COMPETENCY APPRAISAL 1: PHARMACOLOGY

Midterm
BSN4- ERICKSON Y. SANTIAGO & M. BAHINTING
■ can cause localized side effects to skin.
3. Intravenous (IV):
LESSON 1: Nursing Pharmacology: ■ IV drugs are fully available to tissues after administration into the
A Patient- centered Nursing Process Approach bloodstream, offering complete bioavailability and an immediate effect.
■ requires intravenous access that can be painful to the patient and also
PHARMACOLOGY BASICS increases risk for infection.
➢ Drugs are medications or other substances that have a physiological effect when ■ Medications must be administered in sterile fashion
introduced to the body. ■ if two products are administered simultaneously, their compatibility must
➢ Pharmacokinetics is the term that describes the four stages of absorption, be verified.
distribution, metabolism, and excretion of drugs. ■ There is also an increased risk of toxicity.
4. Pulmonary inhalation
■ allows for rapid absorption of drugs in gaseous, vaporized, or aerosol
PHARMACOKINETICS form.
■ Absorption of particulates/aerosols depends on particle/droplet size,
➢ Interactions between drug and body molecules are really just a series of chemical which influences depth of entry through the pulmonary tree to reach
reactions the alveoli.
➢ Understanding the chemical encounters between drugs and biological ■ The ability of the patient to create successful inhalation, especially in
environments is necessary to predict how much of a drug will be metabolized by the presence of bronchospasm, may also influence depth of entry in
the body. the pulmonary tree.
5. Topical and Transdermal Application
4 STAGES ● Topical creams, lotions, and ointments are generally used for local effects;
transdermal patch formulations are used for systemic effect.
➢ Absorption occurs after medications enter the body and travel from the site of ● absorption through the buccal or sublingual membrane may be rapid
administration into the body's circulation. ● absorption through skin is generally slower but produces a steady, long-term
■ Medications can enter the body through various routes of effect that avoids the first pass effect. However, absorption of medication is
administration. affected by blood flow to the skin.
1. Oral (PO) or Enteral (NGT, GT, OGT)
■ Ingestion TRUE OR FALSE
■ Oral route is a convenient route for administration of solid as well as liquid Medication administration route does NOT impact drug absorption.
formulations. ANSWER: FALSE
■ Additional variables include enteric coating or extended-release A patient with damage to the outer layer of skin (or stratum corneum) may experience
formulations, acidity of gastric contents, gastric emptying rate, dietary a more rapid absorption of medication with topical application.
contents, and presence of other drugs. ANSWER: FALSE
■ First pass effect: Blood containing the absorbed drug passes through The first-pass effect impacts absorption of medications administered via the:
the liver, which can deactivate a substantial amount of the drug and A. Pulmonary route
decrease its bioavailability (the percentage of dose that reaches the B. Oral route
systemic circulation). C. Topical route
2. Parenteral Injection D. Parenteral route
■ Subcutaneous and intramuscular administration:
■ Can be difficult for patients to self-administer at home or to administer on
a daily basis. ➢ COMMON FACTORS
■ They can be costly and painful. ■ blood flow
■ cause a break in skin that is an important barrier to infection ■ plasma protein binding
■ can cause fluctuation in drug levels. ■ lipid solubility
 ■ the blood-brain barrier ○ weakened pumping by the heart muscle (due to heart failure).
■ the placental barrier ○ Ex. when administering an antibiotic to a patient with
■ capillary permeability diabetes with an infected toe, it may be difficult for the
■ differences between blood/tissue antibiotic to move through the blood vessels all the way to the
■ volume of distribution. cells of the toe that is infected.
➢ LIFESPAN CONSIDERATIONS ■ Once the drug is in the bloodstream, a portion of it may exist as free
● Neonate & Pediatric drug, dissolved in plasma water.
■ The acid-producing cells of the stomach are immature until around ■ Some of the drug will be reversibly taken up by red cells,
the age of one to two years.
■ Gastric emptying may be decreased because of slowed or irregular
■ some will be reversibly bound to plasma proteins- 95-98%.
peristalsis (forward bowel movement). ■ This Is important because it is the free drug that traverses cell
■ The liver of a neonatal or pediatric patient continues to mature, membranes and produces the desired effect.
experiencing a decrease in first-pass elimination, resulting in higher ■ It is also important because a protein-bound drug can act as a
drug levels in the bloodstream reservoir that releases the drug slowly and thus prolongs its action.
● Older Adult: ■ amount & free drug that Is readily available to tissues, as well as the
■ decreased blood flow to tissues within the Gl tract. potential drug reserve that may be released over time.
■ changes in the gastric (stomach) pH that may alter the absorption of ○ With drug distribution, it is important to consider both the
certain medications amount of free drug that is readily available to tissues, as well
■ Variations in available plasma proteins, which can impact drug level as the potential drug reserve that may be released over time.
of medications that are highly protein-bound ● Protein-Binding
■ use of subcutaneous and intramuscular injections in older patients ■ Albumin is one of the most important proteins in the blood. Albumin
experiencing decreased cardiac output levels can be decreased by several factors such as malnutrition and
■ Decreased drug absorption of medications can occur when liver disease. A certain percentage of almost every drug gets bound
peripheral circulation is decreased. to plasma proteins when it initially enters the bloodstream and starts
■ have less body fat, resulting in decreased absorption of medication to circulate.
from transdermal patches that require adequaté subcutaneous fat ● Blood-Brain Barrier
stores for proper absorption. ■ This blockade is built from a tightly woven mesh of capillaries that
➢ Distribution is the process by which medication is distributed throughout the
protect the brain from potentially dangerous substances, such as
body.
poisons or viruses. Only certain medications made of lipids (fats) or
■ drug distribution- SECOND STAGE
have a "carrier" can get through the blood-brain barrier.
■ Distribution is the process by which medication is dispersed
throughout the body via the bloodstream.
● Placental Barrier
■ Distribution of a medication can also cause unintended adverse or ■ The placenta is permeable to some medications, while others have
side effects. not been specifically studied in pregnant patients. Some drugs can
■ Drugs are designed to primarily cause one effect, meaning they bind cause harm to the unborn fetus during any trimester.
more strongly to one specific receptor site and predictably cause or ■ Therefore, it is imperative to always consult a healthcare provider
block an action. regarding the safety of medications for use during pregnancy.
■ side effects can occur when the drug binds to other sites in addition ● Older Adult:
to the target tissue, causing secondary side effects. ■ The aging adult patient will experience a decrease in total body
■ these side effects can range from tolerable to unacceptable resulting water and muscle mass.
in the discontinuation of the medication ■ Body fat may increase and subsequently result in a longer duration of
○ Ex. Tylenol for pain- can cause stomach irritation action for many medications.
● BLOOD FLOW ■ Serum albumin often also decreases, resulting in more active free
■ Factors that can affect the blood flow and delivery of medication: drugs within the body. This is one reason why many older adult
○ decreased flow (due to dehydration) patients require lower levels of medication
○ blocked vessels (due to atherosclerosis), ● Other Factors that Impact Drug Distribution
○ constricted vessels (due to uncontrolled hypertension), ■ Tissue differences in rates of uptake of drugs.

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 ○ Blood flow: distribution occurs most rapidly into tissues with 2.
LIVER
a greater number of blood vessels that allow high blood flow ■ some drugs and their metabolites are actively transported by the
(lungs, kidneys, liver, brain) and least rapidly in tissues with hepatocytes (liver cells) to bile
fewer numbers of blood vessels resulting in low blood flow ■ If a patient is experiencing decreased liver function, their ability to
(fat). excrete medication is affected and drug dosages must be decreased.
○ Capillary permeability: permeability of capillaries is tissue Lab studies used to estimate liver function are called liver function
dependent. Distribution rates are relatively slower or tests and include measurement of the ALT and AST enzymes that
non-existent in the CNS because of the tight junction the body releases in response to damage or disease.
between capillary endothelial cells and the blood-brain OTHER ROUTES
barrier. Capillaries of the liver and kidney are more porous, ■ Sweat
allowing for greater permeability. ■ Tears
■ Differences in tissue/blood ratios at equilibrium ■ reproductive fluids (such as seminal fluid)
○ Dissolution of lipid-soluble drugs in adipose tissue ■ breast milk
➢ LIFESPAN CONSIDERATIONS
○ Binding of drugs to intracellular sites ● Neonate & Pediatrics:
○ Plasma protein-binding ■ Young patients have immature kidneys with decreased glomerular
➢ Metabolism is the breakdown of a drug molecule. filtration, resorption, and tubular secretion. As a result, they do not
■ the breakdown of a drug molecule usually involves two steps that clear medications as efficiently from the body.
take place primarily in the body's chemical processing plant: the liver ■ Dosing is commonly based on weight in kilograms, and a smaller
■ Everything that enters the bloodstream-whether swallowed, injected, dose is usually prescribed
inhaled, absorbed through the skin, or produced by the body itself-is ■ may have higher levels of free circulating medication than anticipated
carried to this largest internal organ. and may become toxic quickly.
➢ Lifespan Considerations ■ Frequent assessment of infants and children is vital for early
● Neonate & Pediatric identification of drug toxicity.
■ The developing liver in infants and young children produces ■ Observe the child within one minute of administration.
decreased levels of microsomal enzymes. ● Older Adult:
■ This may result in a decreased ability of the young child or neonate to ■ Kidney and liver function often decrease with age, which can lead to
metabolize medications. decreased excretion of medications.
■ In contrast, older children may experience increased metabolism and ■ medication may have a prolonged half-life with a greater potential for
require higher doses of medications once the hepatic enzymes are toxicity due to elevated circulating drug levels.
fully produced ■ Smaller doses of medications are often recommended for older
● Older Adult: patients due to these factors, which is commonly referred to as “Start
■ Hepatic metabolism may experience a significant decline in the older low and go slow”.
adult. As a result, dosages should be adjusted according to the
patient's liver function and anticipated metabolic rate. First-pass True or False
metabolism is also decreased with aging therefore, older adults may Pharmacokinetics comprises four main processes to describe the movement of drugs
have higher "free" circulating drug concentrations and be at higher within the body.
risk for side effects and toxicities. ANSWER: TRUE
➢ Excretion is the process by which the body eliminates waste. Medications enter the body through the oral route alone.
■ Excretion is the final stage of a medication interaction within the ANSWER: FALSE
body. Which of the following is not one of the main processes of pharmacokinetics?
ROUTES OF EXCRETION a. Absorption
1. KIDNEY b. Management
■ The most common route of excretion c. Distribution
■ The rate of excretion can be estimated by taking into consideration d. Metabolism
several factors: age, weight, biological sex, and kidney function.
■ Kidney function is measured by lab values such as serum creatinine,
glomerular filtration rate (GFR), and creatinine clearance.

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 C. 4. can be bought at a store and may be used by multiple individuals.
TRUE OR FALSE: D. 5. may include a wide variety of substances including vitamins, minerals, enzymes, and
Scientists do not have the ability to actually see where a drug is going or how long it is botanicals
active
Answer: FALSE SAMPLE QUESTIONS
■ Mathematical models and precise measurements of blood and urine to The nurse is reviewing dietary supplements and recalls that under the DSHEA, manufacturers of
determine where a drug goes and how much of the drug (or breakdown dietary supplements are required to:
product) remains after the body processes it
a. follow FDA standards for quality control
■ Other indicators, such as blood levels of liver enzymes, can help predict how b. prove efficacy and safety of dietary supplements.
much of a drug is going to be absorbed. c. identify the active ingredients on the label.
d. obtain FDA approval before the products are marketed

When educating patients about the safe use of herbal products, the nurse remembers to include
PHARMACODYNAMICS which concept?

➢ Refers to the effects of drugs in the body and the mechanism of their action. a. Herbal and over-the-counter products are approved by the FDA and under strict regulation.
b. Herbal products are tested for safety by the FDA and the U.S. Pharmacopeia.
As a drug travels through the bloodstream, It Will exhibit a unique affinity for c. No adverse effects are associated with these products because they are natural and may be
the drug receptor site— how strongly it will bind to the site. purchased without a prescription.
➢ BIOAVAILABILITY : Examination of how drugs and receptor sites create a d. Take the product with caution because labels may not contain reliable information.
lock and key system is helpful to understand how drugs work and the amount
of drug that may be left circulating within the bloodstream When taking a patient's drug history, the nurse asks about the use of over-the-counter drugs.
The patient responds by saying. "Oh. I frequently take aspirin for my headaches, but I didn't
MECHANISM OF ACTION mention it because aspirin is nonprescription." What is the best response from the nurse?

a. "That's true, over-the-counter drugs are generally not harmful."

➢ how a medication functions within the body, is essential to understanding the b. "Aspirin is one of the safest drugs out there."
processes medications go through to produce the desired effect c. "Although aspirin is over the counter, it's still important to know why you take it, how
➢ A drug agonist binds tightly to a receptor to produce a desired effect much you take, and how often."
➢ A drug antagonist competes with other molecules and blocks a specific action d. "We need you to be honest about the drugs you are taking. Are there any others that you
or response at a receptor site. haven't told us about?"
■ For example, the cardiac medication atenolol (Tenormin) beta 1 receptor
When making a home visit to a patient who was recently discharged from the hospital. the nurse
agonist used to treat patients with hypertension or heart disease. Beta 1
notes that she has a small pack over her chest and that the pack has a strong odor. She also is
receptor antagonist medications like atenolol produce several effects by drinking herbal tea.
blocking beta 1 receptors: a negative inotropic effect occurs by When asked about the pack and the tea, the patient says, "Oh, my grandmother never used
weakening the contraction of the heart, thus causing less work of the medicines from the doctor. She told me that this plaster and tea were all I would need to fix
heart muscle; a negative chronotropic effect occurs when the heart rate is things." Which response by the nurse is most appropriate?
decreased; and a negative dromotropic effect occurs when the
conduction of the electrical charge in the heart is slowed. Understanding a. "You really should listen to what the doctor told you if you want to get better."
the effects of beta 1 antagonist medication allows the nurse to anticipate b. "What's in the plaster and the tea? When do you usually use them?"
c. "These herbal remedies rarely work, but if you want to use them; then it is your choice."
expected actions of the medication and the patient response
d. "It's fine if you want to use this home remedy, as long as you use it with your prescription
Activity medicines."
a. Prescription Medications
b. Generic Medications
c. Over-the-Counter Medications
d. Herbals & Supplements

A. 1. Include brand-name medications and generic medications

B. 2. can be safe and effective alternatives to their brand-name counterparts and often at a reduced
cost
B. 3. must have the same chemically active ingredient in the same, however, the excipients or the
flavoring can be different.
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 PHARMACOGENETICS MEDICATION SAFETY

➢ is defined as the study of how people's genes affect their response to medicines 1. Effective Concentration
2. Therapeutic Window - most desirable outcome of medication administration
3. Toxic concentrations
EXAMINING EFFECT
Peak and Trough Levels
● A peak drug level is drawn at the time when the medication is being
➢ to ensure its appropriateness.
administered and is known to be at the highest level in the bloodstream
➢ Dosing considerations play an important role in understanding the effect that a
● A trough level is drawn when the drug is at its lowest in the bloodstream right
medication may have on a patient. During administration, the nurse must pay close
before the next dose is given.
attention to the desired effect and therapeutic patient response, as well as the safe
● Medications have a predicted reference range of normal values for peak and
dose range for any medication.
trough levels.
■ Onset: the onset of medication refers to when the medication first begins to
● These numbers assist the pharmacist and provider in gauging how the body is
take effect
metabolizing, protein-binding, and excreting the drug, and assist in the
■ Peak: the peak of medication refers to the maximum concentration of
adjustment of the prescribed drug doses to keep the medication within the
medication in the body, and the patient shows evidence of greatest
therapeutic window.
therapeutic effect
● When administering IV medications that require peak or trough levels, it is vital
■ Duration: the duration of medication refers to the length of time the
for the nurse to time the administration of the medication according to the
medication produces its desired therapeutic effect
timing of these blood draws.
Therapeutic Index
SCENARIO
● Therapeutic Index is a quantitative measurement of the relative safety of a
A 67-year-old female post-operative patient rings the call light to request medication for
drug. It is a comparison of the amount of drug that produces a therapeutic
pain related to the hip replacement procedure she had earlier that day. She notes her
effect versus the amount of drug that produces a toxic effect.
pain is excruciating, a definite 9 out of 10." Her brow is furrowed, and she is grimacing in
● A large (or high) therapeutic index number means there is a large
obvious discomfort. As the nurse providing care for the patient, you examine her
therapeutic window between the effective concentration and the toxic
post-operative medication orders and consider the pain medication options available to
concentration of a medication, so the drug is relatively safe
you
● A small (or low) therapeutic index number means there is a small therapeutic
window between the effective concentration and the toxic concentration. A drug
Duration and Dosing
with a narrow therapeutic range (i.e., having little difference between toxic and
➢ the duration of medication is correlated with the elimination
therapeutic doses) often has the dosage titrated according to measurements of
➢ If a medication has a short half-life (and thus eliminated more quickly from the
the actual blood levels achieved in the person taking it.
body), the therapeutic effect is shorter.
➢ medications may require repeated dosing throughout the day in order to achieve
EXAMPLE
steady blood levels of active free drug and a sustained therapeutic effect.
Patients who start taking phenytoin to control seizures have the drug levels in their
➢ Other medications have a longer half-life (and thus longer therapeutic duration)
bloodstream measured frequently.
and are only given once or twice per day.

EXAMPLE
Oxycodone immediate release is prescribed every 4 to 6 hours for the therapeutic effect
of immediate relief of severe pain, whereas oxycodone ER (extended release) is
prescribed every 12 hours for the therapeutic effect of sustained relief of severe pain.

post-operative medication orders and consider the pain medication options available to
you

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 ADMINISTRATION PREPARATION LESSON 2: ANTIMICROBIALS
Preparing for Administration ANTIMICROBIALS
● As medications are administered, the nurse should perform careful patient
assessments, trend the assessment results, and monitor for side effects or ➢ Bacteria may be identified when a patient has an infection by using a culture and
toxic adverse effects. Drug dosages should be evaluated for potency in action. sensitivity test or a gram stain test..
● Potency ➢ In addition to antibiotics, antimicrobials also include medications used to treat
■ refers to the amount of the drug required to produce the desired effect. viruses and fungi.
■ A drug that is highly potent may require only a minimal dose to ➢ CULTURE AND SENSITIVITY
produce a desired therapeutic effect, whereas a drug that has low ■ A culture is a test performed to examine different body substances for the
potency may need to be given at much higher concentrations to presence of bacteria or fungus.«These culture samples are commonly
produce the same effect. collected from a patient's blood, urine, sputum, wound bed, etc.
■ opioid versus non-opioid medications for pain control. ■ A sensitivity analysis is often performed to select an effective antibiotic to
■ Opioid medications often have a much higher potency in treat the microorganism. If the organism shows resistance to the antibiotics
smaller doses to produce pain relief; therefore, the overall used in the test, those antibiotics will not provide effective treatment for the
dose required to produce a therapeutic effect may be much patient's infection.
less than for other analgesics. ➢ GRAM POSITIVE VS GRAM NEGATIVE
● Selectivity ■ A gram stain is another type of test that is used to assist in classifying. A
■ refers to how readily the drug targets specific cells to produce an gram stain is another type of test that is used to assist in classification of
intended therapeutic effect. pathogens. Gram stains are useful for quickly identifying if bacteria are "gram
■ Drugs that are selective will search out target sites to create positive" or "gram negative," based on the staining patterns of their cellular
a drug action walls.
■ non-selective drugs may impact many different types of cells ■ Utilizing gram stains allows microbiologists to look for characteristic violet
and tissues, thus potentially causing side effects. (Gram +) or red/pink (Gram -) staining patterns when they examine the
● side effect organisms under a microscope. Identification of bacteria as gram positive or
■ occurs when the drug produces effects other than the intended effect. gram negative assists the healthcare provider in quickly selecting an
■ although often undesirable, is generally anticipated by the provider appropriate antibiotic to treat the infection.
and is a known unintended consequence of the medication therapy. ■ Sample Gram Negative Infections
● adverse effects ○ Gram negative bacteria often grow between aerobic and
■ occasional occurrences of unanticipated effects that are dangerous to anaerobic areas (such as in the intestines). Some gram
the patient. Adverse effects are relatively unpredictable, severe, and negative bacteria cause severe, sometimes life-threatening
are reasons to discontinue the medication. disease. The genus Neisseria, for example, includes the
bacteria N. gonorrhoeae, the causative agent of the sexually
transmitted infection gonorrhea, and N. meningitidis, the
SHORT QUIZ causative agent of bacterial meningitis.
1. An unintended pharmacological effect that occurs when a medication is administered
➢ Broad-Spectrum vs. Narrow-Spectrum Antimicrobials
correctly. ADVERSE EFFECT
2. The "sine qua non" of drug effect. Simply put, as the dose of drug increases, the response
■ A broad-spectrum antibiotic will treat gram positive and gram negative
should increase. DOSE RESPONSE bacteria.
3. Refers to the dose required to produce a specific intensity of effect. POTENCY ■ A narrow-spectrum antibiotic will treat either gram positive or gram negative
4. The movement of drugs within the body. PHARMACOKINETICS bacteria.
5. The science of dealing with actions of drugs on the body. PHARMACOLOGY ➢ Antibacterials Actions - Bacteriostatic vs Bactericidal
6. This is the maximum effect of which the drug is capable. EFFICACY ■ Bacteriostatic drugs cause bacteria to stop reproducing; however, they may
7. Effect of a drug, other than the desired effect, sometimes in an organ other than the target not ultimately kill the bacteria.
organ. SIDE EFFECT.
■ Bactericidal drugs kill their target bacteria.
8. A molecule that prevents the action of other molecules, often by competing for a cellular
receptor; opposite of agonist. ANTAGONIST
➢ Antiviral
9. The breakdown of orally administered drugs in the liver and intestines. FIRST PASS EFFECT ■ Antiviral drugs directly impact interaction and reproduction of the offending
10. The science of drug preparation. PHARMACY microorganism. Antibacterial medications are required for treating bacterial
infections; antivirals treat specific viral infections. For example, oseltamivir

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 (Tamiflu) is commonly prescribed to treat influenza. Unlike antimicrobials, ■ It is important to document these findings to reflect the patient's trended
antiviral medications do not kill the offending virus, but they work to reduce response.
replication and development of the virus or gram negative bacteria.
➢ Antifungal
■ Antifungal, or antimycotic agents, are medications that are used to treat
fungal infections.
■ These medications work by killing the cells of the fungus or inhibiting the
reproduction of the cells. Unlike antibacterial and antiviral medications, many
antifungals are applied topically to the affected area.
➢ Dose Dependency/Time Dependency
■ The goal of antimicrobial therapy is to select an optimal dosage that will
result in clinical cure, while reducing the patient's complications or significant
side effects.
■ Many medications may be dose dependent. Other medications are time
dependent.
■ Time-dependent medications have optimal bacterial killing effects at lower
doses over a longer period of time. Time-dependent antimicrobials exert the
greatest effect by binding to the microorganism for an extensive length of
time.
➢ ROUTE
■ It is also important to consider the route of drug administration within the
patient's body.
■ Most convenient: oral
■ Fastest absorption: intravenous
Nursing Process
➢ Assessment
■ Antimicrobials are given to prevent or treat infection. If a patient is prescribed
an antimicrobial, an important piece of the nursing assessment should be to
look for signs and symptoms of infection.
■ Example:
○ Baseline of vital signs
○ Check for IV patency
○ Signs and symptoms of infection
➢ Implementation of Interventions
■ With administration of the antimicrobial medication, it is important for the
nurse to anticipate any additional interventions associated with the
medications.
■ Example:
○ Patient education before oral and parenteral medications
○ Tepid sponge bath
○ Cold compress over swollen or infiltrated IV Site
○ Continuous monitoring of vital signs
○ Patient teaching when giving antimicrobials (completing the
course of antibiotics)
➢ Evaluation
■ It is important to always evaluate the patient's response to medication. With
antimicrobial medications, the nurse should assess for absence of or
decreasing signs of infection, indicating the patient is improving.