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The key to reaching that potential is having knowledgeable answers.

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Principles You cannot expect to know every medications Know where to find information you need Simplify your study of drugs (classifications) Always assess for allergy Apply universal precautions as required In administering the drug there is a risk of potential exposure to hepatitis B virus (HBV), hepatitis C virus (HCV), and the immunodeficiency virus (HIV) through contact of the nurses skin or mucous membranes with patient blood, body fluids, or tissues. The Centers for Disease Control and Prevention (CDCP) in Atlanta recommend that Universal Precautions be employed in caring for all patients and when handling equipment contaminated with blood or blood streaked body fluids. In 1996 the term Standard Precausions replaced with Universal Precautions. Oral Medications: Handwashing Injections: Handwashing and gloves are required. Never take your eyes from the sharp during the disposal process! Heparin Locks, intravenous catheters and IV needles: Wear gloves when inserting. Secondary administration sets or intravenous piggyback sets: handwashing after removing this equipment.

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Application of medication to mucous membranes: wear gloves (gowns, masks, protective eyewear) Applications to skin: exercise nursing judgement. Handwashing may be sufficient protection when applying such drug forms as transdermal patches. Use gloves when applying lotions, ointments, or creams to areas of rash or to skin lesions. Adhere to the principle of the unit-dose system Avoid altering the form of medications Observe parenteral medications foe clarity discoloration or precipitate

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Trained and certified health care workers who may legally give medications include physicians, physicians assistant, paramedics, medical office assistants, and practical, vocational, and registered nurses.

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Dentists, physician, physician assistants, vetenerarians, nurse practitioners, and registered pharmacist may write prescriptions for their specific field or work, within limitations. For example, vetenerarian write prescriptions for animal use only.

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Specific drugs ruled illegal to purchase without the use of a prescription include: - Those that need to be controlled because they are addictive and tend to be abused and dangerous (depressants, stimulants, psychedelecs, and narcotics) - Those that may cause dangerous health threats from side effects if taken incorrectly (antibiotics, cardiac drugs, tranquilizers)

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Numerous undercover illegal laboratories exist and operate within the US today.

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Drug – any chemical substance that affects the living systems by changing their structure of function. (Dutch, meaning DRY) Therapeutic Drugs – AKA medicines, are thise used in the prevention or treatment of disease Pharmacology – study of chemicals – drugs on living tissues and how these chemicals help diagnose, treat, care and prevent disease or correct the pathophysiology of living tissues. Greek pharmakon, drugs and logos, science

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History Treatment and prevention of disease is as old as history of man. In the Early civilization diseases were viewed with great superstition. Prevention and treatment was directed to driving away evil spirits and invoking magical powers. Poisons to coat at the tip of arrows and spears of ancient warriors are still used medicinally.

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Ancient Egypt is the cradles of pharmacology Ebers Papyrus – an Egyptian medical sources written over 3000 years ago and is the earliest document devoted entirely to medicine. 4th Century B.C. – Hippocrates declares that knowledge about health and disease could only come through the study of natural laws.

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Ancient Egypt is the cradles of pharmacology Ebers Papyrus – an Egyptian medical sources written over 3000 years ago and is the earliest document devoted entirely to medicine. 4th Century B.C. – Hippocrates declares that knowledge about health and disease could only come through the study of natural laws.

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4th Century B.C. – Hippocrates declares that knowledge about health and disease could only come through the study of natural laws.

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Dioscorides (1st Century) prepared the “De Materia Medica” which scientifically described 600 different plants and classified them by substance. Has its roots in folklore and tradition that dates back to ancient times when knowledge of medicinal plants were passed down through generations. Dioscorides (or Dioscurides) of Anazarbus (today's Turkey) (Διοσκουρίδης o Πεδάνιος) was a Greek physician born in southeast Asia Minor in the Roman Empire in the first few decades AD. During his lifetime, he traveled extensively seeking medicinal substances from all over the Roman and Greek world. He served in Nero's armies as botanist. All we know from sources other than Dioscorides' own work is his name-Pedanius Dioscorides from Anazarbus. Greeks normally had only one name, but if one received Roman citizenship, he frequently added a Roman name, perhaps from a benefactor. Three candidates for Dioscorides' first-name benefactor are L. Pedanius Secundus, Roman prefect in AD. 56; Pedanius Secundus, who was likely governor of the Roman province of Asia in the early 50s; and Gn. Pedanius Salinator, consul in AD. 60. These possibilities are conjecture, however. Between about 50-70 AD., he wrote his fundamental work, Περί ύλης ιατρικής , known in Latin as De materia medica. This five book study focused upon "the preparation, properties, and testing of drugs" and became the most central pharmacological work in Europe and the Middle East for the next sixteen centuries!

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This work is the first systematic pharmacopoeia. De materia medica was translated and preserved by the Arabs, and finally translated back into Latin by the 10th century.

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12 – 20 A.D. Drug standards were established and measuring systems was developed - apothecary

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Paracelsus (16th Century), (1493–1541) a Swiss scientist first advocated the use of single drugs, as means of treating diseases. “All things are poison, for there is nothing without poisonous qualities. It is only the dose which makes a thing poison.” Father of Pharmacology or grandfather of pharmacology Poison is in everything, and no thing is without poison. The dosage makes it either a poison or a remedy. Paracelsus The dose makes the poison. Paracelsus

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William Harvey (17th century), an English Physiologist, first began to explain how drugs exert their beneficial or harmful effects. Introduced IVTT

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Francois Magendie and Claude Bernard (19th Century), French Physiologist, demonstrated that certain drugs work and specific sites of action within the body.

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Golden Age of Pharmacology Lister and Semmelweis– first introduced the use of antiseptic to prevent infection during surgery.

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Golden Age of Pharmacology Ehrlich – discovered antibiotics

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Golden Age of Pharmacology Banting and Best – discovered insulin

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Golden Age of Pharmacology John Jacob Abel – Father of American Pharmacology

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Golden Age of Pharmacology Margaret Sanger (1900) Atheist, nurse. Safe contraception. She left nursing to put her husband and 3 children in the background – and ultimately separate her husband and was jailed several times. The Margaret Sanger story and the Fight for Birth Control, What every mother should know and My Fight for Birth Control were some of her books

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20th Century – culminated in the development of literally thousands of drugs These drugs altered the practice of medicine and saved millions of human lives.

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Three Basic Concepts Pharmacokinetics – the absorption, distribution, metabolism, and excreation of drugs by the body Pharmacodynamics – the biochemical and physical effects of the drugs and the mechanism of drug actions Pharmacotherapeutics – the use of drugs to prevent and treat diseases

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Pharmacognosy – study of drugs derived from herbal and other natural sources. Toxicology – study of poisons and poisonings

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3 Different Names Chemical Name: most meaningful to the chemist. A scientific name that precisely describes the drugs atomic and molecular structure. Ex. 7-chloro-2-methylamine-5-phenyl3H-1,4 Generic Name or Nonpropriety Name: an abbreviation of the chemical name. Common Name. First name is not capitalized. (ampicillin sodium) Trade Name (Brand Name or proprietary name): is selected by the drug company selling the product. First letter is capitalized followed by the R symbol (Librium)

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each drug can be categorized under a broad subcategory, or subcategories, called classifications. Drugs that affect the body in similar ways are listed in the same classification. Pharmacologic Class: drugs with similar characteristics are grouped under this class. Ex. Beta Blockers Therapeutic Class: categorizes drugs by the therapeutic use.

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Is a model example, a drug that typifies the characteristics of that classification.

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Natural Sources > Plants: alkaloids (most active component in plants), glycosides, gums, Resins, oils > Animal: are also natural drug sources – hormones, oils and fats (cod liver oil), enzymes (suspension of killed modified or attenuated microorganisms > Minerals: Metallic; Non Metallic (salts) Synthetic Drug Sources: Thyroid Hormones and Cimetidine > DNA engineering: bacteria that produce insulin for humans Advantages: no impurities and can manipulate the molecular structure of substances such as antibiotics

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Buccal, Sublingual, and Translingual: to prevent destruction or transformation in the stomach or small intestine. Ex. Ranitidine Gastric: allows direct administration of a drug into the GI system Intradermal: allows drug to be injected into various muscle group at varying tissue depths. Provides rapid action and allows for absorption of relatively large dose (upto 5 ml) Intravenous: injection of a drug and other substances directly into the blood stream through a vein. Appropriate substance to administer: drugs, fluids, blood or blood products, and diagnostic agents. Delivered with great precision. Oral: safest and most convenient and least expensive route. Given to patients who are conscious and able to swallow. Rectal and Vaginal: suppositories, ointments creams, or gels may be instilled into the rectum or vagina to treat local irritation and infection. Can also be absorbed systemically. Respiratory: drugs that are available gases can be administered into the respiratory system through inhalation. Used in emergencies. Subcutaenous: small amount of drugs are injected beneath the dermis and into the

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subcutaenous tissue, usually in the patients upper arm, thigh, or abdomen. Appropriate drugs: nonirritating aqueous solutions and suspensions contained in 0.5 to 2 ml of fluid such as heparin and insulin. Topical: used to deliver a drug via the skin or mucuos membrane. Used for most dermatologic, opthalmic, otic, and nasal preparations. Specialized infusions: given directly to a specific site in the patients body. Types of infusions > Epidural infusion: drug is injected into the epidural space (spinal: subarachnoid) >Intrapleural infusion: drug is injected into the pleural cavity > Peritoneal Infusion: drug is injected into the peritoneal cavity > Intraosseous infusion: drug is injected into the rich vascular network of a long bone. > Intra-articular infusion – drugs are injected into the joint.

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Phases of New Drug Development Phase I – drug is tested on healthy volunteers Phase II – trials with human subjects who have the disease for whhich the drug is thought to be effective Phase III – Large numbers of patients in medical research centers receive the drug in Phase III. This larger sampling provides information about infrequent and rare adverse effects. Phase IV – is voluntary and involves post market surveillance of the drugs therapeutic effects at the completion of phase III.

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Category A: medication are considered safe during pregnancy Category B: animal studies have not shown a risk to retus, but no controlled studies in pregnancy women Category C: Animal studies have shown adverse effects on fetus, but no adequate studies have been conducted on humans. Category D: The drug may cause risk to human fetus, but the potential benefits of use in pregnant women may be acceptable Category E: Studies in animals or humans show fetal abnormalities. The risk clearly outweigh any potential benefit.

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Furosemide – renal and cardiovascular disease Felodipine – dilutes blood Merofenem - antibiotic

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International sources of counterfeit drugs are China, India, and Pakistan Manila, Cebu and Region III hotspots

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Advocates of the fight against counterfeit drugs Learn more about counterfeit drugs and the danger of taking them. Educate the patients about counterfeit medicines, their health impact and how to avoid them Avoid unsafe medicines and vendors Decline suspicioius offers of medicines Evaluate medicines – appearances etc Report counterfeit drugs and their vendors

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> They do not create new responses but alter existing physiologic activity > Drugs interact with the body in several different ways. > Most drugs have several different atoms within each molecule that interlock into vatious location on a receptor > Drugs that interact with a receptor to stimulate a response known as agonist. Drugs that attach to a receptor but do not stimulate a response are called antagonist. They that interact with a receptor to stimulate a response but inhibit other responses are called partial aganonist. > Once administered, all drugs go through stages of: absorption, distribution, metabolism and excretion.

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Deals with a drugs action as it moves through the body. It includes * Drug Absorption - Active transport (requires cellular energy to move the drug from an area of lower concentration to one higher concentration. Used to absorbed electrolytes such as Na, K, and levadopa) Pinocytosis is a uniques form of active transport that occurs when the cell engulfs a drug particle. Employed to transport Vit ADEK. Passive Transport: requires no cellular energy because the drug moves from an area of higher concentration to one of lower concentration Factors affecting absorption > route of administration (Sublingual, IV or inhalation: occurs within seconds or minutes; Oral, IM, or subcutaenous: absorption occurs in slowest rates; rectal, sustained release; absorption occurs in slowest rates; Surgical removal of small intestines; First pass effect: liver metabolizee much of the drug before it enters circulation. > Amount of blood flow: increased blood flow to an absorption site improves drug absorption. Blood flows faster through the deltoid muscle than through the gluteal muscle. Pain and stress can also decrease the amount of drug absorbed (reduced movement of GIT causes gastric retention. High fat meals and solid foods slow rate at which contents leave the stomach and inter the intestines, delaying intestinal absorption of a drug.

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> Form of Drug: drug formulation such as tablets, capsules etc. Combining one drug with another drug, or with food, can cause interactions that increase or decrease drug absorption, depending on the substances involved. * Distribution: is the process by which the drug is delivered to the tissues and fluids of the body. > Blood flow: distributed quickly to those organs with a large supply of blood > Solubility: ability of a drug to cross a cell-membrane depends on wether the drug is water-or-lipid soluble. Lipid-soluble drugs can also cross the blood-brain barrier and enter the brain. > Protein binding: the portion of a drug that bound to a protein is inactive and cant exert therapeutic effect. Only the unbound can exert its effect. * Metabolism (Biotransformation) refers to the bodys ability to change a drug from its dosage from to more water-soluble from that can then be excreted. The process by which the body inactivtes drugs. Liver primary site. Most drugs are metabolized by enzymes in the liver (occurs also in the plasma, kidney, and membranes of the intestines. Diseases like liver cirrhosis and heart failure decreases blood flow in the liver. Genes. Environment: smokers, stressful like surgery. Age like infants and elderly. Excretion: refers to the elimination of drugs from the body. Most drugs are excreated in the kidney and leave the body through urine (also in lungs, exocrine glands, skin, and intestinal tract, breastmilk and saliva. Half life: is the time it takes for the plasma concentration of the drug to fall to half its original value. Measure of time required for elimination. Ex. Digoxin 36 hours OD (long Half life), Aspirin 5 hours, 4 to 6 hours. Concerned also with > Onset of Action: referes to the time interval that starts when the drug is administered and en ds when the therapeutic effect usually begin. > Peak Concentration level: is reached when the absorption rate equals the elimination rate. > Duration of action: is the length of time the drug produces its therapeutic effect. * Pharmacodynamics: is the study of the drug mechanism that produce biochemical or physiologic changes in the body. The response resulting from this drug action is called the drug effect. > Physiologic Change: a drug can modify cell function or rate of function. A drug can alter teh target cells function by: Modifying the cells physical and or chemical environment; Interacting with a receptor (specialized location on a cell membrane or

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inside a cell membrane or inside a cell) > Biochemical Change: Agonist (is an example of a drug that interacts with receptors. It has an attraction, or affinity, for a receptor and stimulate it; Antagonist: if a drug has affinity for receptor but plays little or no intrinsic activity. It prevents a response from occuring. If a drug acts in a variety of receptor, it is said to be non selective and can cause multiple and widespread effects. Drug Potency: refers to the relative amount of a drug required to produce a desired response. Therapeutic index (margin of safety): relationship between a drugs desired therapeutic effects and it adverse effects. It measures: 1. an effective dose for 50% of the patients treated. 2. The minimal dose at which adverse reactions occur.

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ls the use of drugs to treat disease, Category in choosing drugs for treating diseases; Drugs effectiveness The overall health as well as other individual factors can alter the patients response to a drug. Drug Tolerance: occurs when a patient has a decreased response to a drug over time Drug dependence: a patient displays a physical or psychological need for the drug. > Physical dependence causes withdrawal syndromes when drug is stopped. > Psychological dependence is based on the desire to continue taking the drug to relieve tension and avoid discomfort. Type of therapy > Acute therapy: if the patient is critically ill and requires acute intensive therapy > Empiric therapy: based on practical experience rather than on pure scientific data > Maintenance Therapy: for patients with chronic conditions that dont resolve > Supplemental or replacement therapy: to replenish or substitute for a missing substances in the body > Supportive therapy: which doesnt treat the cause of the disease but maintenance other threatened body systems until the patients condition resolves. > Palliative therapy: used for end stage or terminal diseases to make the patient as

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comfortables as possible.

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Drug Interactions Can occur between drugs or between drugs and food. They can interfere with the results of the laboratory test or produce physical or chemical incompatibilities. Potential Drug Interactions > Addictive effects: occurs when two drugs with similar actions are administered to a patient. > Potentiation (Synergestic Effect): occurs when two drugs that produce the same effect are given together and one potentiates of the other drug. > Antagonistic Effects: occurs when the combined response of two drugs is less than the response produced by either drug alone. > Decreased or increased absorption: two drugs given together can change the absorption of one or both of the drugs. Sometimes, an absorption interaction can be avoided by separating drug administration by at least 2 hours. When 2 drugs are given together, they can compete for protein-binding sites, leading to an increase in the effects of one drug as that drug is displaced from the protein and becomes a free, unbound drug. >Decreased or increased metabolism and excretion. > Toxic drug levels can occur when a drugs metabolism and excreation are inhibited by another drug > Food can alter therapeutic effects of a drug as well as the rate and amoungt of drug absorbed from the GIT, affecting bioavailability. Ex. Tyramine can cause hypertensive crisis to a patient taking MAOI, grapefruit can inhibit metabolism of certain drugs and result in toxic blood levels.

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Responsible for more than 100,000 deaths among hospitalized clients. ADR – WHO; any noxious and undesired effect of a drug which occurs with doses used in humans for prophylaxis, diagnosis or theraphy. All drugs however have the potential to affect morse than one body. Adverse Drug Reaction (Side Effect or Adverse Effect): is a harmful undesirable response. > Dose related: result from the known pharmacologic effects of a drug and are typically dose related. Common Drugs Antibiotics Cardio Drugs Chemotherpeutic Drugs Analgesic / antiinflamatory Common ADR – rash, nausea, itching, thrombocyyophenia, vomiting, hyperglycemia and diahrrea. ADE: adverse drug event – an injury resulting from medical intervention related to a drug.

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Side Effects – are nontherapeutic reactions to a drug that are transcient and may not require any nursing intervention. Drowsiness, occurs in histamine Adverse effects are nontherapeutic effects that may be harmful to the patient and that require lowering the dosage or discontinuing the drug. Serious decrease in white blood cells that results in lowered resistance to infection. Right drug, right dose, right patient, and bad effect. The nurse must observe for these effects, know how to manage them, teach the patient necessary information.

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Abbreviations Commonly Found in Drug Orders

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It is an ongoing cyclic process that must respond to the changing requirement of the patient. This problem solving approach to nursing care provides a systematic method of determining the patients health problems, developing a care plan to address those problems, implementing the plan, and evaluating the plans effectiveness. Guides nursing decisions about drug administration to ensure the patients safety and to meet medical and legal standards.

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Anyone who has spent a few nights in a hospital bed remembers being awakened from a sound sleep by a nurse saying “Time to tkae your medication” Try as you might to ignore the request you cant win. The voice decomes more insistent until you have no choice but to open your eyes. Administering medications, evaluating the patients response of determining if the drug is working as planned are pharmacology activities that are part of the nursing process. Steps in the nursing process Assessment: Initial assessment – collect subjective data; assess knowledge of disease process, drug and drug regimen. Ongoing Assessment; Collect data related to effectiveness of the drug; Monitor for adverse reaction. Nursing Diagnosis: Ineffetcive therapeutic Regimen management; Deficient Knowleldge; Noncompliance; anxiety 5 types of ND > Actual – bsed on human responses to health conditions and life processess that exist in an individual, family, or community. > Risk – a clinical judgement that an individual, family, or community is more susceptible to the problem than others in the same or similar situation. > Possible: suspected patient problems requiring additional data for confirmation. > Wellnes: a clinical judgment about an indivisual, group, or commmunity in transition from specific level of wellness to a higher level of wellness > Syndrome: cluster actual or high risk signs and symptoms that are predicitve of certain

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circumstances / events. Planning: set expected outcomes; Develop a teaching plan to correct defecient knowledge or reason for noncompliance Implementation: perfomr any nursing actions before administration of drug; adminster drug according to the six rights; manage adverse reaftions; Manage adverse reactions; teach patient / family about drug, disease process treatment requirement etc. Evaluation: evaluate the effectiveness of nursing interventions to most patient expected of the drug regimen; evaluate patient / family understanding of the drug regimen.

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Read the Label

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Anaphylaxis – (penicillin) hives, rash, difficulty breathing, diaphoresis Nursing Care: Ephineprin 3 mg of 1 to 1,00 solution given SC massage site helps absorption. Repeat 15 to 20 minutes. If you have allergy use medic alert. Delayed Allergic Reaction: not immidiate, reactions not severe. Hives, rashes, swollen joints Nursing Care: discontinue medications. Patient may use antihistamines, corticosteroids and comfort measures. Dermatological Reactions: Hives, dermatitis, erythema Nursing care: good skin hygiene / care Stomatitis: (Chemotherapeutic Agents) swollen gums and tongue, difficulty swallowing, halitosis, pain in the mouth Nursing care: good mouth care, small frequent feedings. Antifungals or local anethesia. Superinfections: fever, diarhea, black hairy tongue, glositis (inflammation of the tongue) vaginal itching and discharge. Nursing Care: good mouth and skin care, antifungals are used. Bone Marrow Depression: fever, chills, sore throat, backpain, dark urine, anemia, thrombocytopenia, leukopenia Nursing Care: monitor CBC closely, protect the patient from infection and injury

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Liver impairment: fever, malaise, jaundice, stools light, urine dark, abdominal pain, liver function studies, AST, ALT and altered as well the PTT because of the bleeding Nursing Care: safety measures, good skin care, comfort measure Renal Impairment: elevation in BUN, creation, decreased hematocrit, altered electrolyt, complain of fatigue and edema. Nursing Care: diet and fluid restrictions, electrolyte replacements, need dialysis, suggested to rest

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Ocular Impairment: blurred vision, color vision changes, blindness Nursing Care: monitor vision and regulate and decrease exposure to light. Auditory Impairment: dizziness, ringing in the ear, tinnitus, loss of hearing and alternative imbalance such as ataxia Nursing Care: Monitor hearing, safetry measures very important CNS Impairment: confusion, insomia, drowsiness all the way up to hallucination Nursing Care: safety measures asre important, avoid activities that require alertness and make sure that patient is oriented to their surroundings. Cholinergic Effects: dry mouth, dysphagia, urinary retention Nursing Care: loozenges, good mouth care and void before taking medications Parkinsonian Like Effects: akathisia, motor restlessness, tremors, drooling, parkinsonian changes in gait Nursing care: Doctor will prescribe anticholinergic medication and antiparkinsonian medication, make sure patient is safe while they are moving around.

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Ticket System A medication order is transferred to three places: a medication ticket, the patients medication sheet, and the patients Kardex file, which contains the nursing care plan. Tickets for all patients are kept in a central location. The nurse sorts them according to time of administration. Each ticket is compared with the Kardex entry. If there is a discrepancy, the nurse checks the original order on the patients chart. After all tickets are verified, the nurse enters the medication room or unlocks the medication chart.

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Everyorder must be transcribed to three different places. Tickets may be lost or misplaced. The tickets may become mixed, so that the wrong patient receives a medication. Time consuming to locate the chart of each patient.

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Mobile-Cart System Compared with the ticket system, the mobile-cart system has many disadvantages. The pharmacist dispenses unit-dose medications directly to the patients drawer. Each drawer is labeled with the patients name. The cart contains all the equipment the nurse might require to administer medications. When a drug is ordered, the nurse transcribes the order to one place – the patients medication sheet found in a medication book on the cart. This book contains the medication sheets for every patient on the unit. When it is time to adminster medications, the nurse washes his or her hands and rolls the cart to the bedside of the first patient, greets the patient by name, unlocks the cart, and opens the medication book to the first patients medication sheet.

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There are two professionals involved in checking the medication in the drawer – the pharmacist and the nurse. All the medication sheets are together on the cart. Time saving The drugs can be signed for immediately after administration. The nurse chacks three times.

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Computer Prinouts Doctors input orders directly on the computer. The order is received in the Pharmacy, where it is added to the patients drug profile. The nursing unit receives the computer printout listing the medications and times of administration. The printout replaces the medication adminitration record (MAR)

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Neither the nurse nor the pharmacist has to interpret the doctors handwriting. The nurse does not have to transfer the written orders to an MAR, thus reducing the chance for error and saving time. Moreover, a computer check will identify possible interactions among the patients medication and alert the nurse and the pharmacist. The administration period for this record covers 24 hours using military time.

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The welfare of the client necessitates proper interpretation of the medication order. It is the nurses responsibility of the pharmacist to check the doctors order.

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Interpretation: Give the client one 25 mg capsule by mouth every 4 hours

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Interpretation:Give 80 mg of elixir acetaminophen by mouth 3 times a day after meals and at bedtime

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3 Basic Units Meter (Length) Gram (Weight) Liter (Volume)

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Is based upon grains which is the smallest unit in the system. Example: NTG 1/100 gr, atrophine sulfate 1/200 gr, morphine sulfate 1/8 gr.

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Special Considerations > Dosages are based on size, weight, age and or BSA > Pharmacokunetics are affected by size, immaturity of the stomach, liver and kidney. > Have smaller body muscle size > Topical medications are rapidly absorbed due to childs thinner skin (systemic) > Lower serum protein levels (medication toxicity) > Unstable temperature increase temperature is increas metabolism and vice versa > To kidney function > Route of administration depends on the debelopmental level / stage.

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Calculation of Dosages Based on Weight The recommended dosages of drugs are often expressed in the literature as a number of milligrams per unit body weight per unit of time. Factors Influence how long a drug produce a therapuetic res[ponse: age, weight, sex, BSA, metabolic, pathologic and psychological condition and time and route of administration No oneformula – or chart that guarantess of dosage at any age.

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The nomogram is a chart uses the weight and height of the client to estimate his body surface are (BSA) in square meters (m2). The body surface area is then placed in a ratio with the body surface area of an average (1.73 m2). The formula with the nomogram method is:

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Clarks rule (for children; based on weight)

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Young’s Rule (for children 2 – 12 years of age)

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Fried Rule (for infants under 2 years)

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Calculating the Rate of IV Administration > When the physician orders intravenous solutions to run for a stated number of hours, the nurse may have to compute the number of drops per minute to comply with the order. > To calculate the flow rate using the ration and proportion method, 3 steps are required. One must determine: 1. The number of ml the client will receive per hour 2. The number of ml the client will receive per minute 3. The number of drops per minute that will equal the number of ml computed in step 2. The drop rate is expresses as ration of drops per ml )gtt/ml)

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Blood administration 19 g needle Started with NSS Slowly 5 ml / min 1st 15 – 30 minutes monitor the patient Infuse 4 hours and below Transfusion Reaction Allergic – hypersensitivity (urticaria and pruritus) Hemolytic Reaction (Blood incompatibility) (pain in the back; hyptotension) Pyrogenic reaction (antibody / antigen) (fever and chills) Nursing Intervention Stop blood and restart Normal Saline Provide airway (obstructed due to edema) Administer benadryl / aspirin / antihistamines Blood is left in the nursing unit and not discarded Collect blood and urine samples (blood precipitation)

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Parentral fluids Main goal os to restore the fluid and electrolyte balance Give medications and specimen IV fluids Maintain sterile techniques Monitor flowrate Know equipment Macro 10 – 12 – 15 Micro 60 gtts/min – easily monitored, used for KVO, used for pedia. Change tubing – 72 hours – if it breaks before then change it. Bottle – 24 bours because bacteria love it.

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Infiltration: cool skin, swelling, decrease IV flowrate (to check, put a tourniquet above the site if IV wont run that would tell the IV is going into the tissue) Nursing Interventions DC IV Do not irrigate it, milk it, do not increase IVFR, hang solution, Do not aspirate Inject eucarnate (which can dissolve the clot) Central Venous Access Devices PICC – pheripheral Implanted Central Catheter

Hematoma Area of ecchymosis (black and blue area) Swelling and leakage of blood Nursing Care Discontinue IV Apply pressure for 5 minutes Ice Bag (apply) Restart site opposite extremity IV clots Decrease Flow Rate

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Medication errors fall into several categories, such as > Ommitting the dose > Administering the wrong dose > Administering an extra dose > Administering the unordered drug > Adminsering by the wrong route > Misinterpretation > The way the amounts are expressed Preventing medication errors 1. Know and follw institutional policies and procedures for medication administration 2. Know where to obtain resources for drug information 3. Verify orders as much as possible before giving medications 4. Inspect for expiration, defects 5. Verify patients ID 6. Take labeled medications right to the bedside 7. Observe for adverse reaction 8. If calculations are necessary, it is wise to check with another person. 9. Be familiar with administration devices before using them

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There is a nationwaide movement to change the methods or ordering of medications such as computer generated physician order. > Never leave a decimal point naked. Ex. 0.2 > Never place a decimal point and zero after a whole number, because the decimal may not be seen and result in a ten fold overdose. (Many deaths have occured from overdose) Ex 2.0 mg read as 20 mg by mistake. Ex. 0.5 should be expresses as 500 mg and 0.4 mf should be expressed as 400 mg > Whenever possible, use the metric system rather than grains, dram, or minims. > Always spell out the word “units” The abbreviation “U” for unit can be mistaken for a zero. Ex. 10 U interpreted as 100 units. The better way is to write out 10 units ex. “qd misiterpreted as qid > Similar names of drugs such as digoxin and digitoxin. Always rely on dose, repeated interpretations and verifications of medications. > Verbal orders should be repeated with verification of number values and put in writing ASAP. > Hold orders for temporarily stopping medications should have a clear parameters for restarting.

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There are two types of law that affect nursing practice – criminal and civil Criminal Law – Relates to offenses against general public that are detrimental to society as a whole. Prosecuted by the government. Nurses should be familiar with government regulations that affect nursing. Nurses who become impaired (unable to function) owing to alcohol or drug abuse leave themselves open to criminal action, as well as to disciplinary action by the state board of nursing. Civil Law – concerned with legal rights and duties of private persons. When an individual believes that a wrong was committed against him or her personally, that individual can sue for damages in the form of money. The legal wrong is called a tort. Malpractice refers to negligence on the part of the nurse. Not all malpractice is a result of negligence. Malpractice claims are also founded on the daily interaction between the nurse and the patient: consequently, the nurse’s personality plays a major role in fostering or preventing malpractice claims. All nurses should be familiar with the principles of psychology. The surets way to prevent claims is to recognize the patient as a human being who has emotional, aw well as physical, needs and to respond to these needs in a humane and competent manner.

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Nurses Legal Responsibility > Interpreting each of the components of the order > Questioning the order by communicationg with the physician if - the nurse cannot read the physicians order - any component of the order is erroneous / ambigous - the nurse has any doubt about the appropriateness of the order, including the patients current status. - any order which does not make sense, such as a large number of tablets / capsules, or a large volume of solution for injection; medication for diseases / problems the patient does not have; unnecessary administration routes, such as IM when a patient can take oral medications. Should an error occur, primary consideration must be given to the patient. The nurse notifies the physician and the immediate supervisor; students notify the instructor. Error-in-medication forms are filled out and appropriate action is taken under the direction of the physician.

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Are rules set to assure consumers that they get what they pay for. The law says that all preparations called by the same drug name must be of uniform strength, quality and purity.

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FDA Concerned with general safety standards in the production of drugs, foods, and cosmetics Responsible for approval and removal of products on the market Additional -Inspecting plants where foods, drugs, or cosmetics are made - reviewing new product applications and petitions for food additives -Investigating and removing unsafe drugs from the market - Ensuring proper labeling of foods, cosmetics, and drugs DEA Concerned with controlled substances only Enforces laws against activities, including illegal drug use, dealing, and manufacturing Monitors need for changing the schedules of abused drugs

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2. To prove or disprove this element, both sides bring in expert witnesses to testify, The nurse-patient relationship is a legal status that is created the moment a nurse actually provides nursing care to another person.

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3. For administration of medications, A nurse is required by the law to exercise the degree of skill and care that a reasonably prudent nurse with similar training and experience, practicing in the same community, would exercise under the same or similar circumstances. When a nursing student performs duties that are customarily performed by a registered nurse, the courts have held the nursing student to the higher standard of care of the registered nurse.

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A frequent cause of medication errors is misreading the physicians order or failing to check with the physician when the order is questionable. Legal Medication Order > Date and time of order > Patients name > Patients inpatient ID number > Drug name and strength of dose > Frequency of dose and or duration of therapy > Physician full signature

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Listen to the patient: “I never took that before.” and the like Double Check when a dose seems high Most oral tablet doses range from ½ to 2 tablets.

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Keep drug knowledge up to date. Attend continuing education programs; update nursing skills.

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Republic Act No. 6675: Generic Act of 1988 Safe Medication which promotes, distibutes, use and acceptance of drugs and medicines identified by their name. Republic Act No. 6425: Penalties for violators of the Dangerous Drug Act of 1972 Republic Act No. 9165 Comprehensive Dangerous Drug Act of 2001 Republic Act 8423 Traditional and Alternative Medicine Act of 1997. Republic Act 9165 New Dangerous Drug Act Republic Act 8203, BFAD 1996 Counterfeit Drugs

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Per R.A. 8203: THE SELLING OF FAKE MEDICINES IS A CRIME PUNISHABLE BY LAW REPUBLIC ACT NO. 8203 (Special Law on Counterfeit Drugs) - AN ACT OF PROHIBITING COUNTERFEIT DRUGS, PROVIDING PENALTIES FOR VIOLATIONS AND APPROPRIATING FUNDS THEREFORE. REPUBLIC ACT No. 3720 (Creating the Food and Drug Store) AN ACT TO ENSURE THE SAFETY AND PURITY OF FOODS, DRUGS, AND COSMETICS BEING MADE AVAILABLE TO THE PUBLIC BY CREATING THE FOOD AND DRUG ADMINISTRATION WHICH SHALL ADMINISTER AND ENFORCE THE LAWS PERTAINING THERETO. REPUBLIC ACT NO. 9502 (Universally Accessible Cheaper and Quality Medicines Act of 2008) AN ACT PROVIDING FOR CHEAPER AND QUALITY MEDICINES, AMENDING FOR THE PURPOSE REPUBLIC ACT NO. 8293 OR THE INTELLECTUAL PROPERTY CODE, REPUBLIC ACT NO. 6675 OR THE GENERICS ACT OF 1988, AND REPUBLIC ACT NO. 5921 OR THE PHARMACY LAW, AND FOR OTHER PURPOSES.

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1938 Food, Drug and Cosmetic Act: before 1938 there was no control over pharmaceuticalc; changed when a drug company distributed a sulfa drug to treat pediatric patients. It was highly toxic and killed more than 100 people inc;luding children 1952 Durham – Humphrey Amendment Act to the Food, Drug and Cosmetic Act: Until 1952, anyone could distribute drugs; drugs require prescription before sold. 1970 Comprehensive Drug Abuse Prevention and Control Act: by 1970 there was widespread abuse of prescription drugs. To contain this problem the law was given. Schedule 1 – reserved for most dangerous substances that have no recognized medicinal use Schedule 2 – high abuse potential with accepted medicinal use Schedule 3 – potential with accepted medicinal uses Schedule IV and V – lower abuse potential with accepted medicinal uses The orphan Drug Act of 1783 - was passed to encourage the development and marketing of products used to treat rare diseases.

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1970 Comprehensive Drug Abuse Prevention and Control Act: by 1970 there was widespread abuse of prescription drugs. To contain this problem the law was given. Schedule 1 – reserved for most dangerous substances that have no recognized medicinal use Schedule 2 – high abuse potential with accepted medicinal use Schedule 3 – potential with accepted medicinal uses Schedule IV and V – lower abuse potential with accepted medicinal uses

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A moral as well as legal dimension is involved in the administration of medications. Nurses are responsible for their actions. The American Nurses Association Code of Ethics contains several statements that apply to drug therapy. Briefly stated, they are:

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Several principles can be used as guides when an ethical decision must be made. These principles are autonomy, truthfulness, beneficence, nonmaleficience, confidentiality, justice and fidelity.

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Is self-determination. It is a form personal liberty in which an individual has the freedom to decide, knows the facts and understands them, and acts without outside force, deceit, or constraints. For patient – implies the right to be informed about drug therapy and right to refuse medication. For the nurse – brings a responsibility to the discuss drug information with the patient and to accept the patients right to refuse.

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The nurse has the obligation not to lie. Telling the truth, however, is not the same as telling the whole truth. In drug research the patient has a right to informed consent - to be told the truth before signing as a participant. The patient must receive full disclosure of risks and benefits and understand the research design to participate freely.

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This principle holds that the nurse should act in the best interest of the patient. Conflict can arise when the nurse decides what is best for the patient and violates the patients rights.

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This principle holds that the nurse must not inflict harm on the patient and must prevent harm whenever possible. For example chemotherapy may reduce the sixe of a tumor but cause nausea, vomiting, decreased white cell count etc. The nurse anticipates what untoward effects of drugs may occur and acts to minimize them.

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Confidentiality is respect for information learned from professional involvement with patients. A patients drug therapy and responses chould be discussed only with those individuals who have a right to know, that is, other professionals caring for the patient. These varying interest may cause conflict.

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Refers to the patients right to receive the right drug, right dose, by the right route , at the right time. In addition, the patient has a right to the nurses carefull assesment, management, and evaluation of drug therapy and to those nursing actions that promote the patients safety and well-being. The nurses obligation is to maintain a high standard of care.

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A nurse should keep promises made to the patient. Statements such as “I’ll be right back” and “I’ll check the chart and let you know” create a covenant that should be respected.

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