of drug action is the amount of time a drug maintains its therapeutic effect. 11 Chapter 5 Pharmacodynamics - Pharmacodynamics is how drugs produce change in patients and helps predict the difference in patient responses to medications. - Further explanation can be found on page 51. Therapeutic Index - Measure of a drug’s safety - Ratio of the drug’s LD50 (average lethal dose to 50% of the animals treated) to its ED50 - The larger/higher the therapeutic index, the safer the drug. - The smaller/lower the therapeutic index, the less safe the drug. - Median effective dose: - Dose that produces therapeutic response in 50% of a group - Sometimes called “average” or “standard” dose - Many patients require more or less. - Median Lethal dose: - Used to assess safety of a drug, and is determined in preclinical trials - The does that will be lethal in 50% of group of animals - Cannot be experimentally determined in humans - Therapeutic index is the measure of a drug's safety margin - The higher the value, the safer the drug - Example: if a drug has a therapeutic index of 4, an error four times the dose would be needed to be lethal - The lower the value, the more dangerous the drug. If a drug has a low therapeutic index, it is a high-alert medication. - The margin for optimal response vs. toxic response is often a decimal point. - The skill of the nurse is critical in determining if the average dose is effective: - Patient observation - Taking of vital signs - Monitoring lab data Interpatient Variability in Drug Responses - The ED50 (aka: Median Effective Dose): - The dose that is required to produce a defined therapeutic response in 50% of the population. 12 - This can be considered a standard dose, and is frequently the dose selected for initial treatment. - Subsequent doses must by “fine tuned” based on the patient’s response - ED50 in a patient may need to be increased or decreased after the patients’ response is evaluated. - The dose required to produce a therapeutic response can vary substantially - among patients, because people differ from one another. - It is not possible to predict how an individual patient will respond to a medication. - Each patient must be evaluated to determine his or her own actual response. - Med error - Assess patient FIRST! - Get baseline - Contact charge nurse and doctor - Check for antidote - Stay with patient Goldilocks’ Effect - There are so many medications that do almost the same therapeutic action. - But each medication dose with each patient is an experiment. - Like Goldilocks, each patient needs a nurse who will work to get the results just right for that patient at that moment. Maximal Efficacy and Relative Potency - Maximal Efficacy: The largest effect that a drug can produce (i.e. the maximum degree of pain relief with drug A, when compared with drug B. - One drug will have a greater maximal efficacy than another). - Watch the intensity of the response with the patient need - Very high maximal efficacy is not always more desirable - Don’t hunt squirrels with a cannon - Relative Potency: The amount of drug we must give to elicit an effect (i.e. drug strength) - Rarely an important characteristic of the drug - Can be important if we lack of potency foresee inconveniently large doses - Implies nothing about maximal efficacy - Refers to to the dosage needed to produce effects Drug-Receptor Interactions - Drugs are chemicals the produce effects by interacting with other chemicals - Receptors are special chemicals in the body that most drugs interact with to produce effects - A receptor is a part of the cell to which a drug binds to produce its effects. 13 - The binding of a drug to its receptor is usually reversible. - When a drug binds to a receptor, it will mimic or block the action of the endogenous regulatory molecules - This will increase or decrease the rate of physiologic activity normally controlled by that receptor - Important Properties of Receptors: - Receptors are normal points of control of physiologic processes. - Under physiologic conditions, receptor function is regulated by molecules supplied by the body. - Drugs can only mimic or block the body’s own regulatory molecules. - Drugs cannot give cells new functions. - Drugs produce their therapeutic effects by helping the body use its preexisting capabilities Receptors and Drug Selectivity - Receptors make selectivity possible. - Each type of receptor participates in the regulation of just a few processes. - Lock and key mechanism, but does not guarantee safety. - Body has receptors for each: - Neurotransmitter - Hormone - All other molecules in the body used to regulate physiologic processes - The more selective a drug is, the fewer side effects it will produce. - REVIEW AUTONOMIC NERVOUS SYSTEM, NEUROTRANSMITTERS, & ALPHA/ BETA Agonists vs. Antagonists - Agonist - Binds to receptor and activates a response - Produces a response that mimics the response of an endogenous substance - Antagonist 14 - Produce their effect by preventing receptor activations of endogenous regulator and/or drugs - Often compete with agonists for receptor - Important to consider with drug-drug and drug-food interactions Customized Drug Therapy - End of single-drug, one-size-fits-all policy - DNA test before receiving drug - Prevention of idiosyncratic responses (unpredictable and unexplained drug reactions) - Pharmacogenetics: area of pharmacology that examines role of heredity in drug response Chapter 9 Individual Variations in Drug Response - Holistic approach to pharmacology - Identify risk factors - Age - Genetics - Biologic characteristics - Personal habits - Lifestyle - - Environment Through assessment, we can gather these: - Psychosocial Influences: socioeconomic factors, illicit drug use, lifestyle preferences - Religious and Spiritual Influences: refusal of medications, blood, surgeries - Cultural and Ethnic Influences: influence beliefs and actions of patients in their medical decisions, dietary considerations, genetic differences in medication effects - Environmental and Community Influences: age distribution, industrial growth, access to healthcare, literacy rate - Genetics: Enzyme breakdowns, changing the function of medications, risk factors - Gender Influences: compliance, healthcare risk factors, body composition 15


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