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FOUNDATIONSFOUNDATIONSOF PHARMACOLOGYOF PHARMACOLOGY
Slide 1
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Greek ³pharmakon´, drugs
and ³logos´, science
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DefinitionDefinition
Deals with the study of drugs and their actions in
living microorganisms
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History of PharmacologyHistory of Pharmacology
Since time immemorial, medicaments havebeen used for treating disease in humans andanimals.
Belief in the curative powers of plants and
certain substances rested exclusively upontraditional knowledge, that is, empiricalinformation not subjected to criticalexamination.
The birth date of pharmacology is not asclear-cut.
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History of PharmacologyHistory of Pharmacology
Ancient Times A series of scattered facts exists thatspeak of the early history of humankind's efforts to harness thehealing properties of naturalcompounds. However, what we knowfor certain is that ancient peoples madeextensive use of plant, animal andmineral sources for this purpose.
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History of PharmacologyHistory of Pharmacology
The Ebers papyrus, written in Egypt in the 16th centuryB.C., lists the extensive pharmacopia of that civilization.Included in this are: beer, turpentine, myrrh, , juniper
berries., poppy, lead, salt andcrushed precious stones. Also
included were products derivedfrom animals, including lizard's
blood, swine teeth, goose grease,ass hooves and the excreta from
various animals. The effects of many of these drugs on patients of
antiquity can only be imagined.
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History of PharmacologyHistory of Pharmacology
From ancient China comes evidence of thatculture's extensive efforts to heal through theuse of natural products. The P en Tsao, or Great Herbal, comprised forty volumes
describing several thousands of prescriptions.
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History of PharmacologyHistory of Pharmacology
Interestingly, the easternherb Artemisia annuaL. (wormwood), usedin China since antiquity
to treat fevers, is thesource of the moderndrug qinghaosu, whichshows great promise
as a modern anti-malarial compound.
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History of PharmacologyHistory of Pharmacology
Antiquity to themodern eraThe ancientsconsidered disease aconsequence of demonic possession,or the wrath of god.Thus, in ancienttimes, the treatmentof illness with natural
products wasinvariablyaccompanied byreligious ritualsdeemed essential to
the healing process.
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Claudius Galen (129Claudius Galen (129± ±200 A.D.)200 A.D.)
first attempted toconsider thetheoreticalbackground of
pharmacology. Both theory andpractical experiencewere to contributeequally to the rationaluse of medicines
through interpretationof observed andexperienced results
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History of PharmacologyHistory of Pharmacology
With time, the thoughts returned to theappreciation that the natural productsthemselves held the power to cure.
Although, traditional
remedies still generallyconsisted of complexmixtures of distinctherbs and minerals,
perhaps only one of which possessed any
activity. Many poisonous mixtures
were made.
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Theophrastus vonTheophrastus von HohenheimHohenheim(1493(1493± ± 1541 A.D.)1541 A.D.)
called Paracelsus, beganto question doctrineshanded down fromantiquity, demandingknowledge of the activeingredient(s) in prescribedremedies, while rejectingthe irrational concoctionsand mixtures of medievalmedicine
He prescribed chemicallydefined substances withsuch success thatprofessional enemies hadhim prosecuted as apoisoner
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JohannJohann JakobJakob Wepfer Wepfer (1620(1620± ±16951695))
the first to verifyby animalexperimentationassertions about
pharmacologicalor toxicologicalactions.
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Claude BernardClaude Bernard
In 1842,discovered thatthe arrow poisoncurare acts at the
neuromuscular junction tointerrupt thestimulation of muscle by nerveimpulses
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OswaldOswald SchmiedebergSchmiedeberg(1838(1838± ±1921)1921)
recognized as thefounder of modernpharmacology
helped toestablish the highreputation of
pharmacology.
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showed that muscarine evoked thesame effect on the heart as electricalstimulation of the vagus nerve
published a classic text, Outline of P harmacology , and in 1885, heintroduced urethane as a hypnotic.
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John J. AbelJohn J. Abel(1857(1857± ±1938)1938)
The ³Father of AmericanPharmacology´, wasamong the first Americans to train in
Schmiedebergµslaboratory and wasfounder of the J ournal of P harmacology and Experimental
Therapeutics (published from 1909 until thepresent)
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After 1920, pharmacological laboratoriessprang up in the pharmaceutical industry,outside established university institutes.
After 1960, departments of clinical
pharmacology were set up at manyuniversities and in industry.
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Fundamental concepts such as structure-activityrelationship, drug receptor, and selective toxicityemerged from the work of, respectively, T. Frazer (1841±1921) in Scotland, J. Langley(1852± 1925) in England, and P. Ehrlich (1854±
1915) in Germany. Alexander J. Clark (1885±1941) in England first formalized receptor theory inthe early 1920s by applying the Law of Mass Action to drug-receptor interactions.
Together with the internist, Bernhard Naunyn(1839±1925), Schmiedeberg founded the first
journal of pharmacology, which has since beenpublished without interruption.
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History of PharmacologyHistory of Pharmacology
For example, the purplefoxglove, Digitalis
purpurea, was one of twenty herbs used in a
folk remedy to treatdropsy in 18th centuryEngland.
From the leaves of this
plant was isolated thecardiac glycosidedigitalis, a drug stillused today to treatheart failure.
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History of PharmacologyHistory of Pharmacology
Over time, as a moresophisticated view of illness evolved, anincreasingly scientific
approach to theisolation of drugsfrom natural productswas taken. In the
early 19th
century,morphine was isolated from the opium poppy ( Papaver
somniferum) and the anti-malarial compound quinine from the bark of the cinchona tree (Cinchona officinalis).
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History of PharmacologyHistory of Pharmacology
M ateria M edicaThe ancient discipline of M ateria
M edica was born, devoted tounderstanding the origin,preparation and therapeuticapplications of medicinal
compounds.It postulated that:
Each disease has a uniquecause for which there is aspecific remedy.
Each remedy has an identifiable nature or essence that is extracted fromthe natural product by chemical extraction.
The administration of a remedy is based on testing the amount of drugneeded to achieve an effect (dose-response).
F rom Stata Norton
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History of PharmacologyHistory of Pharmacology
Paul Ehrlich described drug-receptor binding:
³Corpora non agunt nisi fixate´. P. Ehrlich (1908)
(³Agents do not act unless they are
bound´)
In the United States, transformation was marked by thecreation of the American Society for Pharmacology and
Experimental Therapeutics (ASPET) in 1908.
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History of PharmacologyHistory of Pharmacology
The modern eraThese, and additional advances in the fields of chemistry and physiology, lead to the birth of modern pharmacology in the latter half of the
19th
century.T
hus,M
ateriaM
edica evolvedinto the
experimental scienceof pharmacology,
which is devoted tounderstanding the
physiological actionof these molecules.
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History of PharmacologyHistory of Pharmacology
The 20th
century has witnessed the discovery of a steady stream of important new drugs thathave immeasurably improved the humancondition.
Not very long ago, vast numbers of humansperished prematurely or suffered an existencefilled with pain due to the effects of infection or disorders that are now successfully treated.
chemotherapy of cancer
microbial infections
diabetes
hypertension
depression
AIDS
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SignificanceSignificance
The goal of studying pharmacology is tounderstand how such therapeutics work andto use this knowledge, along with techniquessuch as molecular modeling and computer-
aided design, to develop new ideas that maylead to the miracle drugs of the future.
Additionally, toxicology is an important areaof pharmacology that focuses onunderstanding the adverse effects of certaindrugs and environmental pollutants
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Introduction to DrugsIntroduction to Drugs
Until the end of the 19th century,medicines were natural organic or inorganic products, mostly dried, butalso fresh, plants or plant parts.
These might contain substancespossessing healing (therapeutic)properties or substances exerting a
toxic effect.
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In order to secure a supply of medicallyuseful products not merely at the time of harvest but year-round, plants werepreserved by drying or soaking them invegetable oils or alcohol.
Drying the plant or a vegetable or animalproduct yielded a drug (from French³drogue´ ± dried herb).
Colloquially, this term nowadays often refers
to chemical substances with high potential for physical dependence and abuse
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Sources Of DrugsSources Of Drugs
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Therapeutic MethodsTherapeutic Methods
Drug therapy Treatment with drugs
Diet therapy Treatment with diet Such as low salt low fat for CVD
Physiotherapy Treatment with natural physical forces Such as water, light and heat
Psychological therapy
Identification of stressors and methods toreduce or eliminate stress or the us of drugs
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Slide 34
Definitions, Names,Definitions, Names,Standards, and InformationalStandards, and Informational
SourcesSources
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Slide 35
Foundations of Foundations of PharmacologyPharmacology
Types of drug names Chemical
Most meaningful to chemist, he understands exactly thechemical constitution of drug and exact placing of its atoms or molecular groupings
Generic Common name
Official Name under the drug is listed by the USFDA
Trademark (brand) Proprietary name
Name is registered and that is use is restricted to the owner of the drug
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Slide 37
Foundations of Foundations of Pharmacology (cont¶d)Pharmacology (cont¶d)
CHEMIC AL N AME 2S,5R,6R)-6-([(2R)-2-amino-2-phenylacetyl]amino)
-3,3-dimethyl-7-oxo-4-thia-1-azabicyclo[3.2.0]heptane-2-carboxylic acid
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Drugs ClassificationDrugs Classification
According to the body system they affect According to their therapeutic use
According to physiologic or chemical action
Prescription or Non-prescription OTC or
Illegal ( Recreational)
Slide 38
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Legal Regulations of Drugs inLegal Regulations of Drugs inthe Philippinesthe Philippines
Many laws have been enacted over the lastcentury that affect drug distribution andadministration
Congress passed this law that gave the
BFAD control over the manufacture and saleof drugs, food, and cosmetics
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Drug Standards and ControlsDrug Standards and Controls
A. Drug ControlB. Drug Standards
C. Drug Preparations
D. Classification of Drugs
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Drug ControlDrug Control
International: USFD A National: BFAD, National DrugBoard
Local Regulations: DTI Institutional: Hospital
regulations
Individual: Client and Physician
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Drug StandardDrug Standard
Purity freedom from contaminants
the absence, or degree of absence, of anythingharmful, inferior, unwanted, or of a different
Potency Strength of medicine or drug
Bioavailability
measure of drug absorption
the extent and rate to which a drug is taken up bythe body in a physiologically active form
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Drug StandardDrug Standard
Efficiency To achieve desired result
Safety
freedom from danger: protection from, or not
being exposed to, the risk of harm or injury Toxicity
degree of poisonousness: the degree towhich something is poisonous
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Drug StandardDrug Standard
Testingprocedures
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Slide 45
Sources of Drug InformationSources of Drug Information
American Drug Index Index all medicines in US annually
American Hospital Formulary Service
Drug Interaction Facts
Drug Facts and Comparisons
Handbook on Injectable Drugs
Handbook of Nonprescription Drugs
M artindale±The Complete
Drug Reference
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Slide 46
Sources of Drug InformationSources of Drug Information(cont¶d)(cont¶d)
Package inserts
Natural M edicines Comprehensive Database
P hysicians¶ Desk Reference ( PDR)
Nursing journals
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Sources of Drug InformationSources of Drug Information
Goodman and Gilman, ThePharmacologic Basis of Therapeutics
Cochrane Library
USFD A/
BFAD
Drug Handbook
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Slide 48
Sources of Drug InformationSources of Drug Information(US)(US)
US P harmacopeia (US P ) / National Formulary (NF)
US P Dictionary of US AN and International Drug Names
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Slide 49
Sources of Drug InformationSources of Drug Information(Canada)(Canada)
Compendium of P harmaceuticals and Specialties
P atient Self-Care: Helping P atients M akeTherapeutic Choices
Compendium of Self-Care P roducts Electronic databases
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Slide 50
Sources of PatientSources of PatientInformationInformation
United States P harmacopeia Dispensing Information (US PDI)
Therapeutic Choices
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Slide 51
U.S. Drug LegislationU.S. Drug Legislation
Federal Food, Drug, and Cosmetic Act (1938,1952, 1962)
Controlled Substances Act (1970)
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Drug DevelopmentDrug Development
This process starts with the synthesis of novel chemical compounds.
Substances with complex structures may beobtained from various sources, e.g., plants(cardiac glycosides), animal tissues (heparin),
microbial cultures (penicillin G), or humancells (urokinase), or by means of genetechnology (human insulin).
As more insight is gained into structureactivity relationships, the search for newagents becomes more clearly focused.
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Preclinical testingPreclinical testing
yields information on the biological effectsof new substances.
Initial screening may employ biochemical- pharmacological investigations (e.g.,
receptor-binding assays) or experiments oncell cultures, isolated cells, and isolatedorgans
T i l i l i ti tiT i l i l i ti ti
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Toxicological investigationsToxicological investigations serveserveto evaluate the potential for:to evaluate the potential for:
(1) toxicity associated with acute or chronicadministration;
(2) genetic damage (genotoxicity, mutagenicity);
(3) production of tumors (onco- or carcinogenicity);
and (4) causation of birth defects (teratogenicity). In animals, compounds under investigation also
have to be studied with respect to their absorption, distribution, metabolism, andelimination (pharmacokinetics)
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Clinical testingClinical testing
PH ASE I studies on healthy subjects and seeks to
determine whether effects observed in animalexperiments also occur in humans.
Dose-response relationships are determined
PH ASE II potential drugs are first tested on selected patients
for therapeutic efficacy in those disease states for which they are intended.
Should a beneficial action be evident and the
incidence of adverse effects be acceptably small
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Clinical testingClinical testing
PH A
SE III involving a larger group of patients in whom the
new drug will be compared with standardtreatments in terms of therapeutic outcome.
As a form of human experimentation, theseclinical trials are subject to review and approval by
institutional ethics committees according tointernational codes of conduct (Declarations of Helsinki, Tokyo, and Venice).
During clinical testing, many drugs are revealed tobe unusable.
Ultimately, only one new drug remains from
approximately 10,000 newly synthesizedsubstances.
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Drug is made by a national regulatory body (Food& Drug Administration in the U.S. A., the HealthProtection Branch Drugs Directorate in Canada, UK,Europe, Australia) to which manufacturers arerequired to submit their applications.
Applicants must document by means of appropriatetest data (from preclinical and clinical trials) that the
criteria of efficacy and safety have been met and thatproduct forms (tablet, capsule, etc.) satisfy generalstandards of quality control.
Following approval, the new drug may be marketedunder a trade name and thus become available for prescription by physicians and dispensing by
pharmacists.
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As the drug gains more widespread use,regulatory surveillance continues in the formof post-licensing studies (Phase IV of clinicaltrials).
Only on the basis of long-term experience willthe risk: benefit ratio be properly assessedand, thus, the therapeutic value of the newdrug be determined
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Phases of Drug DevelopmentPhases of Drug Development
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Slide 60
Drug review processDrug review process
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Principles of Drug Action andPrinciples of Drug Action andDrug InteractionsDrug Interactions
Slide 1Mosby items and derived items © 2007, 2004 by Mosby, Inc., an af filiate of Elsevier Inc.
Principles of Drug Action andPrinciples of Drug Action and
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Principles of Drug Action andPrinciples of Drug Action andDrug InteractionsDrug Interactions
Basic principles A strong understanding of the human body¶s
processes are important to grasp drug actionsand drug interactions in the body
How do drugs act in theHow do drugs act in the
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How do drugs act in theHow do drugs act in thebody?body?
1. Drugs do not create new responses but alter existing physiologic activities
2. Drugs interact with the body in several differentways
3. Most drugs have several different atoms within each
molecule that interlock into various location on areceptor
4. Drugs that interact with a receptor to stimulate aresponse is called agonists and the one who do notis called antagonists
Slide 64
Principles of Drug Action andPrinciples of Drug Action and
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Principles of Drug Action andPrinciples of Drug Action andDrug Interactions (cont¶d)Drug Interactions (cont¶d)
Examples: Antagonist²beta blockers
Agonist²epinephrine
Partial agonist²pentazocine
How do drugs act in theHow do drugs act in the
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How do drugs act in theHow do drugs act in thebody?body?
5. Once administered, all drugs gothrough ADME
Absorption
Distribution
Metabolism
Excretion
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PharmacokineticsPharmacokinetics
Is what the body does to the drug.The magnitude of the pharmacological effectof a drug depends on its concentration at thesite of action.
Absorption Distribution
Metabolism
Elimination
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Most drugs have an affinity for certain organsor tissues and exert their greatest action atthe cellular level on those specific areas,which are called target sites.
There are two main mechanisms of action:1. Alteration in cellular environment
2. Alteration in cellular function
Alteration in CellularAlteration in Cellular
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Alteration in Cellular Alteration in Cellular EnvironmentEnvironment
Some drugs act on the body by changing thecellular environment, either physically or chemically.
Physical changes in the cellular environment
include changes in osmotic pressures,lubrication, absorption, or the conditions onthe surface of the cell membrane
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ExampleExample
a drug that changes osmotic pressure ismannitol, which produces a change in theosmotic pressure in brain cells, causing areduction in cerebral edema
drug that acts by altering the cellular environmentby lubrication is sunscreen
a drug that acts by altering absorption isactivated charcoal, which is administered orallyto absorb a toxic chemical ingested into thegastrointestinal tract.
The stool softener docusate is an example of adrug that acts by altering the surface of the
cellular membrane
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Alteration in Cellular FunctionAlteration in Cellular Function
Most drugs act on the body by alteringcellular function.
A drug cannot completely change the functionof a cell, but it can alter its function.
A drug that alters cellular function canincrease or decrease certain physiologicfunctions, such as increase heart rate,decrease blood pressure, or increase urineoutput
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PharmacodynamicsPharmacodynamics
deals with the drug¶s action and effect within thebody.
After administration, most drugs enter thesystemic circulation and expose almost all bodytissues to possible effects of the drug.
All drugs produce more than one effect in thebody. The primary effect of a drug is the desired or
therapeutic effect.
Secondary effects are all other effects, whether
desirable or undesirable, produced by the drug
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RReceptor eceptor
is a specialized macromolecule (a large group of molecules linked together) that attaches or binds tothe drug molecule.
This alters the function of the cell and produces thetherapeutic response of the drug.
For a drug±receptor reaction to occur, a drug must beattracted to a particular receptor.
Drugs bind to a receptor much like a piece of apuzzle.
The closer the shape, the better the fit, and the better the therapeutic response.
The intensity of a drug response is related to how
good the ³fit´ of the drug molecule is and the number of receptor sites occupied
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DrugDrug--Receptor Interactions (cont¶d)Receptor Interactions (cont¶d)
.
Agonists, antagonists, and partialagonists
Agonists Antagonists
Noncompetitive versus competitiveantagonists
Partial agonists Regulation of receptor sensitivity
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DoseDose--responseresponse curves in the presence of competitivecurves in the presence of competitiveand noncompetitive antagonists.and noncompetitive antagonists.
.
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DrugDrug Responses That Do Not InvolveResponses That Do Not InvolveReceptorsReceptors
.
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InterpatientInterpatient Variability In DrugVariability In DrugResponsesResponses
.
Measurement of interpatient variability
The ED50
Clinical implications of interpatient variability
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InterpatientInterpatient variation in drug responses.variation in drug responses.
.
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DrugDrug--Receptor InteractionsReceptor Interactions
Chemical BondsVan der Waals Interactions
Hydrophobic Interactions
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Drug-receptor interactions serve as signals totrigger a cascade of events. This cascade or signaling pathway, is a collection of manycellular responses which serve to amplify thesignal and produce a final effect.
Effectors are thus the molecules that translatethe drug-receptor interaction into changes incellular activity.
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DrugDrug--Receptor InteractionsReceptor Interactions
y y + Ä EFFECT
DRUG DRUG + RECEPTOR DRUG + RECEPTOR EFFECTOR EFFECTOR
INTERACTION COMPLEX SYSTEM
STIMULUS BINDING ACTIVATION TRANSDUCTION AMPLIFICATION RESPONSE
SIGNALLING PATHWAY
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Receptor Signaling PathwaysReceptor Signaling Pathways
Second Messengers:1. Ions (Ca2+, Na+, K+, Cl-)
2. c AMP, cGMP, IP3, Diacylglycerol
3. DN A binding ± Transcriptional regulation.
4. Phosphorylated proteins and enzymes viatyrosine kinase receptors.
Third Messengers:
1. Enzymes (PKC, PK A)
2. Ions (Ca2+, K+)
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Receptor Signaling PathwaysReceptor Signaling Pathways
cAMP
cGMP
DAG and IP3
Arachidonic acid
NO and CO
Na+, Ca2+
, K+, Cl-
EFFECTORS
Adenylate Cyclase (AC)
Guadenylyl Cyclase (GC)
Phospholipase C (PLC)
Phospholipase A (PLA2)
Nitric oxide Synthase
Ions
SECONDMESSENGER
Receptor Signaling PathwaysReceptor Signaling Pathways
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Receptor Signaling PathwaysReceptor Signaling Pathways
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DrugDrug--Receptor InteractionsReceptor Interactions
Theory and assumptions of drug-receptor interactions. Drug Receptor interaction follows simple mass-action
relationships, i.e. only one drug molecule occupies eachreceptor and binding is reversible (We know now there aresome exceptions).
For a given drug the magnitude of the response is proportionalto the fraction of total receptor sites occupied by drug molecules.
Combination or binding to receptor causes some event whichleads to a response.
Response to a drug is graded or dose-dependent.
L f M A tiL f M A ti
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Law of Mass ActionLaw of Mass Action
When a drug (D) combines with a receptor (R), it does so at a rate which is dependenton the concentration of the drug and theconcentration of the receptor.
D = drug
R = receptor
DR = drug-receptor complex
k1 = rate for association
k2 = rate for dissociation
KD = Dissociation Constant
K A = Affinity Constant
k 1[D] + [R] [DR]
k 2
k 2 = K D = [D][R]
k 1
[DR]
1 = K A = k 1 = [DR]
K D k 2 [D] [R]
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PharmacodynamicsPharmacodynamics
Receptor Sites R eceptor-Mediated Drug Effects
The number of available receptor sites influences theeffects of a drug. If only a few receptor sites areoccupied, although many sites are available, theresponse will be small.
If the drug dose is increased, more receptor sites areused and the response increases. If only a fewreceptor sites are available, the response does notincrease if more of the drug is administered.However, not all receptors on a cell need to beoccupied for a drug to be effective.
Some extremely potent drugs are effective even
when the drug occupies few receptor sites
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PharmacodynamicsPharmacodynamics
Dose-response relationships Drug-receptor interactions
Drug responses that do not involve
receptors Interpatient variability in drug
responses
The therapeutic index
.
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DrugDrug--Receptor InteractionsReceptor Interactions
.
Introduction to drug receptors
The four primary receptor families:
Cell membrane-embedded enzymes
Ligand-gated ion channels G protein±coupled receptor systems
Transcription factors
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DrugDrug--Receptor Interactions (cont¶d)Receptor Interactions (cont¶d)
.
Agonists, antagonists, and partialagonists
Agonists Antagonists
Noncompetitive versus competitiveantagonists
Partial agonists Regulation of receptor sensitivity
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Figure 5Figure 5--7 Dose7 Dose--response curves in the presence of competitive andresponse curves in the presence of competitive andnoncompetitive antagonists.noncompetitive antagonists.
.
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DrugDrug Responses That Do Not InvolveResponses That Do Not InvolveReceptorsReceptors
.
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InterpatientInterpatient Variability In DrugVariability In DrugResponsesResponses
.
Measurement of interpatient variability
The ED50
Clinical implications of interpatient variability
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InterpatientInterpatient variation in drug responses.variation in drug responses.
.
The Therapeutic IndexThe Therapeutic Index
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The Therapeutic IndexThe Therapeutic Index
.
D A tiD A ti
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Slide 99
Drug ActionDrug Action
Desired effect: when a drug enters a patient,is absorbed and distributed, and produces theexpected response
Side effects - side effects to explain mild,common, and nontoxic reactions
Adverse effect: ³ Any noxious, unintended andundesired effect of a drug, which occurs atdoses used in humans for prophylaxis,diagnosis or therapy´ (World Health Organization)
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H lfH lf lif f Dlif f D
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Slide 101
Half Half--life of Drugslife of Drugs
Factors modifying thequantity of drugreaching a site of actionafter a single oral dose
D A tiD A ti
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Slide 102
Drug ActionDrug Action
Tolerance term used to describe a decreased response
to a drug, requiring an increase in dosage toachieve the desired effect
Dependence
The individual who takes these drugs at homeincreases the dose when the expected drugeffect does not occur
Principles of Drug Action andPrinciples of Drug Action andD I t ti ( t¶d)D I t ti ( t¶d)
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Slide 103
Drug Interactions (cont¶d)Drug Interactions (cont¶d)
Drug interaction Drug interactions represent 3% to 6% of
preventable in-hospital adverse drug reactioncases
Drug interactions are a major component of the number of hospital emergency departmentvisits and admissions
DD DD
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DrugDrug--DrugDrug
taking of numerous drugs that can potentiallyreact with one another.
Polypharmacy leads to an increase in thenumber of potential adverse reactions.
Slide 104
DD F dF d
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DrugDrug -- FoodFood
When a drug is given orally, food may impair or enhance its absorption.
A drug taken on an empty stomach isabsorbed into the bloodstream at a faster ratethan when the drug is taken with food in thestomach.
Some drugs (eg, captopril) must be taken onan empty stomach to achieve an optimaleffect.
Drugs that should be taken on an emptystomach are administered 1 hour before or 2hours after meals.
Slide 105
Dr gDr g LaboratorLaborator
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DrugDrug -- LaboratoryLaboratory
The presence of disease may influence theaction of some drugs.
Sometimes disease is an indication for notprescribing a drug or for reducing the dose of a certain drug.
Both hepatic (liver) and renal (kidney)disease can greatly affect drug response.
Slide 106
Drug Across Life SpanDrug Across Life Span
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Drug Across Life SpanDrug Across Life Span
Slide 107
The age of the patient may influence theeffects of a drug.
Infants and children usually require smaller doses of a drug than adults do.
Immature organ function, particularly the liver and kidneys, can affect the ability of infantsand young children to metabolize drugs.
An infant¶s immature kidneys impair theelimination of drugs in the urine.
Liver function is poorly developed in infantsand young children.
Drugs metabolized by the liver may producemore intense effects for longer periods.
Drug Across Life SpanDrug Across Life Span
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Drug Across Life SpanDrug Across Life Span
Slide 108
rug erapy n spec arug erapy n spec apopulationspopulations--pediatricspediatrics
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populationspopulations--pediatricspediatrics
Pediatrics-all aspects must be guided by thechild¶s age, weight and level of growth anddevelopment
Safe therapeutic ranges are less well-defined
Choice of drug is restricted because manydrugs used in adults have not beensufficiently investigated
Pediatric physiologic characteristicsPediatric physiologic characteristicsaffecting pharmacokineticsaffecting pharmacokinetics
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affecting pharmacokineticsaffecting pharmacokinetics
Thin, permeable skin ±increased absorptionof topicals
Immature blood-brain barrier²increaseddistribution into the CNS until age 2
Altered protein binding until age 1
Decreased activity of metabolizing enzymesin infants, increased in children
Pediatric physiologic effectsPediatric physiologic effects
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Pediatric physiologic effectsPediatric physiologic effects
Increased percentage of body water
Decreased GFR until one year of age
PediatricsPediatrics
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PediatricsPediatrics
Oral route for meds is preferable For injections, may wish to use EML A (eutectic mixture of lidocaine and prilocaine,local anesthetics)
Site selection for injections²infants, usethigh muscles; older than 18 months of age,
use deltoid; older than 3, use ventroglutealmuscle
Drug Therapy in Older AdultsDrug Therapy in Older AdultsPhysiologic characteristics andPhysiologic characteristics and
h ki ti i th ki ti i t
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pharmacokinetic impactpharmacokinetic impact
Decreased GI motility²slower absorption
Decreased cardiac output²slower absorptionfrom site of administration, decreaseddistribution to sites of action in tissues
Decreased blood flow to liver and kidneys-delayed metabolism and excretion
Drug Therapy in Older AdultsDrug Therapy in Older Adults
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Drug Therapy in Older AdultsDrug Therapy in Older Adults
Decreased total body water and lean bodymass-fat soluble meds stay with patientlonger, water soluble drugs are distributed insmaller area, greater risk for toxicity
Decreased blood flow to liver-slowedmetabolism and detox of drugs
Drug Therapy in Older AdultsDrug Therapy in Older Adults
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Drug Therapy in Older AdultsDrug Therapy in Older Adults
Decreased albumin-decreased availability of protein for binding and transporting. Will alsohave higher concentration of free active drug.
Decreased blood flow to kidneys²impaireddrug excretion, potential toxicity
er u ser u sRenal ImpairmentRenal Impairment
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Renal ImpairmentRenal Impairment
Know baseline renal function
Tailor dosages
Avoid nephrotoxic medications
Be aware of need for additional dosing if
patient is receiving renal replacement therapy
Older AdultsOlder AdultsHepatic ImpairmentHepatic Impairment
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Hepatic ImpairmentHepatic Impairment
Those with cirrhosis, hepatitis, receivinghepatotoxic drugs, have heart failure, areundergoing major surgery or have hadtrauma are at higher risk for toxicities r /tmedications
Know drug effects on hepatic function
Reduce dosages on medications that areextensively metabolized by the liver such as:cimetidine, phenytoin, ranitidine, theophylline
er u ser u sCritical IllnessesCritical Illnesses
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Critical IllnessesCritical Illnesses
Be aware that all medications may havevariable effects in this scenario
Know the actions, usual dosages and sideeffects of medications
Closely monitor renal and liver function tests Monitor serum protein and albumin levels
er u ser u sCritical IllnessCritical Illness
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Critical IllnessCritical Illness
Most drugs will be given IV-for this reason,medications may have faster onset
Many factors may interfere with drug effects if given orally
Considerations when giving medications viafeeding tube
Appropriate scheduling very important
Drug Therapy in Home CareDrug Therapy in Home Care
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Drug Therapy in Home CareDrug Therapy in Home Care
On patient¶s turf
Schedule visit at convenient time for patientand caregiver
Assess patient¶s ability to perform self-care
Assess patient¶s understanding and attituderegarding medication regimen
Inquire if patient is taking any herbalpreparations
Drug Therapy in Home CareDrug Therapy in Home Care
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Drug Therapy in Home CareDrug Therapy in Home Care
Inquire if patient is taking any OTC meds
Assess environment for safety
Educate patient and caregiver indication,proper administration and side effects of
administered medications Between visits, maintain contact with patientto monitor progress and serve as a resource
Herbal and DietaryHerbal and DietarySupplementsSupplements
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SupplementsSupplements
Black cohosh-used to relieve menopausal s/s
Capsaicin-post-herpetic neuralgia
Echinacea-anti-infective, for common cold
Ginger²nausea. Not for morning sickness.
Garlic-cholesterol lowering
Herbal and DietaryHerbal and Dietarysupplementssupplements
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supplementssupplements
Feverfew-for migraines, menstrualcomplaints. Can cause withdrawal s/s.
Ginseng-increase stamina, endurance andmental acuity. Can affect bleeding time, BP,increase hypoglycemia. No longer than 3weeks use with Siberian ginseng.
PharmacokineticsPharmacokinetics
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PharmacokineticsPharmacokinetics
.
Application of pharmacokinetics intherapeutics
Passage of drugs across membranes
Absorption
Distribution
Metabolism
Excretion
Time course of drug responses
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Application of Pharmacokinetics inApplication of Pharmacokinetics inTherapiesTherapies
.
By applying knowledge of pharmacokineticsto drug therapy, we can help maximizebeneficial effects and minimize harm.
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Slide 127
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Passage of Drugs Across MembranesPassage of Drugs Across Membranes
.
Membrane structure
Three ways to cross a cell membrane
Polar molecules
Ions
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Three Ways to Cross a Cell MembraneThree Ways to Cross a Cell Membrane
.
Channels and pores
Transport system
P-glycoprotein
Direct penetration of the membrane
Membrane permeation:Membrane permeation:diffusiondiffusion
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Slide 130
Membrane permeation:Membrane permeation:transporttransport
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pp
Slide 131
Membrane permeation: receptor Membrane permeation: receptor--mediatedmediatedendocytosisendocytosis, vesicular uptake, and, vesicular uptake, and
transporttransport
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transporttransport
Slide 132
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Polar molecules.
.
IonsIons
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.
Quaternary ammonium compounds
pH-dependent ionization
Ion trapping (pH partitioning)
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Figure 4Figure 4--4 Quaternary ammonium compounds.4 Quaternary ammonium compounds.
.
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Figure 4Figure 4--5 Ionization of weak acids and weak bases.5 Ionization of weak acids and weak bases..
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IonIon trapping of drugs.trapping of drugs.
.
AbsorptionAbsorption
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.
Factors affecting drug absorption
Characteristics of commonly used routes of administration
Pharmaceutical preparations for oraladministration
Additional routes of administration
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Factors Affecting Drug AbsorptionFactors Affecting Drug Absorption
.
Rate of dissolution
Surface area
Blood flow Lipid solubility
pH partitioning
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Characteristics of Commonly UsedCharacteristics of Commonly Used
Routes of AdministrationRoutes of Administration
.
Intravenous
Barriers to absorption
Absorption pattern Advantages
Disadvantages
Intramuscular
Barriers to absorption
Absorption pattern
Advantages
Disadvantages
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DrugDrug movement at typical capillary beds.movement at typical capillary beds.
.
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Characteristics of CommonlyCharacteristics of CommonlyUsed Routes of AdministrationUsed Routes of Administration(cont¶d)(cont¶d)
.
Subcutaneous
± No significant barriers to absorption
Oral
± Barriers to absorption
± Absorption pattern
± Drug movement following absorption
± Advantages
± Disadvantages
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MovementMovement of drugs following GI absorptionof drugs following GI absorption..
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Pharmaceutical Preparations for OralPharmaceutical Preparations for OralAdministrationAdministration
.
Tablets
Enteric-coated preparations Sustained-release preparations
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Additional Routes of AdministrationAdditional Routes of Administration
.
Topical
Transdermal
Inhaled
Rectal
Vaginal
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DistributionDistribution
.
Blood flow to tissues
Exiting the vascular system
Entering cells
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Blood Flow To TissuesBlood Flow To Tissues
.
Exiting the Vascular SystemExiting the Vascular System
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Exiting the Vascular SystemExiting the Vascular System
.
Typical capillary beds
Blood-brain barrier
Placental drug transfer
Protein binding
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DrugDrug movement across the bloodmovement across the blood--brain barrier.brain barrier.
.
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Figure 4Figure 4--10 Placental drug transfer.10 Placental drug transfer.
.
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ProteinProtein binding of drugs.binding of drugs.
.
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ProteinProtein binding of drugs.binding of drugs.
.
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Entering CellsEntering Cells
.
D M t b liD M t b li
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Drug MetabolismDrug Metabolism
.
Hepatic drug-metabolizing enzymes
Therapeutic consequences of drugmetabolism
Special considerations in drugmetabolism
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Hepatic DrugHepatic Drug--Metabolizing EnzymesMetabolizing Enzymes
.
Most drug metabolism that takes place inthe liver is performed by the hepatic
microsomal enzyme system, also know asthe P450 system.
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Therapeutic Consequences of DrugTherapeutic Consequences of DrugMetabolismMetabolism
.
Accelerated renal drug exertion
Drug inactivation
Increased therapeutic action
Activation of prodrugs
Increased or decreased toxicity
S i l C id ti i DS i l C id ti i D
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Special Considerations in DrugSpecial Considerations in Drug
MetabolismMetabolism
.
Age
Induction of drug-metabolizing enzymes
First-pass effect
Nutritional status
Competition between drugs
ExcretionExcretion
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ExcretionExcretion
.
Renal routes of drug excretion
Nonrenal routes of drug excretion
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Renal Routes of Drug ExcretionRenal Routes of Drug Excretion
.
Steps in renal drug excretion
Glomerular filtration
Passive tubular reabsorption
Active tubular secretion
Factors that modify renal drug excretion
pH-dependent ionization
Competition for active tubular transport
Age
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Slide 161
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RenalRenal routes of drugroutes of drug excretionexcretion
.
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Slide 163
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Time Course of Drug ResponsesTime Course of Drug Responses
.
Plasma drug levels
Single-dose time course
Drug half-life
Drug levels produced with repeated doses
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Plasma Drug LevelsPlasma Drug Levels
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Plasma Drug LevelsPlasma Drug Levels
.
Clinical significance of plasma drug levels
Two plasma drug levels defined
Minimum effective concentration
Toxic concentration
Therapeutic range
SingleSingle--Dose Time CourseDose Time Course
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SingleSingle--Dose Time CourseDose Time Course
.
The duration of effects is determined largely bythe combination of metabolism and excretion
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Passage of Drugs Across MembranesPassage of Drugs Across Membranes
.
Drugs must cross membranes to enter theblood from their sites of administration.
Therapeutic RangeTherapeutic Range
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Therapeutic RangeTherapeutic Range
.
The objective of drug dosing is to maintainplasma drug levels within the therapeutic range.
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Drug Levels Produced with RepeatedDrug Levels Produced with RepeatedDosesDoses
.
D L l P d d ith R t dD L l P d d ith R t d
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Drug Levels Produced with RepeatedDrug Levels Produced with Repeated
DosesDoses
.
The process by which plateau drug levelsare achieved
Time to plateau Techniques for reducing fluctuations in
drug levels
Loading doses versus maintenance doses
Decline from plateau
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DrugDrug accumulation with repeatedaccumulation with repeatedadministrationadministration..
.
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NURSING PROCESS
AND PHARMACOLOGY
AND PATIENT
EDUCATION
The Nursing ProcessThe Nursing Process
Th i i th f d ti f th
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Slide 176
The nursing process is the foundation for the
clinical practice of nursing. It involves: Assessment
Nursing diagnosis
Planning
Nursing intervention or implementation
Evaluating and recording therapeuticoutcomes
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Nursing ProcessNursing Process
A t
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Assessment
Subjective data
Current health history
Includes dysphagia
Client symptoms as verbalized by client
Current medications Dosage, frequency, route, who prescribed
Dug allergies, OTC, herbal drugs, alcohol, smoking
Past health history
Client¶s environment Primary language and communication needs
Cli t th h d t i t d t
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Clients even those who do not intend to
withhold information, do not always tell abouttheir medications
AssessmentAssessment
Comprehensive collection of data including:
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Comprehensive collection of data including:
Physical examination
Nursing history
Medication history
Professional observation
Assessment is an ongoing process that startswith admission and continues until the patientis discharged from care
Nursing Process (cont¶d)Nursing Process (cont¶d)
Assessment
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Assessment
Objective data ± baseline data Physical assessment
Gross and fine motor control, hand joint range of motion, muscle strength, visual impairment
Laboratory tests Diagnostic studies
Must identify high-risk clients
Client's attitudes and values about taking
medications Client's support system
Nursing DiagnosisNursing Diagnosis
A clinical judgment about individual family or
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A clinical judgment about individual, family, or
community responses to actual or potentialhealth problems/life processes (N AND A-International)
DiagnosisDiagnosis
Five types of nursing diagnoses:
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Five types of nursing diagnoses:
Actual: based on human responses andsupported by defining characteristics
Risk/high-risk: patient may be moresusceptible to a particular problem
Possible: suspected problems requiringadditional data
Wellness: clinical judgment about a transitionfrom one level to a higher level
Syndrome: cluster signs and symptoms topredict certain circumstances or events
Nursing DiagnosesNursing Diagnoses
Common nursing diagnoses related to drug
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Common nursing diagnoses related to drug
therapy Deficient knowledge about drug action,
administration, and side effects related tocultural/language barrier
Pain related to hesitancy to take prescribedmeds due to fear of addiction
Ineffective health maintenance related to nothaving recommended preventive care
Nursing DiagnosesNursing Diagnoses
Common nursing diagnoses related to drug
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Common nursing diagnoses related to drug
therapy Noncompliance related to forgetfulness
Risk for injury related to side effects of drug
Ineffective therapeutic regimen management
related to lack of finances
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PlanningPlanning
Priority setting: identified problems are
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Priority setting: identified problems are
prioritized and needs levels established Measurable goal statements: short- and
long-term goals are established and written
PlanningPlanning
Characterized by goal setting
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Characterized by goal setting
Example: Client EV will independentlyadminister prescribed dose of albuterol by theend of the first session of instruction
Planning (cont¶d)Planning (cont¶d)
Characteristics of a goal
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Characteristics of a goal
Client centered; clearly states the expectedchange
Realistic and measurable
Realistic deadlines
SM ART
Nursing Intervention or Nursing Intervention or ImplementationImplementation
The actual process of carrying out the
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The actual process of carrying out the
established plan of care Nursing actions are suggested
Dependent actions: performed by a nursebased on health care provider¶s orders
Interdependent actions: implemented withthe cooperation of a team
Independent actions: provided by nurse byvirtue of education and license
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Evaluating and RecordingEvaluating and RecordingTherapeutic and Expected OutcomesTherapeutic and Expected Outcomes
All care is evaluated against:
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All care is evaluated against:
Nursing diagnoses (goal statements)
Planned nursing actions
Anticipated therapeutic outcomes
Plans for evaluation must involve patient,family, and significant others
EvaluationEvaluation
Ongoing and related to progress and goal
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Ongoing and related to progress and goal
achievement Related to achievement of goals; if not met,
reassess and continue
Determine need for follow-up
Refer to community resources
DRUG CARDSDRUG CARDS
Name of the drug
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Name of the drug
Reason for taking the drug
Dose amount
Specific times taking the drug
What specific things should or should not bedone while taking the medications
Possible side effects
Possible adverse effects
Helpful and Healthful PointsHelpful and Healthful Pointsto Remember to Remember
Take medication as prescribed by your health
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Take medication as prescribed by your health
care provider. If you have questions, call. Keep medication in original labeled container
and store as instructed
Keep all medicines out of reach of children.
Remind grandparents and visitors to monitor their purses and luggage when visiting.
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Helpful and Healthful PointsHelpful and Healthful Pointsto Remember (cont¶d)to Remember (cont¶d)
Know why you are taking each medication
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Know why you are taking each medication
and under what circumstances to notify thehealth care provider
Alcohol may alter the action and absorption of the medication. Use of alcoholic beverages is
discouraged around the time you take your medications and is absolutely contraindicatedwith certain medications.
Helpful and HealthfulHelpful and HealthfulPoints to Remember (cont¶d)Points to Remember (cont¶d)
Smoking tobacco alters absorption of some
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Smoking tobacco alters absorption of some
medications (e.g., theophylline-type drugs,tranquilizers, antidepressants, and painmedications). Consult your health careprovider or pharmacist for specific
information.
Checklist for HealthChecklist for HealthTeaching in Drug TherapyTeaching in Drug Therapy
Comprehensive drug and health history
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Comprehensive drug and health history
Reason for medication therapy
Expected results
Side effects and adverse reactions
When to notify health care provider or pharmacist
Drug-drug, drug-food, drug-laboratory, drug-environment interactions
Checklist for Health TeachingChecklist for Health Teachingin Drug Therapy (cont¶d)in Drug Therapy (cont¶d)
Required changes in ADL
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q g
Demonstration of learning; may take severalforms, such as listening, discussing, or returndemonstration of psychomotor skills (insulinadministration)
Medication schedule, associated with ADLand drug level of action as appropriate
Checklist for Health TeachingChecklist for Health Teachingin Drug Therapy (cont¶d)in Drug Therapy (cont¶d)
Recording system
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g y
Discussion and monitoring of access tofinancial resources, medication, andassociated equipment
Development and support of backup system
Community resources
Patient and family teaching.Patient and family teaching.
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Medication and CalculationsMedication and Calculations
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Section A: Systems of Measurement withConversion
Section B: Methods for Calculation
Section C: Calculations of Oral Dosages Section D: Calculations of Injectable Dosages
Section E: Calculations of Intravenous Fluids
Section F: Pediatric Drug Calculations
Methods of CalculationMethods of Calculation
Method 1: B ASIC FORMUL A (BF)
dj1
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D (desired) × V (vehicle-amt) = Amount to give
H (on hand)
Ex: Order: ciprofloxacin (Cipro) 0.5 g, po, q12h
Available: Cipro 250-mg tablet
Change 0.5 g to 500 mg (move decimal point 3 spaces toright)
2
500 mg × 1 tab = 2 tablets of Cipro
250 mg
1
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dj1 set per ms with strike-through lines in last line to indicate canceling--see ms Valued Gateway Client, 7/18 /2005
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Methods of CalculationMethods of Calculation(cont¶d)(cont¶d)
Method 3: FR ACTION AL EQU ATION (FE)
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H (on hand) = D (desired)
V (vehicle-amt) X
Order: ciprofloxacin (Cipro) 0.5g, po, q12h (0.5 g = 500mg)
Available: Cipro 250-mg tablet
250 mg = 500 mg (cross multiple)
1 tab X
250 X = 500
X = 2 tablets of Cipro
Methods of CalculationMethods of Calculation(cont¶d)(cont¶d)
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Method 4: DIMENSION AL AN ALYSIS (D A)
V (form) = V (vehicle) x C (H) x D (desired) =H (on hand) x C (D) x 1
Drug label conversion x drug order
factor
4
tab = 1 tablet x 1000 mg x 0.5 g = 2 tablets
250 mg x 1g x 1
1
dj
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dj2 see ms to insert diagonal strike-through lines to indicate canceling Valued Gateway Client, 7/18 /2005
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Methods of CalculationMethods of Calculation(cont¶d)(cont¶d)
Method 5: BODY WEIGHT
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D (desired) × kg × 1 day or dose =
Order: Cipro 20 mg × kg × day in 2 divided doses
Client¶s weight: 88 pounds ( 88 lb ÷ 2.2 = 40 kg) Available: Cipro 100 mg/mL in oral suspension
20 mg × 40 kg × day = 800 mg/day or 400 mg/dose
Give: 4 mL of oral suspension of Cipro
Intravenous Flow RateIntravenous Flow Rate
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Amount of fluid ÷ hours to administer = mL/hr mL/hr x gtt/mL (IV set) = gtt/minute
60 minutes
Ex: Order: 1000 mL of 5% D/0.45% NaCl, q8h
IV set: 10 gtt/mL
1000 mL ÷ 8 hours = 125 mL/hr
1
125 mL x 10gtt/mL = 125 20.8 or 21 gtt/minute
60 minutes 66
Intermittent IntravenousIntermittent IntravenousAdministrationAdministration
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Amount of solution × gtt/mL (IV set) = gtt/min
minutes to administer
Ex: Order: ticarcillin (Ticar) 500 mg, IV, q6h
Available: Ticar 1 g (add 4 mL of diluent)
Set and solution: calibrated cylinder, drop factor: 60 gtt/mLInstruction: dilute drug in 75 mL of D5W and infuse over 40 minutes
3
75 ml × 60 gtt/mL = 225 = 112.5 or 113 gtt/min
40 min to admin 2
2
dj3
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dj3 see ms to insert diagonal lines that indicate cancellation in last line Valued Gateway Client, 7/18 /2005
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Infusion Pump RateInfusion Pump Rate Amount of solution ÷ minutes to admin = mL/hr
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60 min/hr Ex: Order: ticarcillin (Ticar) 500 mg, IV, q6h
Available: Ticar 1 g (add 4 mL of diluent)
Infusion pump
Dilute drug in 100 mL of D5W; infuse over 45 minutes
100 mL ÷ 45 min to admin = (invert the divisor and multiply)
60 min/hr
4
100 mL × 60 = 400 = 133 mL/hr (infusion rate)
45 3
3
dj4
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dj4 see ms for diagonal lines as strike through to indicate cancellation Valued Gateway Client, 7/18 /2005
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PRINCIPLESPRINCIPLES OFOFMEDICATIONMEDICATIONADMINISTRATIONADMINISTRATION
Legal and EthicalLegal and EthicalConsiderationsConsiderations
Standards of care: developed by the state¶s
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nurse practice act, state and federal law,JC AHO, professional organizations
Before administering medication, nurse musthave:
Current license to practice Clear policy statement authorizing the act
Signed medication order
Understanding of rationale for drug use
Understanding of drug action, dosing, dilution,route and rate of administration, side effects,adverse effects to report, contraindications
Legal ResponsibilitiesLegal Responsibilities
Nurse is legally responsible for safe and
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accurate administration of medications
Nurse is expected to have sufficient drugknowledge to recognize and question
erroneous orders
Unit dose wrappings of oral drugs should beleft in place until the nurse is in the presence
of the client and ready to administer themedication
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Contents of Patient ChartsContents of Patient Charts(cont¶d)(cont¶d)
Graphic record
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Flow sheets Consultation reports
Other diagnostic reports
Medication administration record (M AR) or medication profile
PRN or unscheduled medication record
Case management
Patient education record
TheThe KardexKardex
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³Five Plus Five Rights´³Five Plus Five Rights´of Drug Administrationof Drug Administration
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gg
Right client
Right drug
Right dose Right time
Right route
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Safety in MedicationSafety in MedicationAdministrationAdministration
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Institute of Medicine Report (1999)
To Err Is Human: Building a Safer Health Care
System
Bar Code
Safety in MedicationSafety in MedicationAdministration (cont¶d)Administration (cont¶d)
2004 National Patient Safety Goals
dj5
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JC AHO requirements must not use: U for unit
IU for international unit
QOD for every other day
Trailing zero and lack of leading zero MS, MSO4
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Factors Modifying theFactors Modifying theDrug ResponseDrug Response
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Absorption Distribution
Metabolism (biotransformation)
Excretion
Age
Body weight
Toxicity
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Drug Order / PrescriptionDrug Order / Prescription
Date and time the order written
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Drug Name (Generic preferred) Drug Dosage
Route of administration
Frequency and duration of administration
Any special instructions
Physician¶s signature
Drug LabelDrug Label
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Four categories of drug order Four categories of drug order
Standing
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May be an ongoing order or may be given for a specific number of doses or days
One time
Given once and usually at specific time
PRN Given at the client¶s request and nurse¶s
judgment concerning need and safety
ST AT
Given once immediately
To avoid drug error To avoid drug error
Dug label should be read 3 times
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At the time of contact with drug bottle Before pouring the drug
After pouring the drug
Nursing ImplicationsNursing Implications
Check that the medication order is complete
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and legible Know the reason for which the client is to
receive the medication
Check the drug label 3 times before
administration Know the date was ordered and the ending
date
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Administration of OralAdministration of OralMedicationsMedications
Enteral is direct administration to the GI tract
M d il bl i l d f
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Most drugs are available in oral dose forms: Capsules²small, cylindrical gelatin containers
used to administer unpleasant tastingmedications; timed-release capsules (provides agradual and continuous release of the drug);lozenges or troches²flat disks in a flavored base
Tablets (powdered drugs that have beencompressed)
Elixirs²drugs dissolved in water and alcohol
Emulsions of water-in-oil or oil-in-water Liquid suspensions and syrups
Administration of OralAdministration of OralMedications (cont¶d)Medications (cont¶d)
C th d d t d i i t l
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Common methods used to administer oralmedications Unit dose packaging providing a single dose
Soufflé cups
Medicine cups
Medicine droppers
Teaspoons
Oral syringes: plastic syringes calibrated and usedto measure liquid medications
Nipples with additional holes, used for infants
Administration of SolidAdministration of Solid--FormFormOral MedicationsOral Medications
Two techniques for administering medications:
th di ti d d it d di t ib ti
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the medication card and unit dose distribution Perform premedication assessment in all cases
All techniques follow FIVE RIGHTS procedure: RIGHT patient
RIGHT drug
RIGHT route of administration RIGHT dose
RIGHT time of administration
ALWAYS check or recheck the FIVE RIGHTS
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Administration of SolidAdministration of Solid--FormFormOral Medications (cont¶d)Oral Medications (cont¶d)
D t ti f di ti d i i t ti d
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Documentation of medication administration andresponses to drug therapy is called the ³Sixth Right´
General principles apply to all medicationadministration Chart date, time, drug name, dosage, and route of
administration Regularly record patient assessments to evaluate
therapeutic effectiveness
Chart and report any sign of adverse drug effects
Perform and validate essential education about drugtherapy and other aspects of intervention for theindividual
Administration of LiquidAdministration of Liquid--FormFormOral MedicationsOral Medications
General procedures are the same as with
lid f l di ti
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solid-form oral medications Perform premedication assessment in all
cases
All techniques follow the FIVE RIGHTS
procedure
Administration of LiquidAdministration of Liquid--FormFormOral Medications (cont¶d)Oral Medications (cont¶d)
G l i i l f i f t hild d
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General principles for infants, children, andadults Give adults and children the most important
medications first
NEVER dilute medications without specific
orders. DO NOT leave a medication at thebedside without an order to do so
Check an infant¶s ID and be certain the infantis alert
Provide complete documentation of administration and responses to therapy
Administration of LiquidAdministration of Liquid--FormFormOral Medications (cont¶d)Oral Medications (cont¶d)
M i t h i di t
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Measuring techniques vary according toreceptacle used
With a measuring cup: Cover label to prevent smearing; place
fingernail at exact level on measuring cup;read the volume at the level of meniscus
Recheck FIVE RIGHTS.
With an oral syringe: Select syringe of appropriate size. Draw up
prescribed volume of medication from bottle or medicine cup
Administration of MedicationsAdministration of Medicationsbyby NasogastricNasogastric TubeTube
Drugs are administered via NG tube for
ifi ti t i li id f
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specific patients, using a liquid formwhenever possible. Remember: Always flush the tube before and after
administration
Perform premedication assessment
Assemble equipment before administration
Administration of MedicationsAdministration of Medicationsbyby NasogastricNasogastric Tube (cont¶d)Tube (cont¶d)
P d f d i i t ti f lid
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Prepare doses as for administration of solid-form or liquid-liquid form oral medications
Three methods for checking NG tube location
Follow procedure for administering
medication DO NOT attach suction for 30+ minutes
Provide complete documentation of administration and responses to therapy
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Administration of Administration of EnteralEnteral Feedings ViaFeedings ViaGastrostomyGastrostomy or or JejunostomyJejunostomy Tube (cont¶d)Tube (cont¶d)
Formula should be fully labeled
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Formula should be fully labeled Discard unused formula every 24 hours
Follow the guidelines specific for patientsreceiving general nutrition via intermittent or
continuous feedings Follow FIVE RIGHTS
RIGHT patient, RIGHT drug (formula), RIGHT route of administration, RIGHT dose (amount,
dilution, strength), RIGHT time
Administration of Administration of EnteralEnteral Feedings viaFeedings viaGastrostomyGastrostomy or or JejunostomyJejunostomy Tube (cont¶d)Tube (cont¶d)
Verify tube placement and initiate feeding
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Verify tube placement and initiate feeding Flush, then clamp tube
Proceed with tube feeding technique
Intermittent: use Toomey syringe
Continuous: use disposable feeding container and enough formula for a 4-hour period
Provide complete documentation of administration and responses to therapy
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Administration of RectalAdministration of RectalSuppositories (cont¶d)Suppositories (cont¶d)
Technique begins with FIVE RIGHTS
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Technique begins with FIVE RIGHTS Explain procedure and check pertinent
parameters
Patient bends uppermost leg
Apply lubricant to tip of suppository. Placesuppository about 1 inch beyond orifice, pastinternal sphincter
Provide complete documentation of administration and responses to therapy
Administration of a DisposableAdministration of a DisposableEnemaEnema
The dose form will be a prepackaged,
disposable type enema solution
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disposable-type enema solution Equipment is simple
Perform standard premedication assessment
Administration of a DisposableAdministration of a DisposableEnema (cont¶d)Enema (cont¶d)
Technique begins with FIVE RIGHTS
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Technique begins with FIVE RIGHTS Explain procedure and check pertinent
parameters
Time of last defecation
Patient bends uppermost leg
Apply lubricant to rectal tube
Insert lubricated tube and insert solution
Provide complete documentation of
administration and responses to therapy
PercutaneousPercutaneous AdministrationAdministration
Application of medications to the skin or
mucous membranes for absorption
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mucous membranes for absorption Includes:
Topical application of ointments, creams,lotions, or powders to the skin
Inhalation of aerosolized liquids or gases Installation of solutions into the mucous
membranes of the mouth, eye, ear, nose, or vagina
Always follow the six rights of drugadministration
PercutaneousPercutaneous AdministrationAdministration(cont¶d)(cont¶d)
Premedication assessment and explanation
P ti t t hi
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Patient teaching
Hygiene requirements
Proper application techniques and timing
Cautions particular to drug or drugadministration
Side effects
When to contact physician
PercutaneousPercutaneous AdministrationAdministration(cont¶d)(cont¶d)
Documentation
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Documentation Date, time, drug, dosage, route
Record ongoing assessment data, includingsigns of adverse drug effects
Creams, Lotions, OintmentsCreams, Lotions, Ointments
Wash hands, put on gloves
Position the patient
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Position the patient Clean the area
Wear gloves
Shake lotion bottle; use tongue blade to
remove desired amount of ointment or creamfrom container
Use dressings according to orders
Patch TestingPatch Testing
Method to identify sensitivity to contact
materials (soaps pollen dyes)
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materials (soaps, pollen, dyes) Allergens on patch placed in contact with
back, arms, or thighs
Patch left in place for 48 hours
Site aired for 15 minutes, then read Emergency equipment must be available in
case of anaphylactic response
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TransdermalTransdermal Drug DeliveryDrug Delivery
Disk or patch providing controlled release of
medication
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medication Wash hands and put on gloves
Position the patient
Apply topical disk or patch
Application frequency depends on drug Wash hands after application
Label disk with time, date, nurse initials
Topical PowdersTopical Powders
Particles of medication in a talc base
Wash hands put on gloves
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Wash hands, put on gloves Position the patient
Wash and thoroughly dry area
Apply powder, smooth over area for even
coverage
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Eye Drops, Ointments, andEye Drops, Ointments, andDisksDisks
OD (right eye), OS (left eye), OU (both eyes)
Wash hands put on gloves
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Wash hands, put on gloves Position the patient
Inspect affected eye
Expose lower conjunctival sac
Approach eye from below
Never touch eye with dropper, tube
Forms and Routes (cont¶d)Forms and Routes (cont¶d)
Instillations
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Instillations Eye drops:
Forms and Routes (cont¶d)Forms and Routes (cont¶d)
Eye ointment:
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Forms and Routes (cont¶d)Forms and Routes (cont¶d)
Ear drops:
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Forms and Routes (cont¶d)Forms and Routes (cont¶d)
Nose drops and sprays:
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Nose Drops, Nasal SprayNose Drops, Nasal Spray
Patient should blow nose gently
Nose drops
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Nose drops Position patient lying down with head hanging
back
Nose spray
Patient is upright Block one nostril
Shake bottle and insert tip into nostril
Spray while patient inhales
Nebulizers and InhalersNebulizers and Inhalers
Nebulizers
Prepare medication and fill nebulizer P ti t h l
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epa e ed ca o a d ebu e Patient exhales
Put nebulizer in mouth; do not seal completely
Patient inhales
Metered-dose inhalers Follow instructions on inhaler
Dry powder inhalers
Follow instructions on inhaler
Vaginal MedicationsVaginal Medications
Wash hands, put on gloves
Fill applicator
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Fill applicator Place patient in lithotomy position, elevate
hips with pillow
Spread labia and insert applicator or
suppository
ParenteralParenteral AdministrationAdministration
P arenteral means drug administration by any
route other than the gastrointestinal tract Parenteral route
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route other than the gastrointestinal tract Parenteral route
Intradermal
Subcutaneous
Intramuscular (IM) Intravenous (IV)
Safe Preparation,Safe Preparation,Administration, and DisposalAdministration, and Disposal
Attention to detail is necessary in all facets of drug preparation and administration
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ydrug preparation and administration
Injection of drugs requires skill and specialcare
Safety must be practiced to avoid ³sharps´injuries
Equipment Used inEquipment Used in ParenteralParenteralAdministrationAdministration
The syringe has three parts: barrel, plunger,
and tip Syringes are calibrated in minims milliliters
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p Syringes are calibrated in minims, milliliters,
or cubic centimeters
Tuberculin syringes are used to measure
small volumes of medication accurately
Equipment Used inEquipment Used in ParenteralParenteralAdministration (cont¶d)Administration (cont¶d)
The insulin syringe has a special scale for
measuring insulin
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g In the United States, insulin is manufactured
in U-100 concentration
The U-100 syringe holds 100 units of insulin
per milliliter Low-dose insulin syringes are used for
patients receiving 50 units or less of U-100insulin
Equipment Used inEquipment Used in ParenteralParenteralAdministration (cont¶d)Administration (cont¶d)
Prefilled syringes are disposable and have apremeasured amount of medication
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y g ppremeasured amount of medication
Advantages: time saved in preparation, lesschance of contamination
Disadvantages: additional expense, differentholders for different cartridges, volume of second medication limited
Equipment Used inEquipment Used in ParenteralParenteralAdministration (cont¶d)Administration (cont¶d)
The needle has three parts:
Hub
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Shaft
Beveled tip
The needle gauge is the diameter of the holethrough the needle
Needle selection depends on age of patient,and site (subcutaneous, IM, or IV)²seeTable 10-1
Equipment Used inEquipment Used in ParenteralParenteralAdministration (cont¶d)Administration (cont¶d)
Major safety development: needleless
systems
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y Provide an alternative to needles for routine
procedures, reducing the risk of needlestickswith contaminated sharps
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ParenteralParenteral Dose FormsDose Forms
Ampules
Glass containers usually containing a singledose
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dose
Vials
Glass containers that contain one or more
doses Mix-O-Vials
Glass containers with one dose, twocompartments
Preparation of Preparation of ParenteralParenteralMedicationMedication
Equipment needed for preparation of
parenteral medications Drug in sterile sealed container
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p Drug in sterile, sealed container
Syringe of the correct volume
Needles of the correct gauge and length
Needleless access device Antiseptic swab
M AR or medication profile
Preparation of Preparation of ParenteralParenteralMedication (cont¶d)Medication (cont¶d)
Techniques for preparing all parenteralmedications
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gmedications
Use the five RIGHTS: Right Patient, RightDrug, Right Route of Administration, RightDose (Amount and Concentration), Right Timeof Administration
Check the drug dose form ordered against thesource you are holding
Preparing a Medication fromPreparing a Medication fromanan AmpuleAmpule
Move solution to the bottom of the ampule
Cover the ampule neck with a sterile gauzepledget or antiseptic swab while breaking off
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pledget or antiseptic swab while breaking off top
Using an aspiration needle, withdraw
medication from ampule
Preparing a Medication fromPreparing a Medication fromanan AmpuleAmpule (cont¶d)(cont¶d)
Remove the needle from the ampule and
point the needle vertically
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Pull back the plunger. Replace the aspirationneedle with a new sterile needle
Push plunger until medication is at tip of
needle
Preparing a Medication from aPreparing a Medication from aVialVial
Cleanse the top of the vial of diluent
Pull plunger of syringe to fill with an amountof air equal to the volume of the solution to be
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of air equal to the volume of the solution to bewithdrawn
Insert the needle or needleless access device
through the diaphragm, inject air Withdraw the measured volume of diluent
required to reconstitute the powdered drug
Preparing a Medication from aPreparing a Medication from aVial (cont¶d)Vial (cont¶d)
Tap the vial of powdered drug to break upcaked powder; cleanse the rubber diaphragm
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caked powder; cleanse the rubber diaphragmwith swab
Insert the needle or needleless access device
in the diaphragm and inject the diluent in thepowder
Mix thoroughly to dissolve powder
Change needle to correct gauge and length
to administer the medication to the patient
Preparing a Medication from aPreparing a Medication from aMixMix--OO--VialVial
Tap the container a few times to break up the
caked powder Remove the plastic lid protector
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Remove the plastic lid protector
Push firmly on the diaphragm-plunger
Mix thoroughly
Cleanse the rubber diaphragm and removedrug using syringe to administer to patient
Special PreparationsSpecial Preparations
Occasionally two medications may be drawn
into the same syringe for a single injection Medications need to be prepared for use in
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Medications need to be prepared for use inthe sterile field during a surgical procedure
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ParenteralParenteral AdministrationAdministration
Types of parenteral routes
Intravenous
Intramuscular
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Intramuscular
Intra-arterial
Intraperitoneal
Intrathecal Intracardiac
Intrasternal
Subcutaneous RouteSubcutaneous Route
Medication is deposited in the loose
connective tissue between the dermis andmuscle layer
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Equipment; needle length and gauge
Sites
Route: SubcutaneousRoute: Subcutaneous
Action
Sites
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Equipment
Route:Route: IntradermalIntradermal
Action
Sites
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Equipment
Intramuscular RouteIntramuscular Route
Injection deep into muscle mass
Equipment: syringe size, needle length andgauge
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g g
Sites
Age and muscle mass
ParenteralParenteral AdministrationAdministration
Intramuscular administration
0.5 to 2 mL of a drug is typically used
20- to 22-gauge needles 1 to 1½ inches long
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g g ½ g
Route: Intramuscular Route: Intramuscular
Action, sites, equipment, techniques
Ventrogluteal:
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Route Intramuscular (cont¶d)Route Intramuscular (cont¶d)
Dorsogluteal:
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Route Intramuscular (cont¶d)Route Intramuscular (cont¶d)
Deltoid:
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Route Intramuscular (cont¶d)Route Intramuscular (cont¶d)
Vastus lateralis:
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Route Intramuscular (cont¶d)Route Intramuscular (cont¶d)
Z-track:
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IV TherapyIV Therapy
IV therapy is the injection of a solution intothe vein
A large volume of fluid is quickly administered
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to the vein with minimal irritation
Faster absorption occurs through the IV route
than with other parenteral routes
IV Therapy (cont¶d)IV Therapy (cont¶d)
Comfortable access for the patient when
multiple doses of medications are required Drugs can be administered directly to the vein
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Drugs can be administered directly to the veinby syringe injection
Drugs can be administered intermittently or
by continuous infusion through a peripheral or central IV line
IV Therapy (cont¶d)IV Therapy (cont¶d)
Requires extended time to administer
Requires a skilled health care provider toperform
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perform
Patient is less mobile
Increased odds of infection
Increased possibility for severe adverse drugreaction
IV Therapy (cont¶d)IV Therapy (cont¶d)
IV therapy requires a written order from the
physician The physician¶s order must include the date
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The physician s order must include the date,type of solution or medication, dosage, rate,and frequency
Equipment Used for IVEquipment Used for IVTherapyTherapy
IV administration sets connect a large volumeparenteral solution with the intravenousaccess device in the patient¶s vein
M d i
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Macrodrip
Microdrip
Types of Infusion ControlTypes of Infusion ControlDevicesDevices
Controllers
Pumps Syringe pumps
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y g p p
IV Dose FormsIV Dose Forms
IV solutions consist of water containing one or more dissolved particles (solutes)
Osmolality
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Isotonic
IV solution and blood have similar osmolality
Hypotonic Solution has fewer dissolved particles thanblood
Hypertonic
Solution has higher concentration of dissolved
particles than blood
Administration of MedicationsAdministration of Medicationsby the IV Routeby the IV Route
Preparing an IV solution for infusion
Dose forms: ampules, vials, prefilled syringes,large volume IV solution bags
E i t
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Equipment
Sites
Peripheral IV access
Central IV access: for large volume, highconcentration, or hypertonic solutions
Basic Guidelines of IVBasic Guidelines of IVAdministration of MedicinesAdministration of Medicines
Premedication assessment
Equipment Technique
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Venipuncture
Selection of catheter or butterfly needle:
select smallest size feasible to administer thespecific type of fluid
Documentation
Patient teaching
Administration of MedicationAdministration of Medication
Care of sites and implanted ports
Dressing changes
Flushing catheters
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Discontinuing IV infusion
Administration of MedicationAdministration of Medication(cont¶d)(cont¶d)
By a heparin/saline/medlock
Into established IV line (IV bolus)
Through implanted venous access device
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Adding medication
Changing to the next container
EquipmentEquipment
Midline access catheters
Flexible Inserted into the cephalic or basilic vein at the
t bit l f l d th l d i th di t l
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antecubital fossal and then placed in the distalsubclavian vein
Lower rates of phlebitis with the use of midline
access catheters
Cheaper than central venous catheters
Equipment (cont¶d)Equipment (cont¶d)
Peripherally inserted central venous catheters
(PICC) Inserted into the superior vena cava
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Inserted into the superior vena cava
Appropriate for pediatric use
Lower incidences of mechanical complications
Cheaper than other central venous catheters
Requires infrequent site rotation
Monitoring IV TherapyMonitoring IV Therapy
Assessments
Procedures
Nursing interventions
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Complications of IV TherapyComplications of IV Therapy
Phlebitis, thrombophlebitis, infection
Septicemia
Infiltration and extravasation
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Air in tubing/air embolus
Circulatory overload, pulmonary edema
Pulmonary embolism ³Speed shock´
Route: IntravenousRoute: Intravenous
Action
Site
Equipment
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Equipment
Technique
Nursing Implications for Administration of Nursing Implications for Administration of ParenteralParenteral MedicationsMedications
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Sites
Equipment
Technique Developmental needs of pediatric clients
Nursing Process: Overview of Nursing Process: Overview of Medication AdministrationMedication Administration
Assessment
Nursing diagnosis
Planning
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Planning
Interventions
Client teaching
Evaluation
GUIDELINES FOR CORRECTGUIDELINES FOR CORRECTADMINISTRATION OF MEDICATIONADMINISTRATION OF MEDICATION
Preparation
Wash hands
Check for drug allergies, check assessment andK ARDEX
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Check label
Check expiration
Recheck drug calculation with another nurse Verify doses that are potentially toxic
Pour tablet or capsule in the cap or open packet atbedside after identifying the client¶s ID
Pour liquid at eye level ± lower meniscus Dilute drugs that irritate GIT or give with meals
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GUIDELINES FOR CORRECTGUIDELINES FOR CORRECTADMINISTRATION OF MEDICATIONADMINISTRATION OF MEDICATION
Administration
When administering drugs to a group clients,give drug last to the client who needs extraassistance
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assistance
Discard needles and syringes in appropriatecontainer
Discard unused solution from ampoules Appropriately store unused
Write date and time opened and your initialson label
GUIDELINES FOR CORRECTGUIDELINES FOR CORRECTADMINISTRATION OF MEDICATIONADMINISTRATION OF MEDICATION
Administration
Keep narcotics in a double locked drawer
Keys to the narcotic drawer ,must be kept bythe nurse
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the nurse
Keep narcotics in safe place
Avoid contamination of one¶s own skin or inhalation
GUIDELINES FOR CORRECTGUIDELINES FOR CORRECTADMINISTRATION OF MEDICATIONADMINISTRATION OF MEDICATION
Recording
Report drug error immediately; completeincident report
Charting: record drug given dose time route
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Charting: record drug given, dose, time, routeand your initials
Record drugs promptly after given, especially
ST AT dose Record effectiveness and results of
medications especially PRN medications
Report to health provider and record drugs
that were refused Record amount of fluid taken with medication
on I/O chart
Behaviors to avoid duringBehaviors to avoid duringdrug administrationdrug administration
Do not be distracted when preparing meds
Do not give drugs poured by others
Do not pour drugs from containers with labelsthat are difficult to read
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that are difficult to read
Do not transfer drugs from one container to
another Do not pour drugs into the hand
Do not give medications for which theexpiration date has passed
Behaviors to avoid duringBehaviors to avoid duringdrug administrationdrug administration
Do not call the client¶s name as the solemean of identification
Do not give drug if the client sates that thedrug is different from the other drug that he or
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drug is different from the other drug that he or she is receiving
Do not recap needles
Do not mix with large amount of food or beverage or foods that is contraindicated
Technologic AdvancesTechnologic Advances
Enhance safety
Increase accessibility to sites Promote client mobility
I li t dh
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Improve client adherence
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