Nursing 198

INTRODUCTION TO PHARMACOLOGY

Drug: Any chemical that can affect living processes. Very broad term. Includes
prescription and over-the-counter drugs, social drugs (tobacco, alcohol), illegal drugs and
environmental toxins.

Pharmacology: The study of drugs and their interactions with living organisms. Very
broad term. Includes pharmacotherapeutics , pharmacokinetics and pharmacodynamics
as well as toxicology.

Clinical pharmacology: The study of drug action in humans. Use healthy volunteers and
patients. Studies core drug knowledge (pharmacotherapeutics, pharmacokinetics,
pharmacodynamics, contraindications, precautions, adverse effects, drug interactions) and
core patient variables (health status, age, gender, lifestyle, environment, culture and other
variables)

Pharmacotherapeutics (Drug therapy): The use of drugs (medications) to diagnose,

prevent or treat disease or to prevent pregnancy or the medical use of drugs. Study of
drug effects and rationale for use, dosage, route, schedule.

Pharmacokinetics: The study of drug concentrations during the phases of absorption,

distribution, metabolism (biotransformation) and excretion (movement of drugs through the
body). The concentration of a drug at the site of action determines the intensity of response.
This information determines the route, dose, timing of dose to ensure a therapeutic blood
level and to reduce risk of toxicity.

Pharmacodynamics: Study of the impact of drugs on the body and how the drugs
exert their effects. Explores the biochemical and physiological effects of drugs on living
cells and tissues.

Pharmacogenetics: Study of genetically inherited traits that affect the way that drugs affect
the body and the way the body responds to drugs.

Prototype: A drug that typical of drugs within a particular drug class. Learning
about prototype gives information about all drugs in class.

DRUG SOURCES
plants -dates back to primitive times includes alkaloids, glycosides, gums, oils, resins
animals- honnones, biological agents (vaccines) -replaced by genetically engineered drugs
synthetics - produced in the laboratory - today most drugs are synthetic or semi-synthetic
DRUG N OMENCLATURE Name
Chemical - description of drug using chemistry terminology - too difficult for use
Generic - drug company that researches drug suggests name, name assigned by US Adopted
Names Council- one name for each drug. (small case letters)
Trade - brand name. Selected by drug company - easier to remember and pronounce than
generic. 17 year patent granted. Must be approved by FDA to avoid duplication. Each
generic drug may have an unlimited number of brand names. (Capitalized)
Combination p r o d u c t s are sold by brand name - must check to determine components. OTC
products list components by generic names.
Generic vs Trade -all have same active ingredient- may vary in packaging- liquid, tablet,
capsule - may affect absorption. Therapeutically equivalent to brand name.

Classification
by affect on body system - cardiac stimulant, bronchodilator, vasoconstrictor
by therapeutic use - antidepressant, antihypertensive, vasopressor, analgesic
by chemical composition - salicylate, opiate, sulfonamide
NURSING IMPLICATIONS
Extremely important for nurses to accurately identify drug ordered - many drugs have similar
names. Be aware of the reason a drug is ordered and be sure the drug available is appropriate
for the condition being treated.
Verify that brand name and generic name match -many brand names may exist for same generic
drug.
Be familiar with nurse practice acts, drug laws, local regulations and hospital protocols.
Use information to educate clients to promote safety and compliance
SOURCES OF DRUG INFORMATION
Official - US Pharmacopoeia (USP) and National formulary - lists sources, chemicals.
properties of drugs, tests for identity and other information useful to the pharmaceutical
industry
Text books- many available- best for novices
Reference Books -Physician's Desk reference (PDR) most commonly used.
Drug handbooks
Journals - medical and nursing
Internet -many reliable sites - use caution in selection, anyone can post
information eg- medscape.com, fda.gov, pharminfo.com, rxrned.com. Used by
professionals and nonprofessionals. Some sites allow purchase of drugs.
Other professionals - pharmacists, physicians, nurses
Poison control centers - available by phone for information about toxic effects
Pharmaceutical sales representatives - goal is sales - may down play negative information
Newsletters -The. Medical Letter- bimonthly report on clinical trails of 2-3 drugs.
FEDERAL DRUG REGULATION
1906

1912
1938
I 952
1962

Pure Food and Drug Act - Required labeling of bottle if it contained 1 of 11

dangerous drugs (adulterants). Weak law- nothing about safety or effectiveness.
Established USP and NF as official standards and empowered Federal
Government to enforce the standards.
Sherley amendment to 1906 act - prohibits false statements or false advertising
Federal Food Drug and Cosmetic Act - Required testing to prove drug nontoxic and
evaluation of safety by the Food and Drug Administration (FDA) before a
new drug could be marketed. Set standards for drug label.
Durham-Humphrey Amendment - Designated drugs that require a prescription
by a physician and dispension by a pharmacist. Restricted refills unless
prescribed. Recognized OTC drugs that require no prescription.
Kefaufer-Harris Amendment - Proof of safety and effectiveness before marketing.
All drugs marketed between 1938 and 1962 were to be tested for efficacy.
Classifications of efficacy: Effective, Probably effective, Possibly effective, Ineffective.
Drugs in probably or possibly effective class must be upgraded to effective or be taken
off the market. Allows FDA to regulate manufacturing, distribution, advertising and
labeling of drugs. Approved drugs listed in US Pharmacopoeia (USP). Also
established procedures for testing new drugs (SEE NEW DRUG TESTING)
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1978
1983
relatively
1992
1997

Drug Regulation reform Act - shortened time required for approval

Orphan drug Act - provided incentive for drug companies to produce drugs need by
few people.
Revision of 19621aw allows accelerated approval for drugs to treat life threatening or
severely debilitating diseases with fees charged pharmaceutical houses.
FDA Modernization Act- updated regulation of biological products, increased patient access
to experimental drugs and medical devices, and accelerated review of new important drugs.

Pending Internet Pharmacy Consumer Protection - sets standards for on-line Pharmacies
Controlled Drug Legislation
1914
Harrison Narcotic Act- Defined term "narcotic", B a n n e d the import or use of opium, cocaine,
marijuana or other narcotics.
1970

Controlled Substances Act- Rules for manufacture and distribution of drugs with
high potential for abuse. Defines controlled substances by schedules.
Established Drug Enforcement Agency (DEA) responsible for enforcement of law.
Written record must be kept each time a controlled drug is purchased or dispensed.
Inventory of drugs must be reported to DEA every two years (pbannacists,
prescribers, hospitals)
Highest potential for abuse- Schedule I, lowest -Schedule V.
Schedule I (C-1)- no medical use- highest potential for abuse- not
prescribed Schedule II (C-2)- prescribed only by persons registered with
DEA (MD, DO, DDS, NP) oral orders signed within 48 hrs, not renewable
without new order.
Schedule III or IV, oral or written prescriptions, refillable up to 5X within 6 months
Schedule V same as III, IV--some may be dispensed without prescription pharmacist to
adults as long as written record kept.
Classification can be changed by Attorney General or DEA.
Symbol C-11, C-ID, C-IV mus t appear on package label.
State laws may be more stringent

Nursing management of controlled substances:

Documentation of date, time, drug name and dose, patient's name, prescribers name and nurses name on
narcotic log sheet
Storage in a double locked cabinet - key maintained by licensed nurse
Narcotic count performed at start (end) of each shift by a nurse from each shift
failure to adhere to CSA is grounds for loss of license
SAFEGUARDS DURING PREGNANCY
FDA Pregnancy categories
A: Remote risk - controlled studies on humans with no fetal damage noted.
B: Slightly more risk- (animal studies- no risk and no human studies) or (animal studies -risk
but human studies -no risk)
C. Greater risk- (animal studies show risk/ no studies in humans) or no studies in
animals or
humans - weigh risk of disease vs damage
D: Proven risk - human studies show fetal harm - weigh risk in life threatening disease
X: Fetal damage documented - do not use - risk outweighs benefits. CONTRAINDICATED

NEW DRUG DEVELOPMENT

Preclinical testing: (1-5 years)
Animal tests to determine pharmacokinetics, toxicity, potentially biological (useful) effects.
Must submit data and file Investigational New Drug Application (IND) with FDA
before beginning test in humans. Plan for testing also submitted along with names
of investigators.
Clinical testing in humans: (2-10 years)
Phase I-healthy volunteers, or if side effects expected to be severe, may be tested in volunteers
who have disease (determine effects in humans and metabolism of drug- pharmacokinetics,
biological effects)
Phase II - small group of patients (10-200) to determine therapeutic response, dose, safety.
(men, critically ill women)
Phase III -larger, controlled tests in patients validate results of Phase II- use control groups,
double blind and cross-over studies to assess for placebo response. Total of 500-3000 in phase
II and III trials - take drug 3-6 months.
Application for conditional approval of New Drug application - if approved drug is
released for general use.
Phase IV - Drug approved for release -post marketing surveillance continues.
Prescribers monitor clients and voluntarily report adverse responses to the FDA.
Responses not noted in trials often occur with long term use and in use with wider
population (children, elderly). Most drugs are only tested in men. Women of childbearing age are excluded from trials except those with life-threatening diseases but
may receive a drug in phase IV.
Medwatch - a post marketing program that enables health professionals and consumers to
report adverse effects to the FDA via a form or on the internet
Practitioner reporting network - program sponsored by USP - 4 parts
1. Drug product problems - packaging and labeling, problems
2. Radiopharmaceuticals- radioactive drugs,
3. Medication errors- due to labels, packaging, miscalculations, marketing,
advertising, etc.
4. Medical devices - safety of medical devices (eg blood glucose meters)
Medication error index: scale developed by National coordinating council for medication reporting to
evaluate harm caused by errors.
PHARMACOTHERAPEUTICS
The use of drugs (medications) to diagnose, prevent or treat disease or to prevent
pregnancy
(Reason drug used) - Therapeutic use of a drug.
Requires information about drug (core drug knowledge) and the client (core
patient variables)
A knowledge of cellular physiology and pathophysiology is essential for
understanding the
Mechanism of drug action- typical response due to interaction between drug
and cellular receptor.
Dose-response relationships
Dose = amount given at one time, dosage =frequency, size and number of doses
Response is directly related to dosage, increase dosage - increase response. Dose can be adjusted
to meet individual needs.
The amount of medication required to produce a given response may vary considerably from
person to person depending upon factors which affect individual pharmacokinetics and
pharmacodynamics.
The dose-response curve describes the relationship between the clinical response
with the administered dose. Gradual slope = safe drug (large amount of drug
required to increase response), sharp slope= potentially toxic drug (small increase
in drug produces major increase in effect)
Potency is a measure of the amount of drug required to produce a given response smaller dosegreater potency.

PHARMACOKINETICS

Pharmacokinetics is the study of drug movement throughout the body. It includes the phases
of absorption, distribution, metabolism (biotransformation) and excretion (ADME). The
concentration of a drug at the site of action determines the intensity of response.
Information about pharmacokinetics determines the route, dose and timing of
administration to ensure a therapeutic blood level and to reduce the risk of
toxicity.

ABSORPTION
Movement of a drug from its site of administration into the bloodstream. Speed of absorption
affects bow quickly drug will start to work. Amount of drug absorbed (bioavailability) affects
amount delivered to site of action, affecting the intensity of action. Absorption is affected by:
Rate of dissolution-the ability of a drug to go into
solution (bow fast it dissolves) is related to the form of
the drug and the site of administration. The faster the
drug dissolves, the faster it will be absorbed and the
sooner it will start working (onset)
Surface area at site of absorption - small intestine bas larger
surface area than stomach
Blood flow - absorption higher with increased blood flow maintains concentration gradient on each side of membrane
Lipid solubility- higher lipid solubility increases absorption
(non-ionized m olecules are absorbed more rapidly)
Passage of drugs across a membrane:
In order for drugs to move through the body, they must cross cell membranes.
Drugs must be in solution to pass through a membrane. Drugs given by mouth
must be water soluble to disintegrate and go into solution in the aqueous fluids
of the stomach. Drugs that must pass &.rough a membrane must be lipid soluble.
Many drugs are water and lipid soluble
Membranes are layers of cells tightly packed together, generally composed of a double layer of
phospholipids (fat+ phosphate).
Drugs may cross a membrane by direct penetration of the membrane, with the aid
of a transport system or through channels or pores in the membrane. Direct
penetration of the membrane is the most common
Molecules must be lipid soluble to pass through membranes (membranes are primarily
lipids)
Substances that are not lipid soluble do not pass through membranes. Any molecule with an
electrical charge (ionized) or an uneven distribution of charges (polar)is not lipid soluble
and
will not pass through a membrane. Polar molecules are soluble in water (a polar substance),
not in lipids.
Non-lipid soluble substances pass through pores(between cells) or channels in the cell
membrane (only very small ions like Na+, K+, Ca++ use channels).
Substances that are acids or bases may exist as nonionized or as ionized
molecules. When in nonionized state the molecule can cross a membrane, when
ionized it cannot
Passive diffusion is the major process by which drugs enter the bloodstream and
most cells. It involves the movement of small molecules from an area of greater
concentration to a lower concentration. When equilibrium is reached, movement
stops.
Facilitated diffusion requires molecules to bind with a carrier substance such
as a enzyme or protein before diffusion can occur. Glucose and insulin
require facilitated diffusion.
Filtration is the movement of molecules through pores of a
semipermeable membrane - especially important in drug excretion.
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Active transport allows movement of large molecules from areas of low

concentration to areas of higher concentration. Energy (ATP) is needed to
move (pump) ions across the concentration gradient
Pinocytosis involves the surrounding of a particle by the cell membrane,
engulfing it and carrying it inside the cell. Used for transporting fat
soluble vitamins, proteins and strong electrolytes.
Drug bioavailability
The percentage of drug administered that actually enters the systemic circulation and can be
carried to the site of action.
Calculated by comparing the amount of drug present after IV administration with the
amount of drug present at peak plasma level.
Peak plasma level calculated by measuring drug levels over a given time period and
comparing levels from different routes of administration.
Core patient variables affecting absorption
Health status - may affect GI function, circulation. pH of body fluids, movement of drugs
through GI tract
Life span and gender - male and female physiology
varies - age: elderly - delayed gastric emptying possible,
reduced gastric acidity (drugs requiring acidity may not
be absorbed). Reduced cardiac output and circulation
impairs absorption.
Lifestyle, habits and diet affect absorption. Drugs taken with
food are generally absorbed more slowly. Certain drugs bind
with minerals in food or vitamins to render them insoluble.
Drugs given SC will be absorbed more rapidly if the area is
exercised.
Drug dosage forms
Tablets - drug, binders and fillers compressed together. Tablets made by different
companies may disintegrate and dissolve at different rates. Two tablets containing the
same amount of drug (chemically equivalent) may not be absorbed equally because of
differences in dissolution and absorption resulting in differences in bioavailability
(amount of drug free in the bloodstream that can produce a therapeutic effect Tablets
may be scored and may broken in half if a lower dose is needed.
Capsules - medication in powder, liquid or oil form encased by a gelatin shell. Some
capsules may be opened and the medication mixed with small amount of food when patient
has trouble swallowing.
Enteric --coated preparations - drug coated with material that prevents it from absorbing
in the stomach but allows it to go into solution in the intestine. Protects stomach from
irritants, d e l a y s absorption - often unpredictable.

Sustained release preparations - designed to dissolve at variable

rates - some drug released immediately, the rest steadily over time.
Allows fewer doses and steady blood level of drug generally more
expensive and at times absorption is variable.
Liquid oral preparations- may be elixirs or tinctures (drug dissolved in water/alcohol
base), solutions (water based), syrups (sugar solution) or suspensions (finely divided
drug particles dispersed in liquid - settles when standing) for those wbo have difficulty
swallowing tablets or capsules. Generally work quickly because they are already in
solution. May have short shelf life, may require refrigeration.
Sublingual or buccal tablets - dissolve in saliva in mouth and are absorbed through
mucous membranes directly into blood stream.
Transdermal ointments or skin patches- designed to be absorbed in a predictable m anner
through skin into blood stream.
Injectable liquids - may be for subcutaneous (SC, intramuscular (IM) or intravascular
(IV) use.
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Must be sterile and equipment used for delivery must also be sterile.
Injectable powders - not stable in solution. Must be dissolved before use. Directions on
label.

Routes of administration
Drugs given primarily via enteral (GI tract) or parenteral (Injection) routes. Also may be given
locally (skin, eyes, ears, mouth, vagina, rectum), by inhalation, transdermally, and by injection into
a joint. Must be sure drug can be given by prescribed route - there may be several preparations of
the same drug.
Parenteral- by-pass the GI tract, allows rapid onset of action, more predicable absorption, no
first pass effect (IV, SC, ID, lA, and interthecal)
Intravenous (IV) most common parenteral route- drug injected directly
into the bloodstream (no absorption).
Advantages- rapid onset, control over amount in blood, may be dissolved in large amount of
water, dilution allows use of very irritating drugs (chemotherapy)
Disadvantages - expensive, hard to administer, inconvenient and potentially dangerous
(irreversible once in blood). Excess fluid may cause fluid overload (excessive fluid in body
hypertension, pulmonai)' edema). Injection into blood vessel may cause infection, embolism
formation, may be irritating to veins.
Intramuscular (1M) I subcutaneous (SC) - drug injected into muscle or
fatty tissue, absorbed by capillary bed in and around muscle. Drug able to
enter blood stream through large spaces in capillaries. There is no barrier to
absorption. Rate of absorption depends on blood flow and water solubility of
drugs. Water soluble absorbed quicldy (10-30 min.)
Advantages -can be used for poorly soluble drugs, depot preparations (extended absorption
may last for weeks) can avoid frequent administration.
Disadvantages- discomfort, inconvenience, potential injury, unsuitable for large volumes.
Intraarticular- drug injected into synovial fluid of joint, produces local effect
(analgesia) little enters general circulation.
Intrathecal - drug injected into subarachnoid or sulxlural space of spine
to produce high concentration of drug in cerebrospinal fluid - analgesia,
anesthesia, antineoplastics
Enteral - into GI tract, may be absorbed in mouth or from stomach or small intestine
Oral (PO )- drugs must pass through GI membrane (cells tightly packed- no spaces as in
capillaries) Absorption affected by solubility and stability of drug, gastric I intestinal pH
gastric emptying time, food, co-administered drugs and the type of drug preparation (liquids,
tablets, enteric coating, sustained release), Drugs absorbed enter portal circulation and pass
through liver before entering general circulation. Liver may metabolize drug making
it ineffective (first-pass effect)
Advantages- easy, convenient, inexpensive, safer than parenteral- able to prevent absorption if
error made in administration.
Disadvantages- highly variable absorption (bioavailability) from person to person, difficult to
control onset, duration and intensity of action; some drugs destroyed by gastric acid or
digestive enzymes; some drugs deactivated as they pass through liver on way to general
circulation (first-pass effect); client must be conscious and cooperative; drugs may irritate GI
tract, self administration - may forget)
Sublingual or buccal (SL) -drug absorbed directly into circulation through capillaries in
mouth.
Advantage: rapid onset, no first-pass effect, simple to use
Disadvantage: not many preparations
Topical (skin, lungs, mucous membranes)

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Inhalation, transnasal- drug delivered to lungs as gas or aerosol for

local or systemic response
Advantage: ease of administration , rapid onset from lungs
Rectal - suppositories or retention enema placed in rectum, drug
absorbed and some carried into
vena cava -by-passes liver, other enters veins that go to liver- slower absorption but may be
more complete - some rectal doses lower than oral
Advantage: can be administered to unconscious or vomiting person
Disadvantage: uncomfortable
Transdennal: patches applied to skin -drug delivered to systemic circulation slowly over
time.
Advantage: easy application
Disadvantage: may cause local irritation, absorption affected by skin condition
Ophthalmic / otic preparations - used for local response, usually drops or ointment
Distribution
The movement of a drug throughout the body to sites of action and to storage sites
Distribution affected by:
Volume of distribution (Vd) - the amount of drug that leaves the serum and enters all body
compartments (fat. body fluids). When Vd is high- the amount of drug in serum is low.
Blood flow to tissues - carried by capillaries to tissues and organs. Blood flow to heart,
liver and kidneys is best- rapid effect. blood flow to center of abscesses and tumors is
generally poor and drugs cannot reach therapeutic levels.
Protein binding- Some drugs bind with proteins (albumin) which are too large to leave
capillaries. Binding is reversible -only a certain percentage of the drug will be bound at
any time. Percentage bound varies with drug and is expressed as a percentage, bound
drugs cannot leave blood, only free (unbound) drug can. Lowered protein levels
(hypoalbuminemia) results in less binding and more free drug. Drugs that are highly
protein bound remain in the body longer and have longer durations of action than nonprotein bound drugs.
Competitive binding - The number of available protein binding sites is limited and if more
than one highly protein bound drug is administered, the drugs compete for the sites and the
drug with the greatest affinity (chemical attraction) displaces the other drug from the sites.
When a drug is released from its protein binding site, a greater amount of free drug
becomes available and drug toxicity may result Competitive binding is a cause of many
drug interactions.
Storage in body tissues - drugs may be stored in other tissues - predominantly adipose
tissue (highly lipid soluble drugs) for long periods of time and may not be released until
the drug is no longer administered.
Blood-brain barrier - the structure of capillaries in brain provides a natural barrier to
the passage of drugs from the blood stream into brain cells. Highly lipid soluble
drugs pass through easily. Transport systems may be present for some drugs.
Placental barrier - A capillary network in the placenta keeps some drugs from leaving
the maternal circulation and entering the fetal circulation. Lipid soluble, nonionized
drugs pass easily into fetal circulation and into breast milk and may cause fetal
damage.
Ability to vascular system Drugs move to interstitial fluid through the intestinal
s ystem through pores in the capillaries except in brain where cells in capillaries are
tightly packed and drug must cross cell membrane. Fluids and molecules move from area
of greater pressure to one of lower pressure.
Entry into cells - Some drugs attach to receptors on outside of cell to produce effect but
others must move into cells to be effective and all must cross cell membranes to be
metabolized and excreted.
Core patient variables affecting distribution
Health status -liver damage may reduce albumin production
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Life span and gender - Blood brain barrier not well developed in
neonates - drugs more likely to have CNS effects. Elderly - reduced
serum albumin levels if malnourished. Increased % body fat - lipid
soluble drugs stored, plasma level decreased. Decreased total body
water and decreased lean body mass - water soluble drugs more
concentrated (more intense response)
Lifestyle, habits and diet- malnutrition may cause hypoalbuminemia.
Pregnancy - some drugs may bind with rapidly developing fetal
bones and teeth

METABOLISM (Biotransformation)
Alteration of drug by enzyme action; most biotransformation takes place in livereffect of hepatic microsomal enzymes (P-450 system). Other sites where metabolism
takes place include RBCs, plasma, kidneys, lungs and Gl mucosa. Only unbound
drugs can be metabolized.
Metabolism initiated by presence of foreign or alien substances in the blood
stream. It is an effort by the body to neutralize or detoxify the substance.
Metabolism may result in new chemicals (metabolites) that are:
o more water soluble (polar) than parent drug which promotes renal excretion.
o less active than parent drug or inactive which terminates drug action.
o more active than parent drug increasing therapeutic action.
o active - inactive prodrugs become activated producing a pharmacological effect
First pass effect- Drugs taken orally are carried by the hepatic -portal circulation to the liver
before being distributed throughout the body. Some drugs are deactivated and others become
less effective due to metabolism during this "first-pass" through the liver. Use another route.
Cytochrome P-450 system (CYP-450) - the enzyme system in the liver contains 12 isoenzyme
systems that are responsible for metabolism of endogenous substances as well as exogenous
chemicals. A notation system developed to identify the specific microsomal system involved in a
reaction assigns a numeral to each family and letters to subsystems in that family and another
number to identify a specific enzyme. CYP 1, 2 and 3 are the families most often involve in drug
biotransformation. CYP3A4 is the most abundant isoenzyme.
Drugs that are metabolized by a specific enzyme are referred to as substrates of the enzyme.
A drug may stimulate or inhibit liver enzyme synthesis (enzyme induction or inhibition. This
will affect the substrates of that enzyme. Some drugs are self-inducers - they increase their
own metabolism resulting in a condition called tolerance (the need to increase the dose to reach
a therapeutic effect). The dose may need to be adjusted to maintain therapeutic blood levels.
This is the most common cause of metabolic drug-drug interactions.
Competition between drugs for metabolism - liver may be unable to process two
drugs using same metabolic pathway at the same time (enzyme inhibition)smaller doses needed or one or both drugs may reach toxic levels in the body.
Core patient variables affecting metabolism
Health status - liver damage (hepatotoxicity) may alter enzyme system function
Life span and gender- limited metabolism in neonates, liver immature until one year, use of
drugs in neonate requires extreme care. Liver function generally deteriorates with advanced
age.
Lifestyle, habits and diet affect metabolism - malnutrition may interfere with enzyme
formation. Low protein diet may decrease protein binding and increase metabolism of highly
bound drugs. Grapefruit inhibits one isoenzyme system, charcoal and cruciferous vegetables
(cabbage, turnip, radishes) stimulate another. Cigarette smoke may increase drug metabolism.
Pregnancy - some drugs may bind with rapidly developing fetal bones and teeth
EXCRETION
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Removal of the active drug or it's active or inactive metabolites from the body. Most drugs are
excreted by the kidney. Other routes of excretion include the lungs (volatile drugs).skin, feces
(bile-enterohepatic recirculation) and breast milk (lipid soluble drugs). C l e a r a n c e i s the term
u sed to describe rate at which a drug is removed from the circulation
Renal drug excretion
Glomerular filtration - free drugs pass through pores in capillaries into tubules. Drugs bound
to protein, or large molecules cannot exit capillaries.
Passive tubular reabsorption - When the concentration of drugs is higher in the
tubule than in the blood the drug moves through the membrane back into the blood.
Only lipid soluble drugs can move across the membrane, therefore water soluble
(polar) drugs and ions are excreted in the urine. Metabolism changes many drugs to
water soluble metabolites to increase excretion.
Active tubular reabsorption - energy is used to carry from the filtrate into the renal arteriole.
Active tubular secretion -active transport systems (pumps) for organic acids and organic
bases are present in tubules which pump these substances from the blood into the tubules for
excretion.
Hepatic excretion - drug concentrated in bile and excreted into intestine
Lungs - volatile substances excreted unchanged by lungs.
Core patient variables affecting excretion
Health status - renal function, nephrotoxicity, impaired cardiac output decreases renal
perfusion
Life span and gender - neonates have immature kidneys and
cannot adequately excrete drugs for several months. Renal
function declines beginning in early adulthood, reduced
renal excretion (drug accumulates) monitor creatinine
clearance (a 24 hour urine test) in elderly to determine renal
function. Some drugs vary in excretion according to sex.
Lifestyle habits and diet - foods may affect u r i n e pH changing PH of urine filtrate affects which substances will
be in ionized form - ionized substances cannot cross the
membrane. Competition for active tubular transport - the
transport mechanism can only pump a certain number of
molecules at a time, therefore when more than one drug
requires active transport, the excretion of each drug will be
slowed and the action prolonged.
TIME COURSE OF DRUG RESPONSES
Need to understand when a drug response will start (onset), the time when it will be most intense
(peak) and when it will cease (duration). Time course of drug action is generally related to the
concentration of drugs in the blood which determines the concentration at receptors (sites of
action).
Plasma drug levels
Plasma drug levels helps predict concentration at effector sites.
Half-life (t 1/2)- time required for drug in body to be reduced by 50%. This determines
dosing interval need to maintain an effective drug level. Short half-life requires more frequent
administration.
Repeated dosing leads to drug accumulation and a buildup of drug in the body until
a steady level (equilibrium) is reached. Rate and dose of drug intake= amount of
drug excretion, generally requires about five half lives. Maximum therapeutic effect
occurs when steady state is reached. May take several weeks for some drugs. Same
time required for drug to be eliminated when treatment stopped.
Minimum effective concentration (MEC) - (Threshold concentration) - The minimum
amount of drug necessary to cause a response.
Toxic concentration- amount of drug necessary to cause a toxic response.
Therapeutic range -area between MEC and toxic concentration - goal of drug therapy.
Narrow therapeutic range - small difference between MEC and toxic dose - difficult to manage.
Wide therapeutic range - large difference between MEC and toxicity - safe drug.
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PHARMACODYNAMICS
Study of the impact of drugs on the body (physiochemical response) and how drugs affect the
physiology of the cell.
Characteristics of drugs
Drugs generally bind to four protein targets - canier molecules,
enzymes, ion channels or receptors.
Drugs can only modify existing physiological functions- they cannot
create new functions
Drugs create multiple effects in the body - not just the desired
therapeutic effect
The concentration of the drug at the site of action determines the
response (see dose response relationships- pg 4)
Drugs produce effects by drug-receptor interaction, drug-enzyme
interaction or nonspecific interaction.

Theories of drug activity

Drug-Receptor interaction
Receptor- m a c r o m o l e c u l e s (proteins) present on or within cells that respond to body's
own regulatory ch e mi c a ls (hormones, neurotransmitters, other regulatory substances).
Thousand may be present on a cell membrane.
Receptors vary in type and in response and are specific for designated regulatory
chemicals. Drugs must ''fit the receptor in order to be effective (lock and key)
Drugs bind to receptors (drug-receptor complex) and produce a response. Drugs can only
mimic or block the physiological response that the particular receptor controls.
Types of responses include alteration in enzyme systems that regulate cell function;
alteration in cell permeability allowing movement of ions in or out of the cells by
opening or closing ion channels; or alteration in neurohormones resulting in changes in
physiological processes.
The more receptors are occupied, the greater the intensity of the response elicited and
when all receptors are occupied the maximum effect will be produced. Increasing the
dose when receptors are saturated will produce no additional effects.
Agonist- molecules that have affinity for a receptor and activate receptors (efficacy)mimic body responses by occupation of the receptor. The response may be an
increase or decrease in physiological function depending upon which receptor is
stimulated.
Antagonist - molecules that have affinity for and react with cell receptor but produce no
response. Produce effect by preventing activation of receptors by endogenous or
exogenous regulatory molecules. Blocks effect of agonist. No efficacy.
Competitive antagonism: Binding of agonists or antagonists to receptors is usually
reversible. If affinity is equal the drug present in the greatest concentration will occupy
the majority of receptors. Most antagonists are competitive. A few chemicals cause
irreversible binding but are not used because the effect cannot be terminated.
Mixed agonist-antagonists have affinity for more than one receptor but do not have efficacy
at all binding sites.
Receptors can be synthesized or altered - prolonged stimulation of an excitatory agonist
usually results in a decrease in number or sensitivity of receptors while prolonged
inhibition of receptors often results in increased receptor number or sensitivity.
Drug-Enzyme interaction
All biochemical cellular reactions are controlled by enzymes.
A drug may be administered to alter the production of metabolism of an enzyme - increasing or
decreasing the activity of the enzyme.
21

Nonspecific drug effects

Chemical interactions- neutralization (antacids)
Osmotic responses - increase osmolarity and draw fluids into area (osmotic diuresis of
mannitol, laxative action of magnesium hydroxide)
Structural similarity to cell nutrients - incorporated into cell and interfere with cell function
(cancer drugs, antiviral drugs)
Insoluble complexes combine with toxic materials and prevent action or allow excretion or
toxin (binding of arsenic by dimercaprol)
Variables affecting drug dosage
Loading dose
A larger than normal dose given at initiation of drug therapy to bring the serum level up more
quickly that what is required to reach a steady state (5 half lives).
When therapeutic steady state is reached, a maintenance dose is given.

Therapeutic index (TI)

The ratio of effective dose to lethal dose measures the relative safety of a drug. The wider
(larger) the Tl, the safer the drug. A narrow TI requires careful management to ensure the
safe dose is close to the lethal dose. A TI of I means ED = LD
Effective dose- 50 (ED so) The dose that falls in the middle of the dosing range
(50% respond to that dose -50% do not) is used as the standard starting dose for
establishing an individual medication plan.
Toxic dose - amount of drug that produces poisoning - may be single large dose or repeated
smaller doses.
Lethal dose - dose that causes death.
Tolerance
Decreased response to a fixed dose of drug- huger doses must be given to achieve effect
Receptor tolerance - requires increased dose to produce desired response (inc. MEC).
Receptor may adapt to repeated stimulaion by down regulation (fewer or less active
receptors)
Higher dose needed to produce same effect (eg morphine)
Metabolic tolerance - increased metabolism of drugs as a result of stimulation of
hepatic enzymes - increases t 112- need higher dose to maintain same blood
levels. (MEC unchanged)
Tachyphylaxis - Rapid onset of tolerance - uncommon. Higher dose does
not overcome tolerance
Client related variables
Several factors affect individual response to drugs and produce individual variations in dosage:
Age - infants and elderly most affected by organ immaturity or malfunction.
Body weight I composition -weight or body surface area used to adjust dose. Smaller person
needs Jess drug to reach therapeutic concentrations at site of action. Body surface area
considers amount of body fat present - may be factor in lipid soluble drugs.
Pathophysiology - diseases can affect drug response:
o Kidney disease affects renal excretion, drug accumulates in blood and may reach toxic
levels
o Liver disease affects biotransformation, drugs metabolized by liver need reduced dose.
o Acid-base balance - changes in pH affect ionization pharmacokinetics affected

22

o Altered electrolyte balance - more likely to affect body function

than response to drugs (low K levels likely to cause digoxin
toxicity - cardiac arrhythmias)
Placebo effect - drug response as a result of psychological response not to component of
drug.
Client needs positive outlook or effect can be negative
Variable absorption
o Alteration of gastric pH
o Altered gastric and intestinal mobility
o Food in the stomach
Lack of compliance, errors in administration - teach client, 5 rights of administration
Drug and food interactions
Diet, albumin levels, vitamins

ADVERSE DRUG REACTIONS

An adverse reaction is any undesired reaction to a drug - range from annoying to lethal. Annual cost
of treating adverse reaction is about 5 billion and accounts for 5% of hospital admissions.
When a reaction cannot be explained by the disease, abates when drug is stopped, recurs when
drug restarted and cannot be explained by other medications being taken - then it is an adverse
reaction. When a adverse reaction is noted to newly released medication the prescriber should
(voluntary) report it to the FDA. Use Med Watch form.

Side effect - secondary drug effect produced at therapeutic doses. Predictable, dose
dependent reactions.
Allergic reaction - immune (antibody-antigen) response, dependent on degree of
individual sensitivity- not on dose. Requires previous sensitization (exposure) and
development of antibodies. Response is due to release of histamine
Anaphylactic reaction (anaphylaxix)- severe allergic response with
bronchospasm. Laryngeal edema, hypotension and cardiovascular collapse
Treated with epinephrine
Idiosyncrasy (idiosyncratic response)- unusual response (exagerated, decreased or
unexplainable - also called paradoxical) probably due to genetic enzyme deficiency that
alters drug metabolism.
Toxicity- reaction related to excessive dosage. May be due to overdose or drug a
cumulative effect related to faulty metabolism or drug-drug interactions. May involve
any body system - neurotoxicity, nephrotoxicity, immunotoxicity, cardiotoxicity,
ototoxicity. Common usage- any severe adverse reaction regardless of dose.
Iatrogenic disease - drug induced disease
Physical dependence - alteration in body chemistry that results in abstinence syndrome
(withdrawal reaction) when drug is discontinued. Warn client not to stop drugs suddenly.
Carcinogen - chemical capable of inducing cancer. Usually takes many years to
become evident
Teratogenic effect Fetal damage as a result of drug use. Most malformations occur during
the first trimester.

Nursing Implications
Be informed about medications - know expected adverse effects. Obtain history of previous
medication reactions.
Assess for possibility of pregnancy.
Risk categories- very young, very old, very sick, on multiple medications (polypharmacy)
Teach client what to expect from drug and what to report
Assess client for expected and unexpected responses to medications - especially newly
released drugs. Be aware that reactions may occur early or late in treatment regimen.
Monitor effects of drugs on organs - generally liver, kidneys and bone marrow frequent
sites.
o Liver damage - malaise, abdominal discomfort, jaundice, dark urine. Liver function tests
23

o Kidney damage - frequent urinalysis creatinine clearance and serum creatinine.

o Bone marrow depression - periodic blood cell counts - may affect red cells, white cells, both
Drug interactions
Drug - drug interactions
Drug-drug interactions may occur when client takes more than one medication. Drug
interactions may be beneficial or hannful. The more drugs a client takes, the greater the
possibility of an interaction. Most hospitalized patients take 6-10 drugs. Very important to
take a good drug history. Remember- clients often do not report arc medications, be sure to
ask.
Pharmacokinetic Interactions
Altered absorption- may increase or decrease rate or amount of drug absorbed
Drug binding - drug interacts with another drug or substance in GI tract preventing
absorption
Altered GI motility- most drugs absorbed in small intestine (affected by gastric
emptying time), Increasing or decreasing motility of intestine affects time available for
absorption.

Altered Gl pH- change in pH may interfere with dissolution of drug and may affect
ionization. Ionized molecules are not absorbed.
Parenteral drugs may interact and form precipitates that cannot be absorbed.
Some may neutralize each other.
Altered metabolism - may affect hepatic P-450 system enzyme system
Enzyme induction by drugs affects own or other drugs metabolism. Faster metabolism
less therapeutic effect. Includes anticonvulsants, chronic alcohol use, nicotine
Enzyme reduction by drugs - raises serum levels to toxic levels in some cases. Not
clinically noticed i f drug that reduces P-450 is started first because other drugs are
adjusted to maintain serum levels. Can be a problem if inducer is stopped. Grapefruit
may decrease metabolism of calcium channel blockers. Effect occurs even when
grapefruit taken at a different time of day.
Altered excretion - some drugs require active tubular secretion and if more than one
drug requires use of the same system, competition for use may prevent elimination
of one or both drugs causing toxicity.
Pharmacodynamic Interactions
Interactions that increase therapeutic response
Additive effect two drugs with similar action taken together
to increase the response (1+1=2)
Combination may be intentional- codeine and acetaminophen,
or undesirable (alcohol+ aspirin =bleeding)
Synergistic effect - two drugs with different sites or mechanisms of action produce
increased intensity of response than by either drug taken alone. (1+1 = 3) My be
positive or negative.
Potentiation - like synergism - one drug that is weak alone enhances the action of
another drug (1/2 = 1 = 2)
Interactions that reduce therapeutic effects
Antagonism- action of one drug cancels action of another (1+1 = 0). Competitive
antagonism at same receptor- agonist-antagonist interactions may be used as antidote
(narcan and morphine). Administering acid with base produces an inactive salt (heparin
and protamine).
Drug-food interactions
Food may impact on pharmacotherapy by affecting pharmacokinetics or pharmacodynamics
Primary effect is on absorption of oral meds. Generally food slows absorption - a
few drugs are absorbed better with food. Food decreases gastric irritation
24

Drug-nutrient interactions
Specific nutrients in food may interact with drugs. Interactions may affect absorption of
drug or nutrient resulting in excessive absorption or retention of nutrients or drug.

PHARMACOLOGY AND THE NURSING PROCESS

Preadministration assessment - depends on characteristics of the drug and reason for administration
Core Drug Knowledge
Identify all drugs used by client - prescription and over-the-counter (OTC)
Look-up specific information about each drug - pharmacodynamics, pharmacokinetics,
prototype
Determine reason for prescribing drug for each patient- is use appropriate?
Know expected responses- (therapeutic and adverse responses, drug interactions)
Identify contraindications (drug should not be used) or precautions (used with extreme care)
Core Patient Variables
Interview client -Collect relevant baseline data- needed to evaluate responses to treatment
Health and drug history: medical history ( disorders affecting essential systems cardiovascular, hepatic, renal, GI etc), Multiple illnesses- poly-pharmacy, Drug history
(allergy,adverse responses to drugs)
Life span and gender: Age - elderly likely to take multiple drugs. Pregnancy, risk for fetus,
breastfeeding. Ability for self-care (age, developmental level, education, ability to read,
physical impairment, mental impairment).
Lifestyle, diet, habits: Use of alcohol, tobacco, street drugs, caffeine, eating habits, risk for
food drug interactions
Environment Home, work, exposure to sunlight, risk factors for injury, storage of drugs
Culture: Religious restrictions on treatments, family beliefs, genetics affects metabolism
of some drugs
Physical examination
signs and symptoms of disease
risk factors
height and weight, nutritional status
condition of skin - rashes
Review medical record
lab tests
25

diagnostic findings

Analysis
Review data (core drug knowledge and core patient variables) and identify current, actual or risk of
problems developing during drug therapy (interactions, adverse effects)
If life threatening response expected- drug is contraindicated
Use precaution - administer with caution if non-life threatening response likely
Risk of disease outweighs risk of administration- drug relatively contraindicated
Nursing diagnoses
Based on specific risks related to drug - adverse effects or interactions
What potential problems may arise? (risk factors, adverse effects of drug, potential
interactions, precautions Identify risks based on info from assessment and core drug
knowledge e.g -Potential for injury, Sleep disturbance, Altered bowel elimination
constipation/ diarrhea) Risk for injury (falls) related to drug induced sedation
What information does client have about drug regimen - Knowledge deficit RT regimen
How compliant is client?- Ineffective therapeutic management, Ineffective coping
Desired outcomes
Based on nursing diagnosis - prevent or reduce potential problem e,g - Client will be protected
from falls or injury related to sedation
maximum benefit - minimum harm

26

Planning and intervention

The goal of nursing management in drug therapy is to maximize the therapeutic response and
minimize the side effects and adverse effect of a drug.
Identify interventions that help meet desired outcome, e.g teach client to use call bell to get help
when ambulating
Steps to maximize therapeutic effects
Use correct route
Give drug on time.
Monitor serum drug level as ordered
Steps to minimize adverse effects
Identify and report potentially serious interactions to health care provider (HCP)
Administer drug properly. Time drug administration to achieve /prevent drug interactions
- additive or synergistic drugs given together, antagonistic drugs at different times.
Drugs must be administered at appropriate time to meals- empty stomach ( lh ac, 2h pc)
Monitor for adverse responses, changes in health status,
Hold drug if adverse responses (eg hypertension bradycardia), abnormal labs are detected.
Client and family Education
Assessment- knowledge of disease and drug -determine learning needs, learning ability,
special needs, lifestyle
Analysis - determine what needs to be taught (knowledge deficit)
Planning - best way to teach material - demonstrations, discussion, handouts, video
Include following information:
Dosage and Administration
a.Drug name: (generic and trade), therapeutic category, reason for use
Dosage: amount, schedule, memory aids
b.
c.Route: method of administration, how to take drug, what to do if dose
missed
d.
Duration of treatment
e.Drug storage: refrigeration, protected from light, in child proof area
Therapeutic response
a. Expected action
b. When to expect res pons e
c. Measures to enhance effect, prevent adverse responses
Adverse effects/ toxic reactions: how to treat, when to report
Interactions: drug-drug, drug-food
Intervention - teach material, document content, time spent, response to teaching
Evaluation - outcome of teaching
Evaluation - ongoing assessment
Monitor for therapeutic response
Monitor adverse responses / interactions
Determine adherence to regimen (drug levels, pill count, interview)
Assess client satisfaction with regimen
Report findings to health care provider (HCP)

27

CORE PATIENT VARIABLES THAT AFFECI' DRUG THERAPY

DRUG THERAPY IN PEDIATRIC PATIENTS
Children differ from adults in physiological responses to drugs due to immaturity of systems,
greater fluid composition of the body, and smaller size.
Pharmacokinetic variations in infancy
Increased sensitivity to drugs due to immaturity of organs. Very young (under 1 yearespecially under I month) at highest risk.
Pediatrics divided into 6 age groups - premature (less than 36 weeks gestation), full term infant,
neonate (birth - 4 weeks), infant (5 - 52 weeks), children (1-12 years) and adolescent (12-16
years)
Drugs are not tested in children- only 10% of drugs are approved for use under
age 12. Drugs must still be used to treat illnesses.
Effects of immature pharmacokinetic processes Absorption
Oral -delayed gastric emptying for 6-8 months, less acid (first 24 hrs especially) up to I year.
IM- neonate- slow, erratic (poor blood flow)
infant - variable depending on circulation
Percutaneous (transdermal)- skin more permeable, increased absorption -risk of toxicity
Distribution
Greater percentage of body fluid causes dilution of water soluble drugs in all
body fluids -less in the blood - may required higher doses to reach therapeutic
concentration in blood.
Lower fat stores decrease storage of fat soluble drugs - more in blood - may cause toxicity
Lower plasma proteins due to immature liver causes reduced protein binding (up to about 6
months) - higher serum levels of free drug in infant may cause toxicity
Immature blood brain barrier in neonate - increased response to CNS drugs
Metabolism
Immature liver (especially first month) mature by 1 year, from 1-2 years -faster
metabolism than adult - may need higher dose 1kg than adult
Excretion
reduced renal excretion up to 30 months (especially first 3 months)
Adverse drug reactions
Most drugs are not tested in children- use with caution
May be the same or more severe than with adults - some effects dependent upon stage of
development- growth retardation (steroids), discoloration of teeth (tetracycline), Reye's
syndrome (aspirin)
Nursing interventions
Administer oral meds using syringe without needle or measuring dropper.
Tablets may be crushed and mixed with food or fluid (not formula) -dilute in small amount to
be sure entire dose is taken.
If dose is spit out or vomited - estimate amount of drug lost and report to prescriber for orders
Greatest error involves calculations - check each dose before administering.
Immediately report any drug error to prescriber.

28

DRUG THERAPY IN PREGNANCY AND BREAST FEEDING

Must balance risk vs benefit. Most drugs have not been tested on pregnant women and effect on fetus is
determined by laboratory tests. Many pregnant women need to take medication - treatment of chronic
disorders, pregnancy induced problems.
Physiological changes of pregnancy
Decreased intestinal mobility- increased absorption of drugs
Increased hepatic metabolism of some drugs - may need higher dose
Renal blood flow increases by 50% by third trimester- GFR of drugs excreted by kidney increased
Placental drug transfer
All drugs can cross placenta - lipid soluble drugs pass more easily - ionized, polar or protein bound
cross more slowly.
dependency producing drugs can result in drug-dependent infant (shrill cry, vomiting, irritability) Need
to wean off drugs
pain relievers during delivery can depress respiratory depression
Adverse reactions during pregnancy
Drugs may adversely affect mother - some unusual reactions to drugs during pregnancy eg heparin
causes osteoporosis and spinal compression; aspirin suppresses contractions
Teratogenesis- congenital anomalies- 3% of all anomalies due to drugs; Most gross malformations
develop during first trimester (embryonic period). Functional disruption occurs during second and third
trimester (brain development). Difficult to identify teratogens- can't do research on humans. Effect
only found in I 0% of pregnancies exposed to teratogen. Animal studies of limited value as different
species respond differently. Studies done retrospectively on women who used medications during
pregnancy.
FDA Pregnancy categories (1980)
A: Remote risk - controlled studies on human with no fetal risk demonstrated
B: Slightly more risk- (animal studies- no risk but no human studies) or (animal studies -risk
but human studies -no risk)
C: Greater risk- (animal studies show risk/ no studies in humans) or no studies in animals or
humans - weigh risk of disease vs damage
D: Proven risk - human studies show fetal harm - weigh risk in life threatening disease
X: Fetal damage documented - do not use - risk outweighs benefits. CONTRAINDICATED
Preventing teratogenesis
A void all nonessential drug use during pregnancy, especially alcohol and
cocaine
Drugs approved before 1983 are not required to be classified by pregnancy
category.
If drug treatment is necessary - use lowest risk drugs when possible.
Risk highest first 8 weeks - most women do not know they are pregnant
Anyone requiring the use of toxic medications should be counseled to avoid
pregnancy.
Ultrasound can identify defects and extent of damage. Termination of
pregnancy (TOP) may be suggested. Minor abnormalities (cleft lip) may be
repaired after birth.
Drug therapy while breast feeding
Nearly all drugs can enter breast milk, not all will reach effective levels (lipid soluble are most likely to
reach high concentrations)

 When drug is essential - take dose right after feeding, avoid drugs with long half-life, select nonlipid
soluble drugs or highly protein bound drugs, avoid hazardous drugs or drugs that will affect baby.

DRUG THERAPY IN OLDER ADULTS

Problems with medication use in the elderly
Increased sensitivity to drugs due to organ system degeneration.
Increased risk of drug reactions and interactions due to polypharmacy.
Increased severity of illness and multiple pathologies.
Poor compliance with drug regimen.
Pharmacokinetic variations i n the elderly
Absorption
increased gastric pH and decreased motility
decreased blood flow and decreased absorptive surfaces
Distribution
increased body fat and decreased body fluid
decreased cardiac output, reduced circulation
decreased serum albumin
less effective blood brain barrier
Metabolism
decreased liver function - smaller mass and blood flow
Excretion
decreased renal output - reduced GFR and tubular secretion
Pharmacodynamic variations i n t h e e l d e r l y
possible changes in receptor response to drugs - decreased intensity of response to agonist - increased
response to antagonists
Adverse drug responses
More common than in younger adult and major cause of death and hospitalization
Many reactions due to over dose - drug accumulation due to renal/hepatic changes.
Other causes- poly-pharmacy, poor adherence, drugs with low therapeutic index, severe illness.
Prevention
Thorough history- OTC and prescription drugs
Consider pharmacodynamics when reviewing drug actions.
Initiate treatment with lower doses and adjust based on clinical responses or plasma levels
Monitor for drug-drug or iatrogenic responses
Teach clients to discard old, unused medications
Non adherence
40% or more elderly do not take meds as prescribed
greatest error is under dosing with therapeutic failure
unintentional non adherence due to forgetfulness, failure to understand instructions, inability to
pay for meds, complex regimens
intentional noncompliance - doesn't believe drug is necessary, unpleasant side effects,
expensive
Promoting compliance
simplify regimen
teach- rationale for drug, use- especially for intentional noncompliance
give verbal and written instructions
label containers clearly, use easy-open containers
choose appropriate dose form - liquid if difficulty swallowing
30

keep calendar, written record or use weekly dose containers- count pills
determine access to pharmacy, ability to purchase medications
enlist aid of family/friend/ home health care professional
monitor for therapeutic and adverse effects
CULTURAL CONSIDERATIONS

Culture- shared customs and traditions, norms and values, religion, institutions, arts, history and
folklore of a group.
Ethnicity - a group that shares a cultural heritage and is linked by race, nationality or language.
Cultural competence -an awareness of one's own values and beliefs, demonstrated knowledge and
understanding of another's culture and acceptance and respect for cultural differences. Cultural
variations in perception of health
Biomedical view- North American's- describe health from scientific point of view
Magico - religious view - various cultures - supernatural forces control health and illness, use
prayer or intervention of folk healer in addition to scientific treatment (voodoo, hexes, spells,
evil eye)
Holistic view - Native Americans, Chinese - everything in nature is in harmonious balance, any change
creates chaos and disease (yin and yang, hot and cold) use exercise, herbals, nutrition and meditation to
restore harmony
Nursing assessment
Communication - language, nonverbal communication (facial expression, use of touch
Family roles and organization - head of household, gender roles, family goals, lifestyles
Spirituality -formal religion and behaviors that provide meaning to life -may influence diet, health care
practices
Biocultural ecology- specific physical, biological and physiological variations due to ethnicity- genetic
predisposition to disease, variation in response to drugs
Predominant ethnic groups in U.S.
White Americans - European heritage, future oriented, time highly valued, nuclear family
common - nonnuclear family increasing, Christianity predominant religion, Judaism
second., practice traditional western medicine
Black Americans -Afro-American largest group, more present oriented, circular view of
time - not as rigid (most adapt to rigid view of time), many extended families with
grandmother as head of household, most Christian (Baptist, Methodist) with active
participation, Islam is also practiced . Folklore may be practiced due to poor access to
treatment for many, healing considered a gift from God (prayer, laying on of hands, healers,
voodoo). Respond to some drugs differently than whites.
Asian/Pacific Islanders - many variations in culture, Chinese most common in US. Chinese - not ruled
by time, strong family ties, male has predominant role as head of household, many religious
preferences, believe in harmony between the elements of nature (fire, water, wood, earth, metal) and the
cycles of life. Body and spirit must be cared for, believe in balance between yin and yang. Practice
Western and Eastern medicine. M any drugs react differently in many Chinese.
Hispanic Americans - many groups (Mexican, Puerto Rican, Cuban, Latin American) - Mexican most
prevalent Mexicans - present oriented - time concept relaxed, families generally patriarchal, fatalistic
view of health (luck, God's will), most Christian (many sects) Expected to maintain health by eating
and working properly. Use herbs and amulets, holistic healers. Illness is an imbalance among humors
(blood, yellow bile, phlegm and black bile)
Native Americans- over 500 tribes- Navaho predominate, Communicate with silence, carefully
consider responses, Little value for time - activity begins when a group gathers. Grandmothers and
mothers make most decisions, spirituality viewed as harmony with surroundings - Illness is due to lack
of harmony. Healing ceremonies restore balance. Genetic predisposition to type 2 diabetes is high.
Nursing management
A void ethnocentrism, stereotyping and cultural blindness
Use an interpreter -look at patient, do not raise voice, allow time for translation, avoid relatives

Use nonverbal communication and pictures

32

LONG ISLAND UNIVERSITY SCHOOL OF NURSING

Applying the Nursing Process with Clients Taking Medications
Describe the role of the nurse related to the use of______________________________ in the treatment of_____________________
A. Assessment
o History & Physical Assessment
o Knowledge (disease, drug therapy)
B. Analysis
o Nursing Diagnosis
o Potential Complications
o Contraindications
o Collaborative Problems
C. Planning
o Teaching:
Drug administration
Therapeutic response
Side effects
Adverse Effects
Responses to report (nurse/physician)
Potential drug interaction
o Monitor
Therapeutic response
Side/Adverse effects
o Safety Factors
A. Interventions
o Drug Administration
Route
Special considerations
Procedures
o Managing Responses
Independent interventions
Collaborative interventions
o Maintain Safe Environment
B. Evaluation
o Therapeutic Response
o Side Effects
o Adverse /Toxic Effects
o Compliance

o Response to Teaching