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  • Polypharmacy_
  • The metabolism of a drug and its passage from the liver into the circulation – A drug given via the oral route may be extensively metabolized by the liver before reaching the systemic circulation (high first-pass effect) – The same drug—given IV—bypasses the liver, preventing the first-pass effect from taking place, and more drug reaches the circulation
  • Presentation1 A

    1. 1. Pharmacology Rosalie C. Villora MSN, RN
    2. 2. Objectives <ul><li>Identify principles of pharmacology that relate to nursing care. </li></ul><ul><li>Explain absorption, excretion, desired effect. </li></ul><ul><li>Describe the 5 steps of the nursing process. </li></ul><ul><li>Explain how nursing process is used in the administration of medications </li></ul><ul><li>Identify elements in a patient drug history </li></ul><ul><li>Identify common elements in a variety of hospital medication records </li></ul><ul><li>Discuss charting do’s and don’ts </li></ul><ul><li>Discuss confidentiality issues as they apply to medication administration </li></ul>
    3. 3. Pharmacologic Principles <ul><li>Pharmacology - study or science of drugs </li></ul><ul><li>Pharmaceutics - study of how various drug forms influence pharmacokinetic and pharmacodynamic activities </li></ul><ul><li>Pharmacokinetics - study of what the body does to the drug </li></ul><ul><ul><li>Absorption </li></ul></ul><ul><ul><li>Distribution </li></ul></ul><ul><ul><li>Metabolism </li></ul></ul><ul><ul><li>Excretion </li></ul></ul><ul><li>Pharmacodynamics - study of what the drug does to the body, i.e. mechanism of drug actions in living tissues </li></ul>
    4. 4. Pharmacologic Principles cont’d <ul><li>Pharmacotherapeutics - use of drugs and clinical indications for drugs to prevent and treat diseases </li></ul><ul><ul><li>Empirical therapeutics – effective, but mechanism of action is unknown </li></ul></ul><ul><ul><li>Rational therapeutics – specific evidence has been obtained for the mechanisms of drug action </li></ul></ul><ul><li>Pharmacognosy - study of natural (plant and animal) drug sources </li></ul>
    5. 5.
    6. 6. Pharmacokinetics: Absorption <ul><li>The rate at which a drug leaves its site of administration, & the extent to which absorption occurs </li></ul><ul><ul><li>Bioavailability – measure of the extent of drug absorption in the body (0% to 100%) </li></ul></ul><ul><ul><li>Bioequivalent – two drugs have the same bioavailability and same concentration of active ingredients </li></ul></ul><ul><li>Factors That Affect Absorption </li></ul><ul><li>Food or fluids administered with the drug </li></ul><ul><li>Dosage formulation </li></ul><ul><li>Status of the absorptive surface </li></ul><ul><li>Rate of blood flow to the small intestine </li></ul><ul><li>Acidity of the stomach </li></ul><ul><li>Status of GI motility </li></ul>
    7. 7. Neonatal and Pediatric Considerations: Pharmacokinetics <ul><li>Absorption </li></ul><ul><ul><li>Gastric pH less acidic </li></ul></ul><ul><ul><li>Gastric emptying is slowed </li></ul></ul><ul><ul><li>Intramuscular absorption faster and irregular </li></ul></ul><ul><li>Distribution </li></ul><ul><ul><li>The younger the person, the greater the % of total body water </li></ul></ul><ul><ul><li>Greater TBW means fat content is lower </li></ul></ul><ul><ul><li>Decreased level of protein binding </li></ul></ul><ul><ul><li>Immature blood-brain barrier—more drugs enter the brain </li></ul></ul>
    8. 8. Neonatal and Pediatric Considerations: Pharmacokinetics <ul><li>Metabolism </li></ul><ul><ul><li>Liver immature, does not produce enough microsomal enzymes </li></ul></ul><ul><ul><li>Older children may have increased metabolism, requiring higher doses than infants </li></ul></ul><ul><li>Excretion </li></ul><ul><ul><li>Kidney immaturity affects glomerular filtration rate and tubular secretion </li></ul></ul><ul><ul><li>Decreased perfusion rate of the kidneys may reduce excretion of drugs </li></ul></ul>
    9. 9. The Elderly <ul><li>Elderly: older than age 65 </li></ul><ul><ul><li>Healthy People 2010: older than age 55 </li></ul></ul><ul><li>Use of OTC medications </li></ul><ul><li>Increased incidence of chronic illnesses </li></ul><ul><li>Polypharmacy - “prescribing cascade” </li></ul>
    10. 10. The Elderly: Pharmacokinetics <ul><li>Absorption </li></ul><ul><ul><li>Gastric pH less acidic </li></ul></ul><ul><ul><li>Slowed gastric emptying </li></ul></ul><ul><ul><li>Movement through GI tract slower </li></ul></ul><ul><ul><li>Reduced blood flow to the GI tract </li></ul></ul><ul><ul><li>Reduced absorptive surface area due to flattened intestinal villi </li></ul></ul><ul><li>Distribution </li></ul><ul><ul><li>TBW percentages lower </li></ul></ul><ul><ul><li>Fat content increased </li></ul></ul><ul><ul><li>Decreased production of proteins by the liver, resulting in decreased protein binding of drugs (& increased circulation of free drugs) </li></ul></ul>
    11. 11. The Elderly: Pharmacokinetics <ul><li>Metabolism </li></ul><ul><ul><li>Aging liver produces fewer microsomal enzymes, affecting drug metabolism </li></ul></ul><ul><ul><li>Reduced blood flow to the liver </li></ul></ul><ul><li>Excretion </li></ul><ul><ul><li>Decreased glomerular filtration rate </li></ul></ul><ul><ul><li>Decreased number of intact nephrons </li></ul></ul>
    12. 12. Pharmaceutics <ul><li>Dosage form design affects dissolution </li></ul>
    13. 13. First-Pass Effect <ul><li>The metabolism of a drug and its passage from the liver into the circulation </li></ul><ul><li>– A drug given via the oral route may be extensively metabolized by the liver before reaching the systemic circulation (high first-pass effect) </li></ul><ul><li>– The same drug—given IV—bypasses the liver, preventing the first-pass effect from taking place, and more drug reaches the circulation </li></ul>
    14. 14.
    15. 15. <ul><li>Distribution </li></ul><ul><li>Protein-binding </li></ul><ul><li>Water soluble vs. fat soluble </li></ul><ul><li>Blood-brain barrier </li></ul><ul><li>Areas of rapid distribution: heart, liver, kidneys, brain </li></ul><ul><li>Areas of slow distribution: muscle, skin, fat </li></ul><ul><li>Metabolism (Biotransformation) </li></ul><ul><li>Liver (main organ) </li></ul><ul><li>Skeletal muscle </li></ul><ul><li>Kidneys </li></ul><ul><li>Lungs </li></ul><ul><li>Plasma </li></ul><ul><li>Intestinal mucosa </li></ul>
    16. 16. <ul><li>Factors that metabolism </li></ul><ul><li>Fast acetylator </li></ul><ul><li>Barbiturate therapy </li></ul><ul><li>Rifampin therapy </li></ul><ul><li>Delayed drug metabolism results in: </li></ul><ul><li>Accumulation of drugs </li></ul><ul><li>Prolonged action of the drugs </li></ul><ul><li>Factors that metabolism </li></ul><ul><li>Cardiovascular dysfunction </li></ul><ul><li>Renal insufficiency </li></ul><ul><li>Starvation </li></ul><ul><li>Obstructive jaundice </li></ul><ul><li>Slow acetylator </li></ul><ul><li>Erythromycin or ketoconazole drug therapy </li></ul>
    17. 17. Excretion <ul><li>The elimination of drugs from the body </li></ul><ul><li>Kidneys (main organ) </li></ul><ul><li>Liver </li></ul><ul><li>Bowel </li></ul><ul><ul><li>Biliary excretion </li></ul></ul><ul><ul><li>Enterohepatic recirculation </li></ul></ul>
    18. 18. Half-life <ul><li>The time it takes for one half of the original amount of a drug in the body to be removed </li></ul><ul><li>A measure of the rate at which drugs are removed from the body </li></ul><ul><li>Most drugs are considered to be effectively removed after about five half-lives </li></ul><ul><li>Steady state </li></ul>
    19. 19. Onset, Peak, and Duration <ul><li>Onset </li></ul><ul><li>The time it takes for the drug to elicit a therapeutic response </li></ul><ul><li>Peak </li></ul><ul><li>The time it takes for a drug to reach its maximum therapeutic response </li></ul><ul><li>Highest blood level </li></ul><ul><li>Trough Level </li></ul><ul><li>Lowest blood level </li></ul><ul><li>Duration </li></ul><ul><li>The time a drug concentration is sufficient to elicit a therapeutic response </li></ul>
    20. 20.
    21. 21. Pharmacodynamics: Mechanisms of Action
    22. 22. Pharmacotherapeutics: Types of Therapies <ul><li>Acute therapy </li></ul><ul><li>Maintenance therapy </li></ul><ul><li>Supplemental/replacement therapy </li></ul><ul><li>Palliative therapy </li></ul><ul><li>Supportive therapy </li></ul><ul><li>Prophylactic therapy </li></ul><ul><li>Empiric therapy </li></ul>
    23. 23. <ul><li>Contraindication - a ny characteristic of the patient, especially a disease state, that makes the use of a given medication dangerous for the patient </li></ul><ul><li>Intended therapeutic action (beneficial) </li></ul><ul><li>Unintended but potential adverse effects (predictable, adverse reactions) </li></ul><ul><li>Therapeutic index - ratio between a drug’s therapeutic benefits and its toxic effects </li></ul><ul><li>Tolerance - a decreasing response to repeated drug doses </li></ul><ul><li>Dependence - a physiologic or psychological need for a drug </li></ul>
    24. 24. <ul><li>Drug interactions: the alteration of action of a drug by other prescribed drugs, over-the-counter medications, & herbal therapies </li></ul><ul><li>Drug interactions </li></ul><ul><ul><li>Additive effect </li></ul></ul><ul><ul><li>Synergistic effect </li></ul></ul><ul><ul><li>Antagonistic effect </li></ul></ul><ul><ul><li>Incompatibility </li></ul></ul>
    25. 25. <ul><li>Adverse drug reactions: </li></ul><ul><ul><li>Pharmacologic reactions, including adverse effects </li></ul></ul><ul><ul><li>Hypersensitivity (allergic) reaction </li></ul></ul><ul><ul><li>Idiosyncratic reaction </li></ul></ul><ul><ul><li>Drug interaction </li></ul></ul><ul><li>Adverse effects </li></ul><ul><li>Predictable, well-known reactions that result in little or no change in patient management </li></ul><ul><li>Predictable frequency </li></ul><ul><li>Occurrences are related to the size of the dose </li></ul><ul><li>Usually resolve when the drug is discontinued </li></ul>
    26. 26. Other Drug-Related Effects <ul><li>Teratogenic – results in structural defects in the fetus </li></ul><ul><li>Mutagenic – permanent changes in the genetic composition and chromosome structure of living organism </li></ul><ul><li>Carcinogenic – cancer-causing effects of drugs </li></ul>
    27. 27. Pharmacology & The Nursing Process
    28. 28. The Nursing Process <ul><li>A research-based organizational framework for professional nursing practice </li></ul><ul><li>Central to all nursing care </li></ul><ul><li>Encompasses all steps taken by the nurse in caring for a patient </li></ul><ul><li>Flexibility is important </li></ul><ul><li>Critical thinking </li></ul><ul><li>Ongoing and constantly evolving process </li></ul>
    29. 29. The Nursing Process (cont’d) <ul><li>Assessment </li></ul><ul><li>Nursing diagnosis </li></ul><ul><li>Planning </li></ul><ul><li>Goals </li></ul><ul><li>Outcome criteria </li></ul><ul><li>Implementation </li></ul><ul><li>Evaluation </li></ul>
    30. 30. The Nursing Process (cont’d) <ul><li>Assessment </li></ul><ul><li>Data collection </li></ul><ul><ul><li>Subjective, objective </li></ul></ul><ul><li>Medication history </li></ul><ul><ul><li>Prescriptions </li></ul></ul><ul><ul><li>OTCs </li></ul></ul><ul><ul><li>Herbals </li></ul></ul><ul><ul><li>Responses to medications (therapeutic & adverse responses) </li></ul></ul>
    31. 31. The Nursing Process (cont’d) <ul><li>Nursing diagnosis </li></ul><ul><li>Decision about the need/problem (actual or at risk for) of the patient </li></ul><ul><li>Critical thinking, creativity, and accurate data collection </li></ul><ul><li>NANDA format </li></ul>
    32. 32. The Nursing Process (cont’d) <ul><li>Nursing diagnosis </li></ul><ul><li>Three steps </li></ul><ul><li>Human response to illness (actual or risk) </li></ul><ul><li>“ related to” </li></ul><ul><li>“ as evidenced by” </li></ul><ul><li>Planning </li></ul><ul><li>Identification of goals and outcome criteria </li></ul><ul><li>Time frame </li></ul><ul><li>Prioritization </li></ul>
    33. 33. The Nursing Process (cont’d) <ul><li>Goals </li></ul><ul><li>S- specific </li></ul><ul><li>M- measurable </li></ul><ul><li>A- attainable </li></ul><ul><li>R- realistic </li></ul><ul><li>T- time frame specified </li></ul><ul><li>Outcome Criteria </li></ul><ul><li>Specific standard(s) of measurement </li></ul><ul><li>Patient oriented </li></ul>
    34. 34. The Nursing Process (cont’d) <ul><li>Implementation </li></ul><ul><li>Initiation and completion of the nursing care plan as defined by the nursing diagnoses and outcome criteria </li></ul><ul><li>Follow the “Six Rights” of medication administration </li></ul>
    35. 35. The Six Rights of Medication Administration <ul><li>Right drug </li></ul><ul><li>Right dose </li></ul><ul><li>Right time </li></ul><ul><li>Right route </li></ul><ul><li>Right patient </li></ul><ul><li>Right documentation </li></ul>
    36. 36. Other “Rights” (cont’d) <ul><li>Close consideration of special situations </li></ul><ul><li>Prevention and reporting of medication errors </li></ul><ul><li>Patient teaching </li></ul><ul><li>Monitor therapeutic effects, adverse effects, and toxic effects </li></ul><ul><li>Refusal of medication </li></ul>
    37. 37. Six Elements of a Drug Order <ul><li>1. Patient's name </li></ul><ul><li>2. Date order is written </li></ul><ul><li>3. Name of medication </li></ul><ul><li>4. Dosage (size, frequency, & number of doses) </li></ul><ul><li>5. Route of delivery </li></ul><ul><li>6. Signature of the prescriber </li></ul>
    38. 38. Evaluation <ul><li>Ongoing part of the nursing process </li></ul><ul><li>Determining the status of the goals and outcomes of care </li></ul><ul><li>Monitoring the patient’s response to drug therapy </li></ul><ul><ul><li>Expected and unexpected responses </li></ul></ul>