INTERPRETING DRUG LABELS
➔ The formulation or the drug amount per tablet, capsule,
or unit of liquid (for oral and parenteral doses) is printed
on the drug label. Other information found on drug
Pharmacology (from the Greek pharmakon, meaning “drugs,”
and logos, meaning “science”) deals with the study of drugs and
their actions on living organisms. Diseases that cause illness may
be treated in several different ways, which are referred to as
therapies. The various approaches to therapy are called
labels includes lot number, expiration date, proper
storage of the drug, and whether it is a controlled
substance.
➔ Example: 1. Drug Label of An Oral Drug
●
Tylenol
is
the
brand
(trade)
name,
acetaminophen is the generic name, and the
therapeutic methods. Examples of therapeutic methods include
formulation is 500mg per caplet. That the
the following:
container holds 100 caplets is irrelevant when
➔ Drug therapy: Treatment with drugs
calculating the drug dosage.
➔ Diet therapy: Treatment with diet (e.g., a low-salt diet
for patients with cardiovascular disease)
➔ Physiotherapy: Treatment with natural physical forces
(e.g., water, light, heat)
➔ Psychological therapy: The identification of stressors
and methods that can be used to reduce or eliminate
stress
Drugs (from the Dutch droog, meaning “dry”) are chemical
substances that have an effect on living organisms.
Therapeutic drugs, which are often called medicines, are those
➔ Example: 1. Drug Label of A Parenteral Drug
●
This label lists the generic name only (folic
acid). The formulation is 5 mg per mL.
drugs that are used for the prevention or treatment of diseases.
Drugs have several names.
➔ The chemical name describes the drug’s chemical
structure.
➔ The generic name is the official, nonproprietary name
for the drug; this name is not owned by any drug
company and is universally accepted. Generic names are
given in lowercase letters
➔ The brand (trade) name, also known as the
proprietary name, is chosen by the drug company and
is usually a registered trademark. Brand names always
begin with a capital letter. An example of a generic and
brand-name drug listing is Furosemide (Lasix).
➔ Example: 1. Additional information provided on
drug labels.
●
(1)Kadian is the brand (trade) name and
(2)morphine sulfate is the generic name. The
(3)formulation is 60 mg per capsule, and the
container holds (4)100 capsules. It is a
(5)schedule II drug, which is a controlled
substance because of its potential for abuse.
The (6)label indicates how the drug is to be
stored, and the (7)lot number also appears.
PHARMACOLOGY
1
Drugs may be classified by a variety of methods:
➔ According to the body system that they affect (e.g.,
the central nervous system, the cardiovascular system,
the gastrointestinal system);
➔ According to their therapeutic use or clinical
indications (e.g.,antacids, antibiotics, antihypertensives,
diuretics, laxatives);
➔ According to their physiologic or chemical action
(e.g., anticholinergics, beta-adrenergic blockers, calcium
channel blockers, cholinergics).
Drugs
may
be
further
classified
TYPES OF MEDICATION ORDERS:
➔ Stat order- generally used on an emergency basis. It
means that the drug is to be administered as soon as
possible, but only once
as
prescription
or
nonprescription.
➔ Prescription drugs require an order by a health
professional who is licensed to prescribe drugs, such as a
➔ Single order- means administration at a certain time but
only one time.
➔ Standing order- indicates that a medication is to be
given for a specified number of doses
➔ PRN order- means “administer if needed.”
physician, a nurse practitioner, a physician assistant, a
pharmacist, or a dentist.
➔ Nonprescription drugs, or over-the-counter (OTC)
drugs, are sold without a prescription in a pharmacy or
in the health section of department or grocery stores.
➔ Illegal drugs, sometimes referred to as recreational
drugs, are drugs or chemical substances used for non
The pharmacokinetic phase is composed of four processes:
therapeutic purposes. These substances either are
obtained illegally or have not received approval for use by
the FDA.
➔ A biologic or physiologic response results from the
The nurse must accurately determine the right drug prior to
administration. The components of a drug order are as follows
➔ Patient name and birth date
➔ Date the order is written
➔ Provider signature or name if an electronic order, T/O,
or V/O
➔ Signature of licensed staff who took the T/O or V/O, if
applicable
➔ Drug name and strength
➔ Drug frequency or dose (e.g., once daily)
➔ Route of administration
➔ Duration of administration (e.g., × 7 days, × 3 doses,
when applicable)
➔ Number of patient refills
➔ Number of pills to be dispensed
➔ Any special instructions for withholding or adjusting
dosage based on nursing assessment, drug effectiveness,
or laboratory results
pharmacodynamic phase.
➔ A drug interaction is said to occur when the action of
one drug is altered or changed by the action of another
drug. Drug interactions are elicited in two ways:
(1) by agents that, when combined, increase the
actions of one or both drugs; and
(2) by agents that, when combined, decrease the
effectiveness of one or both drugs.
FACTORS THAT AFFECT DRUG THERAPY:
➔ AGE- Infants and the very old tend to be the most
sensitive to the effects of drugs. There are important
differences with regard to the absorption, distribution,
metabolism, and excretion of drugs in premature
neonates, full-term newborns, and children. The aging
process brings about changes in body composition and
organ function that can affect the older patient's
response to drug therapy.
➔ BODY WEIGHT- Compared with the general
population, considerably overweight patients may
require an increase in drug dosage to attain the same
therapeutic response. Conversely, patients who are
underweight, compared with the general population,
PHARMACOLOGY
2
tend to require lower dosages for the same therapeutic
response. It is important to obtain an accurate height
and weight on patients because dosages of medicines are
often calculated with these parameters.
➔ Is the process of drug movement throughout the body
➔ GENDER- Gender-specific medicine is a developing
that is necessary to achieve drug action.
science that studies differences in the normal function of
➔ The four processes are absorption, distribution,
men and women and addresses how people of each
metabolism (or biotransformation), and excretion
gender perceive and experience disease. In almost every
(or elimination).
body system, men and women function differently, as
well as perceive and experience disease differently. In the
case of angina (heart pain), women will present with
nausea, indigestion, and upper back and jaw pain,
DRUG ABSORPTION
➔ The movement of the drug into the Bloodstream after
administration
whereas men will generally present with left-sided chest
pain or pressure.
➔ METABOLIC
RATE-
Patients
with
a
higher-than-average metabolic rate (e.g., patients with
hyperthyroidism) tend to metabolize drugs more rapidly,
thus
requiring
larger
doses
or more frequent
administration. The converse is true for those patients
FOR DRUGS TAKEN BY MOUTH (ENTERAL)
➔ Most oral drugs enter the bloodstream following
absorption across the mucosal lining of the small
with lower-than-average metabolic rates (e.g., patients
with hypothyroidism).
➔ ILLNESS- Pathologic conditions may alter the rate of
intestine
➔ The epithelial lining of the small intestine is covered with
VILLI, finger-like protrusions that increase the surface
absorption, distribution, metabolism, and excretion of a
area available for absorption. Absorption is reduced if
drug. For example, patients who are in shock have
the villi are decreased in number because of disease, drug
reduced peripheral vascular circulation and will absorb
intramuscularly or subcutaneously injected drugs more
slowly. Patients who are vomiting may not be able to
effect, or the removal of some or all of the small intestine.
➔ Following absorption of oral drugs from the GI tract,
they pass from the intestinal lumen to the liver via the
retain a medication in the stomach long enough for
dissolution and absorption.
➔ PSYCHOLOGY- Attitudes and expectations play a
portal vein.
➔ In the liver, some drugs are metabolized to an inactive
form and are excreted, thus reducing the amount of
major role in a patient's response to therapy and in his or
active drug available to exert a pharmacologic effect. This
her willingness to take the medication as prescribed.
is referred to as the first-pass effect or first-pass
Other psychological considerations are the placebo effect
metabolism.
and the nocebo effect. It is well documented that a
patient's positive expectations about treatment and the
care received can positively affect the outcome of
therapy; this is a phenomenon known as the placebo
effect (from Latin, meaning “I will please”). A placebo is
a drug dosage form (e.g., tablet, capsule) that has no
pharmacologic activity because the dosage form has no
active ingredients. Although more difficult to prove
because of ethical considerations, it is also believed that
Absorption across the mucosal lining of the small intestine
occurs through:
1.
Passive Transport- does not require energy to move
drugs across the membrane.
➔ Diffusion- drugs move across the cell
membrane
from
an
area
of
higher
concentration to one of lower concentration
negative expectations about therapy and the care received
➔ Facilitated Diffusion- relies on a carrier
can have a nocebo effect (from Latin, meaning “I will
protein to move the drug from an area of
harm”), which results in less-than-optimal outcomes of
higher concentration to an area of lower
therapy.
concentration.
➔ TOLERANCE- occurs when a person begins to require
a higher dosage of a medication to produce the same
effects that a lower dosage once provided.
➔ DRUG DEPENDENCE- which is also known as
addiction or habituation, occurs when a person is
unable to control his or her desire for ingestion of drugs.
The dependence may be physiologic, in which the
person develops withdrawal symptoms if the drug is
withdrawn for a certain period, or psychological, in
which the patient is emotionally attached to the drug.
PHARMACOLOGY
3
2.
Active Transport- requires a
●
Administration with food and other drugs
●
Changes in the liver function
FACTORS THAT AFFECT ABSORPTION
carrier, such as an enzyme or protein, to
➔ Blood Flow
move the drug against a concentration
➔ Pain
gradient.
➔ Stress
➔ Hunger
➔ Fasting
3.
Pinocytosis- Is a process by which cells carry a drug
across their membrane by engulfing the drug particles in
a vesicle
FOR
DRUGS
TAKEN
BY
MOUTH
(ENTERAL)
-Dissolution
solid form (e.g., tablet or capsule) must disintegrate into
small particles and combine with a liquid to form a
➔ Exercise
DRUGS GIVEN INTRAMUSCULARLY
flow
DRUGS GIVEN SUBCUTANEOUSLY
solution, a process known as dissolution (drugs in
➔ Subcutaneous tissue has decreased blood flow when
liquid form are already in solution), in order to be
compared with muscle, so absorption is slower when
absorbed from the gastrointestinal (GI) tract into the
drugs are given subcutaneously.
bloodstream.
➔ However, drugs that are given subcutaneously have a
➔ Tablets are not 100% drug. Fillers and inert
substances—
such
as
simple
syrup,
vegetable
gums,aromatic powder, honey, and arious elixirs— called
excipients are used in drug preparation to allow the
drug to take on a particular size and shape and to
enhance drug dissolution.
DRUGS
TAKEN
BY
more rapid and predictable rate of absorption than those
given by mouth.
DRUGS GIVEN RECTALLY
➔ Are absorbed slower than drugs administered by the oral
route.
MOUTH
(ENTERAL)-
Disintegration
➔ Absorption is slower because the surface area in the
rectum is smaller than the stomach, and it has no villi.
➔ Suppository is placed in ref to harden it.
➔ Disintegration is the breakdown of an oral drug into
smaller particles. The rate of dissolution is the time it
takes the drug to disintegrate and dissolve to become
available for the body to absorb it. Generally, drugs are
both disintegrated and absorbed faster in acidic fluids
DRUG DISTRIBUTION
➔ The movement of the drug from the circulation to body
tissues
➔ Drug Distribution is influenced by:
with a pH of 1 or 2 rather than in alkaline fluids (those
●
Rate of Flow to the tissue
with a pH greater than 7)
●
Drugs Affinity to the tissue
●
Protein Binding
➔ Enteric-coated (EC) drugs resist disintegration in the
gastric acid of the stomach, so disintegration does not
occur until the drug reaches the alkaline environment of
the small intestine.
FOR
➔ pH
➔ Are absorbed faster in muscles that have increased blood
➔ For the body to utilize drugs taken by mouth, a drug in
FOR
➔ Food
DRUGS
TAKEN
PROTEIN BINDING
➔ As drugs are distributed in the plasma, many bind with
BY
MOUTH
(ENTERAL)-
Bioavailability
plasma
●
➔ Refers to the percentage of administered drug available
●
Drug Form
●
Route of administration
●
Gastric Mucosa and Motility
and
Acidic drugs such as aspirin and methotrexate
basic drugs (morphine, amantadine) bind to
by absorption and first-pass metabolism. The
➔ Factors that alter bioavailability
lipoproteins,
with albumin or lipoproteins; however,
➔ For orally administered drugs, bioavailability is affected
varies based on the rate of first-pass metabolism
(albumin,
and neutral drugs such as nortriptyline bind
for activity
bioavailability of oral drugs is always less than 100% and
proteins
alpha-1-acid-glycoprotein [AGP])
AGP.
●
Liver makes protein
➔ Drugs that are more than 90% bound to protein are
known as highly protein-bound drugs
●
Example: Warfarin, Glyburide, Sertraline,
Furosemide, and Diazepam
PHARMACOLOGY
4
➔ The portion of the drug bound to protein is inactive
➔ However, in the case of drugs with long half-lives, it may
because it is not available to interact with tissue receptors
not be acceptable to wait for a steady state to be
and therefore is unable to exert a pharmacologic effect
achieved. By giving a large initial dose, known as a
➔ The portion that remains unbound is free, active drug.
●
loading dose, that is significantly higher than
Free drugs are able to exit blood vessels and
maintenance dosing, therapeutic effects can be obtained
reach
while a steady state is reached.
their
site
of
action,
causing
a
pharmacologic response
DRUG EXCRETION
➔ Low plasma protein levels
●
Potentially decrease the number of available
➔ The process of elimination of drugs from the body
binding sites and can lead to an increase in the
➔ The main route of drug excretion, elimination of drugs
amount of free drug available, resulting in drug
accumulation and toxicity
from the body, is through the kidneys.
➔ Drugs are also excreted through bile, the lungs, saliva,
➔ Blood vessels in the brain have a special endothelial
sweat, and breast milk
lining where the cells are pressed tightly together (tight
➔ The kidneys filter free drugs (in healthy kidneys, drugs
junctions); this lining is referred to as the blood -brain
bound to protein are not filtered), water-soluble drugs,
barrier (BBB). The BBB protects the brain from foreign
substances, which includes about 98% of the drugs on
the market.
●
Some drugs that are highly lipid soluble and of
low molecular weight (e.g., benzodiazepines)
are able to cross the BBB through diffusion,
and drugs that are unchanged
➔ Renal Dose- may sakit sa kidney, decrease the dose.
FACTORS THAT AFFECT DRUG EXCRETION
➔ Urine pH
●
and others cross via transport proteins.
●
base drugs
Water-soluble drugs (e.g., atenolol and
●
penicillin) and drugs that are not bound to
transport proteins (free drugs) are not able
to cross the BBB, which makes it difficult for
➔ Prerenal Conditions
●
➔ Intrarenal Conditions
●
➔ The liver is the primary site of metabolism.
referred
to
as the
cytochrome P450 system, or the P450 system, of
drug-metabolizing
enzymes—
convert
drugs
to
metabolites.
➔ A large percentage of drugs are lipid soluble, thus the
liver metabolizes the lipid-soluble drug substance to a
water- soluble substance for renal excretion
amount of drug in the body to be reduced by half
The amount of drug administered, the amount
of drug remaining in the body from previous
Affect glomerular filtration and tubular
secretion and reabsorption
➔ Post Renal Conditions
●
COMMON
Adversely affect glomerular filtration
TESTS
TO
DETERMINE
RENAL
FUNCTION
1.
Creatinine
●
➔ The drug half-life (t½) is the time it takes for the
●
Reduce blood flow to the kidney and result in
decreased glomerular filtration
DRUG METABOLISM/ BIOTRANSFORMATION
enzymes—collectively
Alkaline urine promotes elimination of weak
acid drugs
these drugs to reach the brain
➔ Liver
Acidic urine promotes elimination of weak
a metabolic by-product of muscle that is
excreted by the kidneys
2.
Blood Urea Nitrogen
●
the metabolic breakdown product of protein
metabolism
doses, metabolism, and elimination affect the
half-life of a drug
➔ A drug goes through several half-lives before complete
elimination occurs, and drug half-life is used to
determine dosing interval.
➔ By knowing the half-life, the time it takes for a drug to
reach a steady state (plateau drug level) can be
determined.
●
A steady state occurs when the amount of
drug being administered is the same as the
amount of drug being eliminated;
●
a steady state of drug concentration is necessary
to achieve optimal therapeutic benefit. This
takes about four half-lives, if the size of all
doses is the same
➔ The study of the effects of drugs on the body
➔ A drug’s primary effect is the desirable response
➔ The secondary effect may be desirable or undesirable
Dose-response relationship- the body’s physiologic response to
changes in drug concentration at the site of action
➔ Potency refers to the amount of drug needed to elicit a
specific physiologic response to a drug.
●
a drug with low potency, such as codeine,
produces minimal therapeutic responses at low
concentrations.
PHARMACOLOGY
5
●
A drug with high potency, such as fentanyl,
produces significant therapeutic responses at
low concentrations
➔ Maximal efficacy- The point at which increasing a
THERAPEUTIC DRUG MONITORING
A. Plasma Drug Level
●
specific time, and it indicates the rate of drug
drug’s dosage no longer increases the desired therapeutic
response
➔ Closely related to dose-response and efficacy is the
Therapeutic index (TI)
●
Describes
the
relationship
between
the
absorption
●
●
The therapeutic index is the difference
between these two points
➢ TD50 is the dose of a drug that
produces a toxic response in 50% of
●
produces a therapeutic response in
If the drug is given intravenously, the peak time
is usually 30 to 60 minutes after the infusion is
complete
●
If the drug is given intramuscularly, the peak
time is usually 2 to 4 hours after injection
B. Trough drug level
●
The lowest plasma concentration of a drug,
and it measures the rate at which the drug is
the population.
➢ ED50 is the dose of a drug that
If the drug is given orally, the peak time is
usually 2 to 3 hours after drug administration.
therapeutic dose of a drug (ED50) and the
toxic dose of a drug (TD50).
The highest plasma concentration of drug at a
eliminated.
●
Trough levels are drawn just prior to the next
dose
50% of the population
of
drug
regardless
of
route
of
administration.
RECEPTOR THEORY
➔ Most receptors, which are protein in nature, are found
on cell surface membranes or within the cell itself. The
four receptor families:
●
Cell membrane– embedded enzymes
➢ the ligand-binding domain for drug
binding is on the cell surface. The
drug activates the enzyme inside the
Onset
cell, and a response is initiated
➔ The time it takes for a drug to reach the minimum
●
Ligand-gated ion channels
➢ The
effective concentration (MEC) after administration
channel
crosses
the
cell
membrane. When the channel opens,
Peak
ions flow into and out of the cells.
This primarily affects sodium and
➔ occurs when it reaches its highest concentration in the
blood
calcium ions.
●
G protein–coupled receptor systems
➢ The
Duration of action
three components to this
receptor response are (1) the receptor,
➔ the length of time the drug exerts a therapeutic effect
(2) the G protein that binds with
guanosine triphosphate (GTP), and
(3) the effector, which is either an
enzyme or an ion channel
●
Transcription factors
➢ Found in the cell nucleus on DNA,
not on the surface. Activation of
receptors
through
transcription
factors regulates protein synthesis and
is prolonged. With the first three
receptor groups, activation of the
receptors is rapid
AGONIST & ANTAGONIST
➔ AGONISTS
●
Drugs that activate receptors and produce a
desired response
PHARMACOLOGY
6
➔ ANTAGONISTS
●
●
Secondary effects of drug therapy. All drugs
Drugs that prevent receptor activation and
have side effects. In some instances, the side
block a response
effects
NONSPECIFIC & NON SELECTIVE DRUG EFFECTS
➔ Drugs that affect multiple receptor sites
may
be
desirable
(e.g.,
using
●
Anti-TB drug- orange urine
●
Chronic illness, age, weight, gender, and
ethnicity all play a part in drug side effects
➔ Maraming side effects
Bethanechol
be
effect of drowsiness is beneficial).
Nonspecific
➔ Example:
may
diphenhydramine at bedtime, when its side
prescribed
for
B. ADVERSE DRUG REACTIONS
●
postoperative urinary retention to increase bladder
therapy that occur at normal drug dosages.
contraction. This drug stimulates cholinergic receptors
●
located in the bladder, and urination occurs by
strengthening bladder contraction. However, because
bethanechol is nonspecific, other cholinergic sites are
Unintentional, unexpected reactions to drug
Adverse drug reactions are always undesirable
and must be reported
C. DRUG TOXICITY
●
also affected: the heart rate decreases, blood pressure
Occurs when drug levels exceed the therapeutic
range; toxicity may occur secondary to
decreases, gastric acid secretion increases
overdose (intentional or unintentional) or drug
accumulation.
Nonselective
●
➔ Drugs affect multiple receptors
Factors that influence drug toxicity include
disease, genetics, and age
➔ Example: Epinephrine, which is used for treatment of
anaphylaxis or severe asthma exacerbations, acts on the
alpha1, beta1, and beta2 receptors affecting multiple
body system
➔ Cardio, respiratory system,
MECHANISM OF DRUG ACTION
1.
Stimulation
●
A drug that stimulates enhances intrinsic
activity (e.g., adrenergic drugs that increase
heart rate)
2.
Depression
➔ Depressant drugs decrease neural activity and
bodily functions (e.g., barbiturates and opiates)
3.
Irritation
➔ Drugs that irritate have a noxious effect, such as
astringents.
4.
Replacement
➔ Replacement drugs such as insulins, thyroid
drugs, and hormones replace essential body
compounds
5.
Cytotoxic Action
➔ Cytotoxic drugs selectively kill invading
parasites or cancers
6.
Antimicrobial Medication
➔ Antimicrobial drugs prevent, inhibit, or kill
infectious organisms.
7.
Modification of immune system
➔ Drugs that modify immune status modify,
enhance, or depress the immune system (e.g.,
interferons and methotrexate)
➔ Steroid, anticancer (example)
SIDE EFFECTS, ADVERSE DRUG REACTIONS, DRUG
TOXICITY
➔ Refers to the study of genetic factors that influence an
individual’s response to a specific drug.
➔ Genetic factors can alter drug metabolism
BIOLOGIC VARIATION
➔ Pharmacogenomics refers to the study of how genetics
play a role in a person’s response to drugs (absorption,
distribution, metabolism, and excretion).
➔ The use of pharmacogenomics, the goal is to develop
precision medicine, which uses the person’s genetic
makeup to determine appropriate drug therapy, thereby
improving patient outcomes and safety
➔ Certain classifications of medications have different
effects in individuals with specific genetic markers.
Tolerance
➔ refers to a decreased responsiveness to a drug over the
course of therapy
➔ Caffeine is medication. It is a bronchodilator.
Tachyphylaxis
➔ refers to an acute, rapid decrease in response to a drug; it
may occur after the first dose or after several doses
Placebo Effect
➔ drug response not attributed to the chemical properties
of the drug
➔ Ex. injecting sterile water to patient, then biglang
gumaling.
A. SIDE EFFECTS
PHARMACOLOGY
7
DRUG INTERACTION- Defined as an altered or modified
●
action or effect of a drug as a result of interaction with one or
a
photosensitive
drug
undergoes
photochemical reactions within the skin to
multiple drugs.
cause damage.
CATEGORIES
●
type of reaction is not immune mediated.
●
may be the result of the drug dose
➔ Pharmacokinetic interactions are changes that occur
in the absorption, distribution, metabolism, and
excretion of one or more drugs.
➔ Pharmacodynamic interactions are those that result in
additive, synergistic, or antagonistic drug effects.
Additive Drug Effect
➔ When two drugs are administered in combination, and
the response is increased beyond what either could
produce alone
➔ The sum of the effect of the two drugs.
➔ Can be desirable or undesirable.
➔ 1 plus 1 = 2
Synergistic Drug Effects and Potentiation
➔ The clinical effect of the two drugs given together is
substantially greater than that of either drug alone
➔ 1 plus 1 = 1
Antagonistic Drug Effects
➔ One drug reduces or blocks the effect of the other.
➔ Antagonistic effects are desirable
➔ 1 plus 1 = 0
Drug- Drug Interaction
➔ The most common symptoms of drug-drug interactions
include
nausea,
heartburn,
headache,
and
lightheadedness
The following rights of the patient shall be respected by all those
involved in his care:
1.
Right to Appropriate Medical Care and Humane
Treatment
Drug- Nutrient Interaction
●
care corresponding to his state of health,
➔ Food may increase, decrease, or delay the body’s
without any discrimination and within the
pharmacokinetic response to drugs
limits of the resources, manpower and
Drug- Laboratory Interaction
➔ Drugs often interfere with clinical laboratory testing by
cross-reaction with antibodies, interference with enzyme
reactions, or alteration of chemical reactions
Every person has a right to health and medical
competence available for health and medical
care at the relevant time.
2.
Right to Informed Consent
●
The patient has a right to a clear, truthful and
substantial explanation, in a manner and
Drug- Induced Photosensitivity Reaction- a skin reaction
language understandable to the patient, of all
caused by exposure to sunlight. It is caused most often by the
proposed procedures, whether diagnostic,
interaction of a drug and exposure to ultraviolet A (UVA) light
preventive,
1.
Photoallergic reaction
●
occurs when a drug undergoes activation in the
skin by ultraviolet light to a compound that is
more allergenic than the parent compound.
●
type of delayed hypersensitivity reaction.
●
is not related to drug dose and only requires
previous exposure, or sensitization, to the
offending agent
2.
curative,
rehabilitative
or
therapeutic, wherein the person who will
perform the said procedure shall provide his
name
and
credentials
to
the
patient,
possibilities of any risk of mortality or serious
side effects, problems related to recuperation,
and probability of success and reasonable risks
involved: Provided, That, the patient will not
be subjected to any procedure without his
Phototoxic reaction
PHARMACOLOGY
8
written informed consent, except in the
orders him to submit to a physical or
following cases:
mental examination by a physician;
a.
in emergency cases, when the patient
b.
is at imminent risk of physical injury,
demand;
decline or death if treatment is
c.
withheld or postponed. In such cases,
the
b.
c.
●
The patient has the right to demand that all
physician can perform any
information, communication and records
pertaining to his care be treated as confidential.
good practice of medicine dictates
Any health care provider or practitioner
without such consent;
involved in the treatment of a patient and all
when the health of the population is
those who have legitimate access to the
dependent on the adoption of a mass
patient's record is not authorized to divulge any
health program to control epidemic;
information to a third party who has no
when the law makes it compulsory
concern with the care and welfare of the patient
for
without his consent, except:
everyone
to
submit
to
a
a.
when the patient is either a minor, or
b.
third party consent is required;
when
disclosure
of
●
c.
the confidential nature of such
the success of treatment, in which
information;
d.
medical treatment or advancement of
when the patient waives his right in
medical
writing.
de-identification of patients and
science
subject
to
Informed consent shall be obtained from a
shared medical confidentiality for
patient concerned if he is of legal age and
those who have access to the
of sound mind. In case the patient is incapable
information.
●
Informing the spouse or the family to the first
required, the following persons, in the order of
degree of the patient’s medical condition may
priority stated here under, may give consent:
be allowed; Provided, That the patient of legal
a.
spouse;
age shall have the right to choose on whom to
b.
son or daughter of legal age
inform. In case the patient is not of legal age or
c.
either parent;
is mentally incapacitated, such information
d.
brother or sister of legal age or
shall be given to the parents, legal guardian or
e.
guardian
his next of kin.
If a patient is a minor, consent shall be
4.
Right to Information
●
In the course of his/ her treatment and hospital
If next of kin, parents or legal guardians refuse
care, the patient or his/her legal guardian has a
to give consent to a medical or surgical
right to be informed of the result of the
procedure necessary to save the life or limb of a
evaluation of the nature and extent of his/her
minor or a patient incapable of giving consent,
courts, upon the petition of the physician or
3.
when it is needed for continued
consent shall be in order;
obtained from his parents or Legal guardian;
●
when the patients waives in writing
information to patient will jeopardize
of giving consent and a third party consent is
●
when it is in the interest of justice and
upon the order of a competent court;
material
case, third party disclosure and
f.
when such disclosure will benefit
public health and safety;
legally incompetent, in which case, a
e.
when the patient waives this right.
diagnostic or treatment procedure as
procedure;
d.
when the public health and safety so
disease, any other additional or further
●
contemplated medical treatment on surgical
any person interested in the welfare of the
procedure or procedures, including any other
patient, in a summary proceeding, may issue an
additional medicines to be administered and
order giving consent.
their generic counterpart including the possible
Right to Informed Consent
complications and other pertinent facts,
●
The privacy of the patients must be assured at
statistics or studies, regarding his/her illness,
all stages of his treatment. The patient has the
any change in the plan of care before the
right to be free from unwarranted public
change is made, the person’s participation in
exposure, except in the following cases:
the plan of care and necessary changes before
a.
when
his
mental
or
physical
its implementation, the extent to which
condition is in controversy and the
payment maybe expected from Philhealth or
appropriate court, in its discretion,
any payor and any charges for which the
patient maybe liable, the disciplines of health
PHARMACOLOGY
9
care practitioners who will furnish the care and
heishe suffers from the terminal phase of a
the frequency of services that are proposed to
terminal illness: Provided, That
be furnished.
●
a.
The patient or his legal guardian has the
consequences of his choice;
right to examine and be given an itemized
b.
bill of the hospital and medical services
consequences of his decision;
and other health care providers, regardless of
c.
the manner and source of payment. He is
●
7.
Right to Religious Belief
●
treatment or procedures which may be
right to be informed by the physician or his/her
contrary to his religious beliefs, subject to the
delegate of his/her continuing health care
limitations
requirements following discharge, including
subsection: Provided, That such a right shall
instructions about home medications, diet,
not be imposed by parents upon their children
physical activity and all other pertinent
who have not reached the legal age in a life
information to promote health and well-being.
threatening situation as determined by the
At the end of his/her confinement, the patient
attending physician or the medical director of
is entitled to a brief, written summary of the
the facility.
least
the
history,
physical
8.
examination,
in
the
preceding
The patient is entitled to a summary of his
diagnosis, medications, surgical procedure,
medical history and condition, He has the right
ancillary and laboratory procedures, and the
to view the contents of his medical records,
plan of further treatment, and which shall be
except
provided by the attending physician. He/she is
incriminatory information obtained about
likewise entitled to the explanation of, and to
third parties, with the attending physician
view, the contents of the medical record of
explaining contents thereof. At his expense and
his/her confinement but with the presence of
upon discharge of the patient, he may obtain
his/her attending physician or in the absence of
from the health care institution a reproduction
the
of the same record whether or not he has fully
attending
physician,
the
hospital’s
psychiatric
notes
and
other
representative.
settled his financial obligation with the
The patient shall likewise be entitled to medical
physician or institution concerned.
●
his/her previous confinement.
The health care institution shall safeguard the
confidentiality of the medical records and to
The Right To Choose Health Care Provider and
likewise ensure the integrity and authenticity
Facility.
of the medical records and shall keep the same
●
The patient is free to choose the health care
within a reasonable time as may be determined
provider to serve him as well as the facility
by the Department of Health.
except when he is under the care of a service
●
The health care institution shall issue a medical
certificate to the patient upon request. Any
demands or when the patient expressly or
other document that the patient may require
impliedly waive this right.
for insurance claims shall also be made available
The patient has the right to discuss his
to him within a reasonable period of time.
patient’s request and expense. He also has the
9.
Right to Leave
●
The patient has the right to leave a hospital or
right to seek a second opinion and subsequent
any other health care institution regardless of
opinions, if appropriate, from another health
his physical condition:
care provider/practitioner.
●
Right to Self-Determination
●
●
facility or when public health and safety so
condition with a consultant specialist, at the
6.
described
Right to Medical Records
●
certificate, free of charge, with respect to
5.
The patient has the right to refuse medical
The patient or his/her legal guardian has the
course of his/her illness which shall include at
●
his decision will not prejudice public
health and safety.
bill.
●
he releases those involved in his care
from any obligation relative to the
rendered in the facility or by his/her physician
entitled to a thorough explanation of such a
he is informed of the medical
The
patient
has
himself/herself
of
Provided, That
a.
the
any
right
to
avail
recommended
he/she is informed of the medical
consequences of his/her decision;
b.
he/she releases those involved in
diagnostic and treatment procedures. Any
his/her care from any obligation
person of legal age and of sound mind may
relative to the consequences of his
make
decision;
an advance written directive for
physicians to administer terminal care when
PHARMACOLOGY
10
c.
●
his/her decision will not prejudice
groups,
the
media,
health
insurance
public health and safety.
corporations, people’s organizations, local
No patient shall be detained against his/her
government organizations, shall launch and
Will in any health care institution on the sole
sustain
basis of his failure to fully settle is financial
education campaign to make known to people
obligations. However, he/she shall only be
their rights as patients, as declared in this Act.
allowed to leave the hospital provided
Such rights and obligations of patients shall be
appropriate arrangements have been made to
posted in a bulletin board conspicuously placed
settle the unpaid bills: Provided, farther, that
in a health care institution.
unpaid bills of patients shall be considered as
●
a
nationwide
information
and
It shall be the duty of health care institutions to
lost income by the hospital and health care
inform patients of their rights as well as of the
provider/practitioner and shall be deducted
institution's rules and regulations that apply to
from gross income as income loss for that
the conduct of the patient while in the care of
particular year.
such institutions.
10. Right to Refuse Participation in Medical Research.
●
The patient has the right to be advised if the
health care provider plans to involve him in
medical research, including but not limited to
human
experimentation
which
may be
performed only with the written informed
consent of the patient. Provided, further, That,
an institutional review board or ethical review
board in accordance with the guidelines set in
the Declaration of Helsinki be established
The nurse’s role is much more than a mechanical achievement of
objectives. It is a professional role requiring knowledge, skills,
judgment and commitment. The role of nurses in pharmacology
and drug safety is continuously changing. Some of the roles of
nurses are as follows but not limited to:
➔ Holistic Health Care Provider
for research involving human experimentation:
●
Provided, finally, That the Department of
and color
Health shall safeguard the continuing training
and
education
of
provider/practitioner
future
to
health
ensure
●
➔ Communicator
the
●
health care team to deliver quality care to
country.
patients
➔ Patient's Advocate
The patient has the right to communicate with
●
Ensure patient’s safety
relatives and other persons and to receive
●
Give patients a voice
visitors subject to reasonable limits prescribed
●
Protect Patient’s rights
●
Connect Patient to resources
institution.
➔ Educator
12. Right to Express Grievances.
The patient has the right to express complaints
●
Teach patients about drug action and effects
●
Instruct patients on precautions to take when
and grievances about the care and services
received without fear of discrimination or
taking specific medication
➔ Researcher
reprisal and to know about the disposition of
●
●
Inform action, gather evidence for theories,
such complaints.
and contribute to developing knowledge in a
The Secretary of Health, in consultation with
field of pharmacology
health care providers, consumer groups and
other concerned agencies shall establish a
grievance system wherein patients may seek
redress of their grievances. Such a system shall
afford
all
parties
concerned
with
the
opportunity to settle amicably all grievance
13. Right to be Informed of His Rights and
Obligations as a Patient
●
Communicate appropriate information to the
development of the health care delivery in the
by the rules and regulations of the health care
●
Provide preventive, curative, and palliative care
care
11. Right to Correspondence and to Receive Visitors
●
Deliver necessary treatment regardless of race
Every person has the right to be informed of his
rights and obligations as a patient. The
Department of Health, in coordination with
health care providers, professional and civic
Nursing responsibilities in medication management include
prescription, calculation, constitution, checking, administration,
patient assessment, documentation and patient medication
education.
➔ To ensure that the correct dosage is given at the correct
time and by the correct route, observing any special
requirements
➔ To observe/report any side effects and consequences of
drug interactions
➔ To take action to alleviate unavoidable side effects
PHARMACOLOGY
11
➔ To observe and assess the patient so that medical and
➔ Elixirs are sweetened, hydroalcoholic liquids used in the
nursing decisions can be made
➔ To participate in education and guidance of patients
preparation of oral liquid medications.
➔ Emulsions are a mixture of two liquids that are not
(and in some cases their relatives) with regard to their
drug therapy
mutually soluble.
➔ Suspensions are liquids in which particles are mixed but
➔ To take action to promote patient compliance and the
achievement of therapeutic objectives
not dissolved.
➔ Transdermal medication: is stored in a patch placed on
➔ To provide nursing care to help reduce, or obviate, the
the skin and is absorbed through the skin to produce a
need for drug therapy
systemic effect. A patch may be left in place for as little as
➔ To follow recognized procedures for the control of
12 hours or as long as 7days depending on the drug.
medicines and pharmaceutical products
Transdermal drugs provide more consistent blood levels
➔ To contribute to the evaluation, research and
than oral and injectable forms, and they avoid GI
development of new treatments, and/or the reassessment
of existing treatments
absorption problems associated with oral products.
➔ Topical medications: are most frequently applied to
➔ To contribute to the development of medicine
the skin by painting or spreading the medication over an
management in a changing environment
The Nursing Process is the foundation for the clinical practice
of nursing. It provides the framework for consistent nursing
area and applying a moist dressing or leaving the area
exposed to air.
➔ Instillations:
are
liquid
medications
usually
administered as drops, ointments, or sprays in the
actions hence can also be a tool to execute responsibilities of
following forms- eyedrops, eye ointment, eardrops, nose
nurses in medication management
drops/ sprays
➔ Inhalation: delivery of drug to the airway mucosa
➔ Nasogastric
and
Gastrostomy
Tubes:
Before
administering drugs, always check for proper tube
placement of any feeding tube that enters the mouth,
nose, or abdomen, and always assess the gastric residual.
➔ Suppository: is a solid medical preparation that is coneor spindle-shaped for insertion into the rectum, globular
or egg-shaped for use in the vagina, or pencil-shaped for
insertion into the urethra. Suppositories are made from
glycerinated gelatin or high-molecular weight
polyethylene glycols and are common vehicles for a
variety of drugs.
➔ Parenteral: administered via injection. Methods of
parenteral
administration
subcutaneous,
include
intramuscular,
intradermal,
Z-track
technique,
intravenous ,and intraosseous administration.
Enteral
➔ drugs are administered directly into the gastrointestinal
tract
Percutaneous
➔ refers to the application of medications to the skin or
mucous membranes for absorption
Parenteral
➔ refers to intradermal (ID), subcutaneous (subcut),
A variety of forms and routes are used for the administration of
drugs.
intramuscular (IM), or intravenous (IV) injections
METHODS OF PERCUTANEOUS ADMINISTRATION
➔ Tablets and capsules: are the most common drug
forms; they are convenient and less expensive and do not
require additional supplies for administration.
➔ Liquids: Forms of liquid medication include elixirs,
1.
Topical application of ointments, creams, powders,
or lotions to the skin;
●
ADVANTAGE:
emulsions, and suspensions.
PHARMACOLOGY
12
➢ The action of the drug, in general, is
a.
localized to the site of application,
her own ophthalmic medication.
which reduces the incidence of
b.
systemic side effects
●
DISADVANTAGE:
prevent contamination between the
eyes, as well as the possible spread of
and difficult to apply
infection, and to use a separate tissue
➢ They usually have a short duration of
to wipe each eye.
action and thus require frequent
c.
reapplication
b.
eyes or the immediate surrounding
If appropriate, teach the patient how
areas, especially when an infection is
to apply the medication and dressings
present. Dispose of tissues in a
Teach personal hygiene measures that
manner that prevents the spread of
are appropriate to the underlying
infection.
cause of the skin condition (e.g., acne,
c.
d.
e.
f.
d.
administration of eye medications,
When dressings are ordered, suggest
especially when the medications are
the purchase of gauze and other
being used to treat infections or
necessary supplies.
increased intraocular pressure.
Stress gentleness and moderation
e.
of
medications that have changed color
medication to be applied.
or become cloudy or that contain
Emphasize that the patient must
particles. (If the patient's visual acuity
avoid touching or scratching the
is reduced, someone else should check
affected area
the medications for clarity.)
Tell the patient to wash his or her
f.
●
or
applying
the
●
solutions
onto
the
consulting
the
healthcare
disorder.
mucous
In general, aqueous solutions are quickly
3.
Inhalation of aerosolized liquids or gases for
absorption through the lung
●
The respiratory mucosa may be mediated via
the inhalation of sprays or aerosols.
●
Aerosols use a flow of air or oxygen under
Drugs in suppository form can be used for
pressure to disperse the drug throughout the
local or systemic effects on the mucous
respiratory tract.
●
Oily preparations should not be applied to the
rectum.
respiratory mucosa, because the oil droplets
A drug may be inhaled and absorbed through
may be carried to the lungs and cause lipid
the mucous membranes of the nose and lungs.
pneumonia.
It may be dissolved and absorbed by the
●
Bronchodilators and corticosteroids may be
mucous membranes of the mouth or applied to
administered by inhalation through the mouth
the eyes or ears for local action.
with the use of an aerosolized, pressurized
It may be painted, swabbed, or irrigated on a
metered-dose inhaler (MDI) or a dry powder
ADVANTAGE
inhaler (DPI)
●
ADVANTAGE:
➢ Drugs are well absorbed across
➢ The advantages of the inhalers are
mucosal surfaces, and therapeutic
that the medications can be applied
effects are easily obtained
directly to the site of action (the
DISADVANTAGE
bronchial smooth muscle), smaller
➢ Mucous membranes are highly
doses are used, and the drug is rapidly
selective with regard to absorptive
activity, and they differ in sensitivity.
●
use
provider who is managing the eye
mucosal surface
●
not
first
area
membranes of the vagina, the urethra, or the
●
must
affected
oily liquids are not.
●
patient
over-the-counter eyewashes without
absorbed from mucous membranes, whereas
●
The
hands before and after touching the
membranes of the mouth, eye, ear, nose, or vagina
●
Tell the patient to discard eye
with regard to the amount of
the spread of infection.
Instillation
Stress punctuality with regard to the
contact dermatitis, infection).
medication. Stress the prevention of
2.
Have the patient wash his or her
hands often and avoid touching the
Patient Teaching (Topical Application)
a.
Tell the patient to wipe the eyes
gently from the nose outward to
➢ The medications are sometimes messy
●
Teach the patient how to apply his or
absorbed.
●
DISADVANTAGE;
Patient Teaching (Mucous Membrane)
PHARMACOLOGY
13
➢ The
need
to
follow
strict
development of capsules and compressed
administration protocol to prevent
tablets. However, the term is still used to refer
transmission of disease
●
to tablets and capsules
Patient Teaching (Inhalation)
a.
●
As appropriate to the circumstances,
drugs that have been dissolved in alcohol and
teach the patient, a family member, or
water. Elixirs are used primarily when the drug
a significant other how to operate the
nebulizer that is to be used at home.
b.
c.
of the equipment.
The dispersion is maintained by an emulsifying
Before the patient is discharged, have
agent such as sodium lauryl sulfate, gelatin,
the patient, a family member, or a
or acacia.
the medications that have been
in a liquid base. All suspensions should be
prescribed for at-home use.
shaken well before administration to ensure the
Stress the need to perform the
thorough mixing of the particles.
any
difficulties
●
that are
been dissolved in a concentrated solution of
sugar (usually sucrose) and water. Syrups are
healthcare provider's evaluation
particularly effective for masking the bitter
Explain the procedure, and allow the
taste of a drug.
●
been compressed into small disks. In addition
without
active
to the drug, tablets contain one or more of the
available
from
ingredients
the
are
pharmacy
the
technique
following ingredients:
●
before
allow
tablet
to
hold
together;
In addition to technique, the patient
encourage
should be informed about adverse
;lubricants, which are required for efficient
effects, how to carry the medication,
manufacturing; and
●
Have
the
patient
dissolution
in
body
fluids
fillers, which are inert ingredients that make
the size of the tablet convenient
perform
the
●
self-administration of the prescribed
Advantages
➢ Safe,
convenient,
and
relatively
amount of ordered medication.
economical, and dose forms are
Have the patient demonstrate the
readily
ability to read the canister counter to
determine the amount of medication
remaining in the container.
for
most
Disadvantage
has
the
slowest
and
least
dependable rate of absorption of the
commonly
used
routes
of
administration because of frequent
Oral Route
Capsules
available
medications.
●
➢ It
METHODS OF ENTERAL ADMINISTRATION
are
small,
cylindrical,
gelatin
containers that hold dry powder or liquid
changes
in
the
gastrointestinal
environment that are produced by
food, emotion, and physical activity.
medicinal agents
●
the
disintegrators, which are substances that
refilled when needed.
●
binders, which are adhesive substances that
medication administration.
how to store it, and how to have it
1.
Tablets are dried powdered drugs that have
Teaching aids for MDIs and DPIs
practice
i.
Syrups contain medicinal agents that have
experienced after discharge for the
department to encourage patients to
h.
Suspensions are liquid dose forms that
contain solid, insoluble drug particles dispersed
patient to demonstrate the technique.
g.
●
the equipment correctly and verbalize
report
f.
Emulsions are dispersions of small droplets of
water in oil or small droplets of oil in water.
procedure exactly as prescribed and to
e.
will not dissolve in water alone.
●
Explain the operation and cleansing
significant other demonstrate using
d.
Elixirs are clear liquids that are composed of
Lozenges are flat disks that contain a medicinal
➢ Another limitation of this route is
agent in a suitably flavored base. The base may
that a few drugs (e.g., insulin,
be a hard sugar candy or a combination of
gentamicin) are destroyed by digestive
sugar with sufficient gelatinous substances to
fluids and must be given parenterally
give it form. Lozenges are held in the mouth to
for therapeutic activity.
dissolve
slowly,
thereby
releasing
the
therapeutic ingredients.
●
Pills are an obsolete dose form that is no
longer
manufactured
because
of
the
PHARMACOLOGY
14
3.
Nasogastric Tube Route
●
Medications are administered via a nasogastric
(NG) tube, nasoduodenal (ND) tube, or
nasojejunal (NJ) tube to patients who have
impaired swallowing, to those who are
comatose, or to those who have a disorder of
the esophagus
4.
Gastrostomy/ Jejunostomy Tube Route
●
Enteral formulas are available in a variety of
mixtures to meet the individual patient's needs.
The four general categories are as follows: (1)
intact nutrient(polymeric); (2) elemental; (3)
disease or condition specific; and (4) modular
nutrient.
●
The type of formula ordered will be selected by
the healthcare provider to meet the patient's
energy
●
maintain
body
tissue that has been damaged or depleted by
➢ Allow the patient to drink a small
illness or injury
amount of water to moisten the
so
to
functions and growth demands and to repair
Patient Teaching (Oral)
mouth
requirements
that swallowing the
medication is easier.
➢ Encourage the patient to keep his or
her head forward while swallowing.
➢ Drinking a full glass of fluid should
be encouraged to ensure that the
medication reaches the stomach and
that it is diluted to decrease the
potential for irritation.
➢ Always remain with the patient while
the medication is taken.
➢ Do not leave the medication at the
bedside unless an order exists to do so
(e.g.,medication such as nitroglycerin
may be ordered for the bedside)
➢ Discard the medication container
(e.g., a soufflé cup, a unit-dose
package)
2.
METHODS OF PARENTERAL ADMINISTRATION
When drugs are given parenterally rather than orally, the following
factor are involved
➔ the onset of drug action is generally more rapid but of
shorter duration;
➔ the dosage is often smaller because drug potency tends
not to be altered immediately by the stomach or liver;
Rectal Route
●
A suppository is a solid form of medication
that is designed for introduction into a body
orifice. At body temperature, the substance
and
➔ the cost of drug therapy is often higher
➔ ADVANTAGE
●
dissolves and is absorbed by the mucous
completely as possible
membranes. Suppositories should be stored in
●
a cool place to prevent softening.
●
Disposable Enema
●
ADVANTAGE:
➔ DISADVANTAGE
avoids the irritation of the mouth, the
●
DISADVANTAGE
➢ Absorption via this route varies
depending on the drug product, the
ability of the patient to retain the
suppository or enema, and the
presence of fecal material
Drugs can be absorbed at a steady and
controlled rate
➢ Bypasses the digestive enzymes and
esophagus, and the stomach.
Drugs can be absorbed as rapidly and
●
More expensive
●
Requires skill and special care
EQUIPMENTS
a.
Syringes
●
Are generally made of hard plastic; glass
syringes are rarely used in clinical practice.
●
A syringe has three parts. The barrel is the
outer portion on which the calibrations for the
PHARMACOLOGY
15
measurement of the drug volume are located).
a.
The plunger is the inner cylindrical portion
●
●
Intradermal injections
●
are made into the dermal layer of skin just
that fits snugly into the barrel. This portion is
below the epidermis. Small volumes, usually
used to draw up and eject the solution from the
0.1 mL, are injected. The absorption from
syringe. The tip is the portion that holds the
intradermal sites is slow, thereby making it the
needle.
route of choice for allergy sensitivity tests,
Syringes are considered to be sterile when the
desensitization injections, local anesthetics, and
package is still intact from the manufacturer.
vaccinations
All syringes, regardless of their manufacturer,
●
are available with a Luer-Slipor Luer-Lok tip
Intradermal injections may be made on any
skin surface, but the site should be hairless and
receive little friction from clothing. The upper
chest, the scapular areas of the back, and the
inner aspect of the forearms are the most
commonly used areas
b.
Subcutaneous (subcut) injections
●
Are made into the loose connective tissue
between the dermis and the muscular layer
●
Absorption is slower and drug action is
generally longer with subcut injections as
compared
with
intramuscular
(IM)
or
intravenous (IV) injections.
●
Many drugs cannot be administered by this
route because ordinarily no more than 2 mL
can be deposited at a subcut site. The drugs
must be quite soluble and potent enough to be
effective in a small volume without causing
significant tissue irritation.
●
Common
sites
used
for
the
subcut
administration of medications include the
upper arms, the anterior thighs, and the
abdomen. Less common areas are the buttocks
and the upper back or scapular region.
b.
Ampule- Dose Form
●
are glass containers that usually contain a single
dose of a medication. The container may be
scored or have a darkened ring around the neck
to indicate where the ampule should be broken
open for withdrawing the medication
c.
Vials- Dose Form
●
are glass or plastic containers that contain one
or more doses of a sterile medication.
ROUTES
PHARMACOLOGY
16
c.
Intramuscular Route
●
Are made by penetrating a needle through the
epidermis, dermis, and subcut tissue into the
muscle layer. The injection deposits the
medication deep within the muscle mass.
●
Sites: Vastus Lateralis, rectus femoris, gluteal
area, ventrogluteal area, dorsogluteal, deltoid
muscle
TYPES OF INTRAVENOUS SOLUTION
➔ Intravenous (IV) solutions consist of water (e.g., a
d.
solvent) that contains one or more types of dissolved
Intravenous Injections
●
The term intravenous (IV) administration
refers to the introduction of fluids directly into
●
particles (e.g., solutes).
➔ The solutes that are most commonly dissolved in IV
the venous bloodstream.
solutions are sodium chloride, dextrose, and potassium
The advantage of this technique is that large
chloride.
volumes of fluids can be rapidly administered
➔ The solutes that dissolve in water and dissociate into ion
into the vein for volume expansion in cases of
particles (e.g., Na+, K+, Cl−) are called electrolytes
shock, or more rapid onset of medications
because these ions give water the ability to conduct
administered
electricity. Total parenteral solutions contain all the
intravenously
in
cases
of
emergency.
electrolytes
necessary
in
addition
to
enough
carbohydrates (usually dextrose),amino acids, and fatty
acids to sustain life
A. Isotonic Solution
●
are ideal replacement fluids for the patient with
an intravascular fluid deficit
●
• Eg: 0.9% sodium chloride, lactated Ringer's
B. Hypotonic Solution
●
have lower osmolality than serum. This type of
solution contains fewer electrolytes and more
free water, so the water is rapidly pulled from
the vascular compartment into the interstitial
and intracellular fluid compartments.
TYPES OF INFUSION CONTROL PUMP
1.
The programmable infusion pumps apply external
pressure to the administration set tubing to squeeze the
solution through the tubing at a specific rate (e.g., a
●
C. Hypertonic Solution
●
solutions are used in particular situations
programmed for a specific volume over time.
because of their tonicity, hypertonic solutions
Syringe pumps hold a prefilled syringe and apply
are rarely used in this way because they have the
positive pressure to the plunger to deliver a specific
potential to pull fluid from the intracellular
volume of medicine over a set time. Syringe pumps are
and
more commonly used when small volumes need to be
administered
have an osmolality that is higher than that of
the serum. Although hypotonic and isotonic
certain number of mL/min or mL/hr). These pumps are
2.
• Eg: 0.2% or 0.45% sodium chloride
interstitial
compartments
into
the
intravascular compartment
●
Eg: parenteral nutrition solutions
SOLUTION CONTAINER
➔ Large Volume Solution Containers
●
Intravenous solutions are available in both
plastic and glass containers in a variety of types
PHARMACOLOGY
17
●
and concentrations) and in volumes that range
drugs, topical hormones), which can cause a reaction
from 100 to 2000 mL.
when they come in contact with the skin
Both the glass and plastic containers are
vacuum sealed.
➔ Small Volume Solution Containers
●
Some
medicines
(e.g.,
MEDICATION ERRORS
➔ Medication errors can be defined as the failure of a
antibiotics)
are
planned action to be completed as intended or the use of
administered by intermittent infusion through
an apparatus known as a tandem setup,
a wrong plan to achieve a goal.
➔ Medication errors include
piggyback, or IV rider. These medicines are
●
●
Prescribing errors
given by a setup that is hung in tandem and
➢ Suboptimal drug therapy decisions
connected with the primary setup.
➢ Drug prescribed for patient with
The secondary setup may consist of a drug
known allergy or intolerance
infusion from a small volume of fluid in a small
➢ Incorrect dose for diagnosis
bag or bottle or from a volume control set
➢ Unauthorized drug prescribed
(Buretrol, Volutrol)
●
Transcription or order communication
errors
➢ Misinterpretation
or
misunderstanding of drug ordered or
any directions
➢ Illegible handwriting
➢ Unapproved abbreviations
➢ Omission of orders
●
Dispensing errors
➢ Wrong drug or dose sent to nursing
unit
➢ Wrong formulation or dosage form
●
Administration errors
●
Errors of monitoring or education for
proper use.
PERIPHERAL INTRAVENOUS ACCESS/ SITES
➔ the metacarpal veins, the dorsal vein network, the
cephalic vein, and the basilic vein are commonly used
➔ The veins of the forearm area that could be used for
PREVENTION OF MEDICATION ERRORS
➔ Changes in the ordering system used for medications
and laboratory studies.
➔ Medications and classifications that pose significant risk
in the acute clinical setting were identified. These are
additional venipuncture sites
CENTRAL VENOUS ACCESS
now known as high-alert medications
➔ Regular reports shows that medication errors are the
result of the similarity of sound-alike names (e.g.,
➔ Central IV access devices are used for the following
Mucomyst and Mucinex; Evista and Avinza).As
situations: when the purpose of therapy dictates (e.g.,
large-volume,
recommended both the generic name and the brand
high- concentration, or hypertonic
solutions are to be infused); when peripheral sites have
been exhausted as a result of repeated use or when the
name should be included on the order form
➔ When a medication error or variance does occur, an
incident report —which includes the date, the time that
condition of the veins for access is poor; when long-term
the drug was ordered, the drug name and dose ,the route
or home therapy is required; or when an emergency
of administration, and the therapeutic response or
condition mandates adequate vascular access
adverse clinical observations—should be submitted
➔ The central veins that are most commonly used for
central venous catheters are the subclavian and jugular
veins. When upper body veins are not acceptable, the
femoral veins may be accessed for short-term or
emergency use
MEDICATION SAFETY
➔ Medication safety is freedom from accidental injury
from medications. The nurse should be aware of how to
properly handle certain medications (e.g.,chemotherapy
The “five-plus-five” rights of medication administration are
important goals for medication safety.
1.
Right Patient- The right patient determination is
essential. Two forms of identification before drug
administration are required.
PHARMACOLOGY
18
2.
3.
Right Drug- The nurse must accurately determine the
should be used for every drug calculation so that a step is not
right drug prior to administration.
missed.
Right Dose- Refers to verification by the nurse that the
dose administered is the amount ordered and that it is
safe for the patient for whom it is prescribed.
4.
Right Time- Refers to the time the prescribed dose is
ordered to be administered. Daily drug dosages are given
at specified intervals, such as twice a day (bid), three
times a day (tid), four times a day (qid), or every 6 hours
(every 6hrs)
5.
Right Route- Is ordered by the health care provider and
indicates the mechanism by which the medication enters
the body.
6.
Right
Assessment- Requires the collection of
appropriate baseline data before administration of a
drug. Examples of assessment data include taking a
complete set of vital signs and checking lab levels prior to
drug administration.
7.
Right Documentation- Requires the nurse to record
immediately the appropriate information about the drug
administered.
Many
systems
are
available
for
documenting drug administration. The most common is
the paper medication administration record (MAR)
8.
The right to education requires that patients receive
accurate and thorough information about the drugs they
are taking and how each drug relates to their particular
condition.
9.
The right evaluation determines the effectiveness of the
drug based on the patient’s response to the drug.
Evaluation in this context asks whether the medication
did for the patient what it was supposed to do.
10. The patient has the right to refuse the medication,
and it is the nurse’s responsibility to determine the
reason for the refusal, explain to the patient the risks
involved with refusal, and reinforce the important
benefits of and reasons for taking the medication.
Keeping in mind that the goal is to prepare and administer drugs
in a safe and correct manner, the following recommendations are
offered:
➔ Think. Focus on each step of the problem. This applies
to both simple and difficult problems.
➔ Read accurately. Pay particular attention to the
location of the decimal point and to the operation to be
performed, such as conversion from one system of
measurement to another.
➔ Picture the problem.
➔ Identify an expected range for the answer. The dose
should be reasonable.
➔ Seek to understand the problem. Do not merely
master the mechanics of the mathematical operations.
Seek a second opinion to ensure that the calculation is
correct.
➔ To decrease drug errors, always perform three
checks prior to administering a drug: (1) when
retrieving the drug from a dispensing system, (2) when
preparing the drug, and (3) just prior to administering
the drug to the patient
METRIC SYSTEM
➔ To be able to convert a quantity, one of the values must
be known, such as a gram (g, G), liter (l, L), meter
(m),milligram (mg), milliliter (mL), millimeter (mm), or
microgram (mcg).
➔ Grams, liters, and meters are larger units, whereas
milligrams, milliliters, millimeters, and micrograms are
smaller units. Because the conversion between degrees of
magnitude always involves multiplying by a power of 10,
converting from one magnitude to another is relatively
easy.
CONVERSION WITHIN METRIC SYSTEM
➔ The easiest way to convert larger units to smaller units is
1.
The right to a complete and clear order
to move the decimal point the appropriate number of
2.
The right to have the correct drug, route (form), and
spaces to the right. In the illustration below, grams have
dose dispensed;
been converted to milligrams by moving the decimal
3.
The right to have access to information;
point three spaces to the right:
4.
The right to have policies to guide safe medication
administration;
5.
The right to administer medications safely and to
identify problems in the system;
6.
The right to stop, think, and be vigilant when
administering medication
➔ To convert smaller units to larger units, move the
decimal point the appropriate number of spaces to the
left. In the illustration below, milligrams have been
converted to grams by moving the decimal point three
spaces to the left (thousandths):
Nurses perform basic mathematical operations on a regular basis
when preparing drugs for administration. To accurately calculate
drug dosages, a systematic process is used. The same process
PHARMACOLOGY
19
(3) dimensional analysis (DA)
➔ These methods are used to calculate most enteral and
parenteral drug dosages. The nurse should select one of
the methods to calculate drug dosages and use that
method consistently. All but the dimensional analysis
requires using the same units of measure. It is most
helpful to convert to the system used on the drug label.
If the drug is ordered in grams (g, G) and the drug label
gives the dose in milligrams (mg), convert grams to
milligrams (the measurement on the drug label) and
proceed with the drug calculation.
➔ For drugs that require individualized dosing, calculation
by body weight (BW) or by body surface area (BSA) may
be necessary. These last two methods are mostly used for
HOUSEHOLD SYSTEM
the calculation of pediatric dosages and for drugs used in
the treatment of cancer (antineoplastic drugs).
➔ Because of the lack of standardization of spoons, cups,
and glasses, household measurement is not as accurate as
the
metric
system,
therefore
measurements are
METHOD 1: BASIC FORMULA
approximate.
➔ A teaspoon (t) is considered to be equivalent to 5 mL in
the metric system. Three teaspoons equal 1 tablespoon
(T), therefore 1 T equals 15 mL. Ounces (oz) are
fluidounces in the household measurement system, and
there are 2 T in 1 oz therefore 1 ounce equals 30mL in
the metric system
➔ Where:
➔ D: is the desired dose (as ordered)
➔ H is the drug on hand (available)
➔ V is the vehicle or volume of a drug form (tablet, capsule,
liquid)
➔ A is the amount calculated to be given to the patient
Example:
1.
Order: Cefaclor 0.5 grams PO twice a day
Available: Cefaclor: 500mg/ capsule
CONVERSION WITHIN HOUSEHOLD SYSTEM
CALCULATION METHODS- ENTERAL AND
PARENTERAL DRUG DOSAGES
➔ The three general methods for the calculation of drug
dosages are the
(1) basic formula (BF)
(2) ratio
and
proportion/fractional equation
(RP/FE)
PHARMACOLOGY
20
2.
Order: Phenobarbital 30 mg PO STAT
Available: Phenobarbital 15mg/ tablet
How many tablets should the patient receive per dose?
Example
1.
Order: Ciprofloxacin 500 mg PO every 12 hours
Available: Ciprofloxacin 250 mg per tablet
METHOD
2:
FRACTIONAL
RATIO
EQUATION
AND
&
How many tablets should the patient receive per dose?
PROPORTION/
RATIO
AND
PROPORTION LINEAR METHOD
➔ The ration and proportion (RP) method can be
expressed linearly or as a fraction (a fractional equation
➔ Where
as follows)
➔ H= 250 mg
➔ V= tablet (tab)
➔ D= 500 mg
➔ x= unknown number of tablet
➔ Where:
➔ D is the desired dose ( as ordered)
➔ H is the drug on hand ( available)
Example:
1.
Order: Amoxicillin 100 mg PO qid
Available: Amoxicillin 250 mg per 5 mL
How many milliliters should the patient receive per
dose? Conversion is not needed because both are
METHOD 3: DIMENSIONAL ANALYSIS
➔ Dimensional Analysis is a calculation method known
as units and conversions. The D, H, and V are still used
expressed in the same unit of measure
in DA. The advantage of DA is that all the steps for
calculating drug doses are conducted in one equation
without
having to remember various formulas.
However, conversion factors still need to be memorized.
Steps for Dimensional Analysis
1.
Identify the unit/form (tablet, capsule, mL) of the drug
to be calculated. Place the unit/form to one side of the
2.
Order: Aspirin 162 mg PO once daily
Available: Aspirin 81 mg per tablet
equal sign (=). This is your desired unit/form.
2.
Determine the known dose and unit/form from the
drug label that matches the unit/form of the desired
How many tablets should the patient receive per dose?
dosage. Place this on the other side of the equal sign.
3.
Continue
with
additional
fractions
using
a
multiplication operation between each fraction until all
but that one unit you want is eliminated.
4.
Multiply
the
numerators
and
multiply
the
denominators.
5.
Solve for x (the unknown)
Example
1.
The fractional equation (FE) setup is written as a fraction and is
more commonly used than the linear setup.
Order: Amoxicillin 500 mg PO every 8h
Available: 250 mg per capsule
How many capsules (cap) will the nurse administer per
dose?
PHARMACOLOGY
21
2.
Order: Amoxicillin 0.5 g PO every 8h
Available: 250 mg per capsule
How many capsules will the nurse administer? A
conversion is needed between grams and milligrams.
Following the steps for DA, the equation looks like this
METHOD 5: BODY SURFACE AREA- WEST
NOMOGRAM
➔ The measurement of body surface area (BSA) is the
most precise method for calculating drug dosage. BSA
can measured using the West Nomogram or the square
root method
➔ As with other methods of calculation, the three
components are D, H, and V as indicated in the above
problem. With dimensional analysis, the conversion
factor (CF) is built into the equation and is included
when the ordered drug’s unit of measurement and the
drug available differ.
METHOD 4: BODY WEIGHT
When calculating the BSA using the metric system (cm and
Example
1.
Order: Fluorouracil 12 mg per kg per day intravenous
kg), the following formula applies
(IV) for a patient who weighs 176 lb
Available: Two vials of fluorouracil 50 mg per mL
How many milliliters should the nurse administer per
day?
PHARMACOLOGY
22
The following drug dosage for this patient is calculated using a
BSA of 1.9 m2
1.
Order: CIS platin 20 mg per m2 intravenous (IV) today
Available: CISplatin 1 mg per mL
How many milligrams are ordered?
a.
To calculate the child’s dose, multiply 20 mg
with 1.9 m2 to get 38 mg.
b.
How many milliliters will the nurse administer
Basic Formula:
2.
Order: Ceftriaxone 250 mg IM every 12h
Available: Ceftriaxone 350 mg per 1 mL
Ratio/ Proportion/ Fractional Equation:
How many milliliters will the nurse administer per dose?
How many milliliters will be administered every 24
hours?
CALCULATING DOSAGES- DRUGS THAT REQUIRE
RECONSTITUTION
CALCULATING SUSPENSIONS & SOLUTIONS
➔ Both enteral and parenteral drugs may come in powder
form due to the drug’s instability in liquid. The liquid
used to reconstitute a dry powder is called a diluent.
➔ Diluents can be sterile water intended for injection, 0.9%
saline solution, or a special liquid supplied by the
manufacturer.
➔ The nurse must follow directions for reconstitution on
the label exactly. Below is a label of an oral preparation
that requires reconstitution
CONSIDERATIONS WHEN CALCULATING DOSAGES
OF ORAL DRUGS
Most drugs are administered orally. Oral drugs are available in
tablet, caplet, capsule, powder, and liquid forms. Oral medications
are absorbed by the gastrointestinal (GI) tract, mainly from the
small intestine.
➔ Oral medications have several advantages:
➔ the patient can often take oral medications without
assistance,
➔ the cost of oral medications is usually less than that of
parenteral preparations, and oral medications are easy to
store.
The disadvantages include
➔ Variation in absorption as a result of food in the GI tract
and pH variation of GI secretions,
➔ irritation of the gastric mucosa by certain drugs (e.g.,
potassium chloride), and
Example:
1.
Order: Cefadroxil oral solution 1 g PO every 12h
Available: Cefadroxil oral solution 250 mg per 5 mL
How many milliliters will the nurse administer per dose?
➔ destruction or partial inactivation of the drugs by liver
enzymes. Oral drugs (tablets, capsules, liquids) that may
irritate the gastric mucosa should be taken with 6 to 8
ounces of fluids or should be taken with food
Tablets, Capsules, and Liquids
➔ Tablets come in different forms and drug strengths.
●
Many tablets are scored and thus can be readily
broken when half of the drug amount is
needed.
●
Capsules are gelatin shells that contain
powder or timed-release pellets (beads).
PHARMACOLOGY
23
●
●
Capsules that are sustained release (pellet)
➔ a desire to increase the effectiveness of the drug, the
or controlled release should not be crushed and
parenteral route may be the route of choice. Parenteral
diluted because the medication will be
medications
absorbed at a much faster rate than indicated
(intradermally
by the manufacturer.
(subcutaneously [subcut]), within the
Many medications sold in tablet form are also
(intramuscularly [IM]), or in the vein (intravenously
available in liquid form. When the patient has
[IV]).
are
administered
[ID]),
into
under
the
the
fatty
skin
tissue
muscle
difficulty taking tablets, the oral liquid form of
the medication is given. The liquid form can be
in a suspension, syrup, elixir, or tincture. Some
liquid medications that irritate the stomach,
such as potassium chloride, are diluted. The
tincture form is always diluted.
●
Tablets that are enteric coated (with a hard
shell) must not be crushed because the
medication could irritate the gastric mucosa.
Enteric-coated drugs pass through the stomach
into the small intestine where the drug’s enteric
coating dissolves, and then absorption occurs.
Injectable Preparations
➔ The appropriate drug container (vial or ampule) and the
correct selection of needle and syringe are essential in the
preparation of the prescribed drug dose. The route of
administration is part of the medication order.
Syringes
➔ The syringe is composed of a barrel (outer shell), plunger
(inner part), and the tip where the needle joins the
syringe. Syringes are available in various types and sizes,
including tuberculin and insulin syringes. Syringes
prefilled with drugs may be glass, plastic, or metal. The
tip of the syringe, inside of the barrel, and the plunger
Drugs Administered via Nasogastric Tube
should remain sterile.
➔ Oral medications can be administered through a
nasogastric
or
other
feeding
tube
for
enteral
administration. If the patient is receiving a tube feeding,
the drug should not be mixed with the feeding solution.
➔ Mixing the medications in a large volume of tube feeding
solution decreases the amount of drug the patient
receives for a specific time.
➔ The
medication
(but
not
timed-release
or
sustained-release capsules and psyllium hydrophilic
mucilloid) should be diluted in 15 to 30 mL of water or
other desired fluid unless otherwise instructed.
➔ The medication is administered through the tube via a
syringe, followed by another 15 to 30 mL of water to
ensure that the drug reaches the stomach and is not left
in the tube.
➔ Check the policy at your institution.
CONSIDERATIONS WHEN CALCULATING DOSAGES
OF PARENTERAL DRUGS
When medications cannot be taken by mouth because of
➔ an inability to swallow,
➔ a decreased level of consciousness,
Vials and Ampules
➔ A vial is usually a small glass vacuum container with a
self-sealing rubber top. Some are multiple-dose vials, and
when properly stored, they can be used over time.
➔ An ampule is a glass container with a tapered neck for
snapping open and using only once. Caution is advised
when snapping an ampule to prevent skin laceration.
Also, glass fragments can occur, therefore a filter needle
must be used to withdraw medication.
➔ Drugs that deteriorate readily in liquid form are
packaged in powder form in vials for storage. Once the
dry form of the drug is reconstituted (usually with sterile
or bacteriostatic water or 0.9% saline), the drug is used
immediately or must be refrigerated. Check the
accompanying drug circular for specific storage lengths
and other instructions. Once the drug in a multi dose
vial is reconstituted, the vial should be labeled with the
date and time of reconstitution and the initials of the
person who reconstituted the drug. The shelf life of a
reconstituted drug is determined by the manufacturer
and can be found on the drug label.
➔ an inactivation of the drug by gastric juices,
PHARMACOLOGY
24
CALCULATION METHODS- INSULIN DOSAGES
and even fatal consequences. The nurse must read drug
inserts carefully to obtain administration information
Drug Calculation in Units
and must pay attention to the amount of drug that can
➔ Drugs are most commonly measured in grams,
be given per minute. If the drug is pushed into the
milligrams, or micrograms. However, some are measured
bloodstream at a rate faster than that specified in the
in units. This includes insulin and heparin. Typically,
drug literature, adverse reactions can occur.
➔ Nurses have an important role in the preparation and
units are not converted to any other measure.
➔ Most insulins are produced in concentrations of 100
administration of IV solutions such as 0.9%sodium
units per mL. Insulin should be administered with an
chloride (normal saline, [NS]), 0.45% sodium chloride
insulin syringe, which is calibrated to correspond with
(½NS), 5% dextrose in water (D5W),and Lactated
the concentration of 100 units of insulin per mL in
Ringer’s solution (LR) and also IV drugs.
➔ The nursing functions and responsibilities during IV
the vial.
➔ For example, if the prescribed insulin dosage is 30 units,
preparation include the following:
using an insulin syringe calibrated to 100 units per mL,
●
Gathering equipment
withdraw insulin from the vial to the 30-unit mark (Fig.
●
Knowing IV sets, including drop factors
11D.1). (Note that 30 units is not interchangeable with
●
Calculating appropriate IV flow rates
30 mL or 0.3 mL.)U-100 insulin syringes are available in
●
Mixing and diluting drugs in IV fluids
various sizes, such as low-dose insulin syringes that hold
●
Knowing
➔ The size of the insulin syringe does not alter the
calibration of 100 units per mL. Some insulin is available
insulin
pen
injectors
pharmacokinetics
and
pharmacodynamics of drugs and their adverse
a total of 0.3 mL or 0.5 mL.
in
the
and
insulin
pumps.
Administering insulin with a tuberculin syringe should
effects
➔ Nursing responsibilities continue with assessment of the
patient for expected outcomes and adverse effects of the
therapy in addition to assessment of the IV site
be avoided. Although both syringes have 1mL capacities,
➔ The nurse calculates the IV flow rate according to the IV
the tuberculin syringe is calibrated in milliliters rather
tubing’s drop factor, the volume of fluids to be
than units. It is critical that the correct type and dose of
administered, the length of time for infusion, and
insulin is administered to avoid severe aberrations of the
whether an electronic infusion device will be used. IV
patient’s blood glucose.
infusions are ordered to be delivered in some unit of
measure over time (e.g., mL/h, mcg/kg/min, unit/h,
drops per minute [gtt/min]). Nurses calculate the rate of
infusion in milliliters per hour when using an electronic
infusion device. If the nurse needs to manually regulate
the rate, the flow rate is calculated in drops per minute.
The type and size of IV administration tubing must be
known when calculating drops per minute.
Example:
1.
Order: Regular insulin 23 units subcut
Indicate on the appropriate syringe the amount of
insulin to be withdrawn.
CALCULATION METHODS- INTRAVENOUS FLOW
RATE
Intravenous Administration Sets IV administration sets
include printed information on the packaging cover, such as the
drop factor, or the number of drops per milliliter.
➔ A set that delivers large drops (10 to20 gtt/mL) is a
macrodrip set, and one that delivers small drops (60
gtt/mL) is a microdrip(minidrip) set. A macrodrip IV set
is commonly used for adults, and a microdrip IV set is
used when small amounts of drug or more precise
➔ Intravenous (IV) therapy is used to administer fluids
that contain water, dextrose, vitamins, electrolytes, and
drugs. Today an increasing number of drugs are
administered by the IV route for direct absorption and
fast action. Methods of IV administration include
intermittent bolus; IV push(IVP), usually with a syringe;
intermittent infusions; IV piggyback (IVPB); and
continuous infusions.
➔ Drugs given IVP are usually small in volume and are
administered over a few seconds to a few minutes.
Medications administered by this route have a rapid
onset of action, and calculation errors can have serious
administration is warranted.
➔ At times, primary IV fluids are given at a slow rate,
ordered to keep the vein open (KVO), also called to
keep open (TKO). The reasons for KVO include a
suspected or potential emergency situation for rapid
administration of fluids and drugs and the need for an
open line to give IV drugs at specified hours. For KVO, a
microdrip set (60 gtt/mL) and a 250-mL IV
solution bag may be used. KVO is usually regulated to
deliver 10 to 30 mL/h.
➔ Drugs prescribed as IVPB (Fig. 11E.3) are administered
via separate tubing for IV drugs, the secondary IV line
PHARMACOLOGY
25
set, which is connected into a port (rubber stopper) on
the IV connector on the continuous or primary IV line
set; the port should be above the IV pump.
Intermittent Infusion Adapters and Devices
➔ When continuous IV infusion is to be discontinued but
the patient still requires IV access, the IV tubing is
Intravenous Administration Sets IV administration
Drugs prescribed as IVPB are administered
via separate tubing for IV drugs, the
secondary IV line set, which is connected
into a port (rubber stopper) on the IV
connector on the continuous or primary IV
line set; the port should be above the IV
pump.
removed and a saline lock is attached.
➔ Saline locks have ports (stoppers) where needles and
needleless or IV tubing can be inserted as needed to
continue drug therapy.
➔ The use of a saline lock increases the patient’s mobility
by not having an IV line tagging along, and it is cost
effective because less IV tubing, solution, and equipment
are needed.
Secondary Intravenous Administration
➔ Sets Two secondary IV administration sets available to
administer IV drugs are the calibrated cylinder
(volume-controlled chamber) with tubing such as the
Buretrol, Volutrol, and Soluset—and the secondary IV
set, which is similar to a regular IV set except the tubing
is shorter.
➔ The cylinder can be used with a primary or secondary
line and when measurement of small-volume IV therapy
needs to be more accurate, such as in pediatric or critical
care settings.
➔ The volume-controlled chamber holds up to 150 mL
of solution. The secondary IV line set is primarily used
to piggyback onto a primary line (IVPB). The cylinder
and some secondary IV tubing contain a port to inject
medications. When using a calibrated cylinder, such as
the Buretrol, add 15 mL of IV solution, such as 0.9%
sodium chloride, to flush the drug out of the IV line
after the drug infusion is completed. The flush volume is
added to the patient’s intake. Check hospital policy for
guidance
Electronic Infusion Devices Pumps
➔ Electronic intravenous devices used in hospitals and
some community settings.
➔ Such IV pumps are set to deliver a prescribed rate of
volume. IV pumps deliver IV solutions against
resistance. If the flow is obstructed, an alarm sounds,
however the alarm does not sound until the pump has
exerted its maximum pressure to overcome resistance.
➔ Pumps do not recognize infiltration, therefore the nurse
must frequently assess the IV site.
➔ When an electronic IV device is used, the flow rate is set
in milliliters per hour (mL/h).
➔ IV pumps are recommended for use with all IV therapy,
however some noncritical IV solutions and drugs can be
administered using gravity by manually calculating drops
per minute.
PHARMACOLOGY
26
➔ Ongoing nursing assessment is essential with any IV
therapy to ensure proper duration of administration.
3.
the time frame or how long to infuse the fluid.
➔ As with previous drug calculations, the nurse should
➔ Several electronic infusion devices are available that
select one method, be familiar with it, and consistently
include electronic volumetric pumps (IV pumps),
use it to calculate IV flow rate. When delivering IV drugs
syringe pumps, and patient-controlled analgesia (PCA)
via electronic devices, the flow rate is calculated for
devices. Fig. 11E.6 shows a variety of electronic IV
milliliters per hour (mL/h).
regulators for the administration of IV solutions and
drugs. Part A shows a syringe pump, part B shows a
single-channel infusion pump, and part C shows a
dual-channel infusion pump. Part D shows a PCA
pump, part E shows the Alaris System large-volume
pump with PCA, and part F shows the Medley pump
module attached to the Medley programming module
Ratio and Proportion/ Fractional Equation
Calculating Intravenous Flow Rate: Drops Per Minute
➔ When an electronic device is not used and the nurse
manually regulates the IV rate, the nurse must calculate
the number of drops per minute (gtt/min). The flow rate
in drops per minute is determined by the size of the IV
tubing (gtt/mL) as discussed earlier in this chapter. To
Safety Considerations for Intravenous Infusions
convert hours to minutes, multiply the hours with 60
➔ All IV infusions and sites should be checked frequently.
minutes.
Common problems associated with IV infusions are
kinked tubing, infiltration, and so-called free-flow IV
rates. If IV tubing kinks, the flow is interrupted and the
prescribed amount of fluid will not be given.
➔ The access site can also clog, which obstructs the flow.
When infiltration occurs, IV fluid extravasates into the
tissues and not into the vascular space. Trauma occurs to
the tissues around the IV site.
➔ A free-flow IV rate refers to a rapid infusion of IV
fluids that is faster than prescribed, which can cause fluid
overload due to rapid infusion. Because of the possibility
of a free-flow IV rate, electronic infusion pumps with
multiple safety features are commonly used today.
Electronic infusion pumps are not without flaws, and
→
mechanical problems can occur. Also ,incorrectly
programming an infusion pump can result in an
incorrect infusion rate. Frequent monitoring of IV
infusions can prevent complications of IV therapy such
as fluid overload, thrombus formation, and infiltration.
Calculating Intravenous Flow Rate: Milliliters Per Hour
Calculating Intravenous Heparin Infusions
➔ Like insulin, heparin is prescribed in unit dosages.
➔ Regardless of the method used to determine the rate, the
Heparin is a high-alert drug that is available in multiple
nurse should have the following information before
calculating the flow rate:
1.
the volume to be infused,
2.
the drop factor of the infusion set, and
concentrations from 10 units/mL to 50,000 units/mL.
➔
It is important for the nurse to identify the label dosage
strength
and
verify
the
patient’s
medication
PHARMACOLOGY
27
administration record; significant risk of causing serious
Dimensional Analysis
injury or death can occur with errors.
➔ Heparin labels must be read carefully to ensure the
correct drug is being administered. The following
heparin labels are examples of available strengths. Note
that only one is indicated for heparin flush (100
units/mL). All other labels indicate “NOT for Lock Flu
Drug Measured in Milliequivalents
➔ Electrolytes are often ordered in milliequivalents
(mEq).
Most drugs administered in critical care are titrated (adjusted)
according to the patient’s response to the drug therapy. The
patient is monitored closely for therapeutic effects and any adverse
events. When calculating critical care drugs, any method
previously discussed is effective, however dimensional analysis is
the best method because units and conversion factors are
Example
1.
calculated in one equation.
Ordered: 1000 mL D5W with heparin sodium 20000
units to infuse at 30 mL/h Calculate the units per hour.
Example:
➔ Order: Dobutamine HCl 2 mcg/kg/min, titrated to
maintain hemodynamic goals in a patient who weighs
2.
Order: Heparin sodium 750 units/h
Available: Heparin sodium 25000 units in 500 mL D5W
Calculate the milliliters per hour.
180 lb
Available: Dobutamine HCl 250 mg in 500 mL of
D5W
➔ Calculate micrograms per kilograms per minute.
Calculate milliliters per hour.
CALCULATING DOSAGES FOR DRUGS MEASURED IN
UNITS OR MILLIEQUIVALENTS
➔ Some medications, such as heparin and insulin, are
measured in units. Typically, units are not converted
into any other measure
Drug Measured in Units
➔ Order: Heparin 2500 units subcutaneous daily
➔ Available: Heparin 10,000 units per mL in a
multiple-dose vial (10 mL)
Basic Formula
ROUNDING RULES
➔ Tablets and caplets can be rounded to the nearest half if
they are scored
➔ Some tablets are scored in fourths. In this case, the
dosage can be rounded to the nearest fourth.
➔ Tablets and caplets that are extended release, sustained
release, controlled release, or enteric coated should not
be split because splitting or crushing these preparations
destroys the properties that render the drug long lasting.
For this reason, capsules are rounded to the nearest
whole number.
Ratio & Proportion
➔ Liquid drugs can be rounded to the nearest tenth; the
exception to this rule is when calculating dosages of
drops, which are rounded to the nearest whole number.
➔ When rounding, determine how many places beyond the
decimal point are appropriate. The general rounding
rules are:
PHARMACOLOGY
28
1.
If a number to the right of the digit needs to be
CPOE (Computerized Provider Order Entry)
rounded and is 4 or less, round down. For
technology checks for potential drug interactions and
example, when rounding 1.343 to the
the appropriateness of drug dosages ordered, as well as
hundredth place, the number becomes 1.34.
for laboratory findings (e.g., therapeutic drug levels at
Rounding 1.343 to the tenth place, it becomes
the time of order entry). Automated systems use
1.3. Rounding 1.343 to a whole number, it
robotics and bar-coding technology to fill the orders
becomes 1.
2.
If a number to the right of the digit needs to be
entered by the physician.
2.
Medications and classifications that pose significant risk
rounded and is 5 or greater, round up. For
in the acute clinical setting were identified. These are
example, when rounding 1.745 to the
now known as high-alert medications, and they include
hundredth place, the number becomes 1.75.
insulin, heparin, opioids, injectable potassium or
Rounding 1.745 to the tenth place, it becomes
potassium
1.7. Rounding 1.745 to a whole number, it
blocking agents, and chemotherapeutic agents.
becomes 2.
growing risk of harm. Medication errors are defined as the
4.
Use of smart pumps for controlled administration
5.
The avoidance of verbal orders for high-alert medicines
6.
The use of generic and brand names on the MAR to
7.
8.
In a true culture of safety, everyone in the organization is
committed and driven to keep patients safe from harm. Risk
management is a process that identifies weaknesses in the system.
It then allows changes to be made in order to minimize the effects
of adverse patient outcomes. Most organizations have a risk
management department staffed with nurse managers and risk
managers who conduct root cause analysis (RCA), a method of
problem solving used to identify potential workplace errors. Such
analysis presents opportunities for learning and focuses on
strategies that can be put in place to correct problems.
In order to decrease these errors and maintain quality patient care
and patient safety, preventive measures were developed and
implemented
1.
Another process that involves the goal of eliminating
with all of the medications that the patient is actually
taking. This process makes use of a single, shared, and
updated medication and allergy list for patients across
the continuum of inpatient and outpatient care that is to
be used during handoffs, or the transition of patients
punitive approaches in reporting drug errors because they focus
gross misconduct.
The standardizing of drug concentrations and dosing
involves comparing a patient's current medication orders
statement (2010), and it encourages organizations to avoid using
system, although it does not tolerate disregard for a patient or
drugs
medication errors is medication reconciliation, which
The ANA supports the concept of Just Culture in its position
does not hold individual practitioners responsible for a failing
sound-alike
infusion charts
dispensing, administering, or monitoring medications.
the system can be repaired and the problem fixed. A Just Culture
with
nks to an external site.)
occur at any point in the process: ordering, transcribing,
Culture, individuals would be encouraged to report drug errors so
errors
(https://www.ismp.org/tools/confuseddrugnames.pdfLi
preventable inappropriate use of medications. These errors can
on punishing individuals for reporting such errors. In a Just
neuromuscular
Use of bar-coded drug administration
CULTURE OF SAFETY
However, with substantial and increasing medication use comes a
concentrate,
3.
avoid
Medications are offered by health services throughout the world.
phosphate
during care.
9.
When a medication error or variance does occur, an
incident report—which includes the date, the time that
the drug was ordered, the drug name and dose, the route
of administration, and the therapeutic response or
adverse clinical observations—should be submitted.
10. Dosage Forms: To Crush or Not to Crush- Although
some drugs can be used crushed, some should not be
crushed.
(http://www.ismp.org/tools/donotcrush.pdf
Links to an external site.)
11. To avoid drug errors, many facilities are creating
medication safety zones by implementing policies that
provide for a medication room or safety area. When a
nurse enters this safety zone, he or she is not to be
disturbed.
12. Develop secure, convenient, and responsible methods for
collecting and destroying medications and controlled
substances. General guidelines include take-back events,
mail-back programs, and collection receptacles.
13. Employers implement safer medical devices for their
employees, provide a safe and secure workplace
Adverse drug events occur most commonly during
environment with educational opportunities, and
ordering and at the administration stage. Therefore
develop written policies to help prevent sharps injuries
preventive measures are being implemented that include
14. When the nurse is unsure about a dosage, potential side
substantial changes in the ordering system used for
effects, expected therapeutic effects, contraindications, or
medications and laboratory studies. The use of the
adverse reactions, an external resource—a drug reference
PHARMACOLOGY
29
book, pharmacist, or an acceptable technology resource
➔ May also contribute to premature birth, low birth
(e.g., Micromedex, Epocrates)—should be consulted to
determine the correct answer.
weight & abruption placenta.
➔ Folic acid is recommended to be given 1 month before
conception and for the 1st 2-3 months after
conception@ 0.4mg-0.8mg
➔ Folate rich foods like green leafy vegetables , asparagus,
papaya, strawberries and oranges should also be given
ADVERSE REACTIONS TO FOLIC ACID
IRON
➔ Fetal and maternal daily requirement for iron is 27 mg
/day during pregnancy. Goal in giving iron supplements
➔
FA side effects are uncommon however patients may
experience:
is to prevent maternal iron deficiency anemia and not to
supply the fetus with iron.
➔ The recommended iron demand during the course of
pregnancy are as follows:
●
1st trimester : 6.4mg/day
●
2nd trimester : 18.8mg/day
●
3rd trimester : 22.4mg/day
➔ Pregnant patients generally have decreased hematocrit
early in 3rd trimester, if w/ below 30%, the iron dosage
must be increased.
In taking iron preparations the most common side effects
are:
➔ Nausea & vomiting
➔ Constipation (drink a lot of fluid, eat a lot of fruits &
vegetables increased in fiber)
➔ Black, tarry stools
➔ GI irritations
➔ Epigastric pain
➔ Discoloration of urine
➔ Diarrhea
rash
●
allergic bronchospasm
●
pruritus
●
erythema
●
malaise
●
urine may turn intensely yellow.
MULTIPLE VITAMINS
Prenatal Vitamin preparations are routinely recommended for
pregnant women that contains:
➔ Vitamin A
➔ B complex
➔ B12
➔ Vitamin C
➔ Calcium
➔ Vitamin D
➔ Vitamin E
➔ Iron
DRUGS FOR MINOR DISCOMFORTS OF PREGNANCY
NAUSEA & VOMITING
NURSING CONSIDERATIONS FOR IRON
➔ As the nurse, observe the following in giving iron
preparation:
➔ Dilute iron with water and use straw in giving liquid
iron to prevent staining of teeth.
➔ Iron is best absorbed with juice and on an empty
stomach
➔ Vit.C increases iron absorption
➔ If there would be gastric irritation, you may administer
iron w/food
➔ Don’t administer iron w/milk,cereal,tea,coffee or eggs
●
●
Tea and Coffee contain Tannins which can
inhibit iron absorption.
➔ Don’t mix antacid with iron, give iron 2 hrs before or
4 hrs after antacid
FOLIC ACID
➔ To prevent spontaneous abortion, and neural tube
defects (failure of the embryonic neural tube to close
properly) can lead to spina bifida, or skull & brain
malfunction of the baby.
➔ (morning sickness)
➔ 88% of patients’ complaints
➔ The FDA approves pyridoxine hydrochloride &
doxylamine succinate for treatment of morning
sickness
➔ MOA-(Mechanism of Action)
●
Competes w/histamine for h2 receptor sites
➔ Dosage: 2 tabs @ bedtime (hs) PO
➔ SE: CNS depression so avoid driving and operates
machinery
➔ CI: known hypersensitivity to doxylamine succinate
HEARTBURN
➔ Also called pyrosis is a burning sensation in the
epigastric & sternal regions that occurs w/reflux of acidic
stomach contents.
➔ Antacids= first line of therapy for heartburn in
pregnancy.
➔ Long term use is discouraged to prevent fetal problems
➔ Over the counter antacids commonly used in pregnancy:
●
Aluminum hydrochloride
➢ MOA: neutralizes gastric acidity
PHARMACOLOGY
30
➢ Dosage: recommended 600 mg in
5-6x per day
37 weeks of pregnancy, regardless of birthweight.
➢ SE: constipation, dehydration and GI
obstruction
➢ SE: AlaTae, so it is constipation
●
Magnesium hydrochloride
➢ MOA: anti-flatulent & neutralizes
gastric acidity
➢ SE: diarrhea, dehydration and GI
obstruction (Magtatae)
➔ Causes may be related to hormonal changes specifically
progesterone –decreases gastric motility.
sodium=1st
NON- PHARMACOLOGICAL TREATMENT FOR
PRETERM LABOR
1.
Bed Rest
2.
Hydration (6-8 glasses/day)
3.
pelvic rest
4.
screening for UTI
5.
patient’s monitoring for uterine activity, vaginal bleeding
or discharge
CONSTIPATION & PAIN
➔ Docusate
Preterm birth is any birth that occurs before the completion of
line
of
treatment
for
constipation during pregnancy
➔ PAIN: headache from eye strain, hormonal changes and
sinus congestion are common.
➔ Acetaminophen- most common non-prescription drug
during pregnancy & can be used during all trimesters of
pregnancy
➔ Dosage: 325mg or 500mg @ 3-4 hrs interval but not
6.
PHARMACOLOGICAL TREATMENT
TOCOLYTIC THERAPY:
➔ indicated for pregnant client experiencing PTL( Pre
Term Labor)
➔ MOA: to decrease premature uterine contractions using
terbutaline sulfate & MgS04 (Magnesium Sulfate)
➔ Also can be used: ▪ Indomethacin ▪ nifedipine
➔ PHARMACOKINETICS: given initially terbutaline
0.25mg q 20 mins to 6 hrs if the maternal pulse is less
exceeding 8 tabs/24 hrs.
than 120 beats/ min. Contractions will be monitored to
➔ Rate of absorption is dependent on the rate of gastric
emptying
Fetal Monitoring
determine if they will continue or cease.
➔ PHARMACODYNAMICS: IV and Subcu
➔ onset of action is 6-15 mins
➔ Peak=30-60 mins
➔ Duration of action =1.5-4 hrs subcutaneously
➔ SIDE EFFECTS
During your NCM 107 you were able to learn about changes in
●
Tremors
pregnancy and with this changes, normal and expected
●
dizziness
pharmacokinetics and pharmacodynamics of drugs are also
●
nervousness
changed during pregnancy. These are the changes in drug action
●
tachycardia
during pregnancy:
●
hypotension
●
chest pain
●
palpitations
●
Nausea & vomiting
●
hyperglycemia
●
▪hypokalemia
1.
effect of circulating steroid hormones on the liver's
metabolism of drugs;
2.
ease renal perfusion;
3.
resulting in more rapid renal excretion of drugs;
4.
expanded maternal circulating blood volume, resulting
in dilution of drugs;
5.
alteration in the clearance of drugs in later pregnancy,
resulting in a decrease in serum and tissue concentration
of drugs.
Terbutaline Sulfate
➔
is contraindicated in patients with cardiac disease and in
those with poorly controlled hyperthyroidism or
diabetes mellitus ,thus this is given
MgS04(Magnesium Sulfate)
➔ is a Ca antagonist & CNS depressant that relaxes the
smooth muscle of the uterus through Ca displacement
You have learned that a health pregnancy should complete the
37-38 weeks of gestation in order to have a safe and healthy
delivery of both mother and her baby. In some cases preterm labor
is occurring, this is defined as cervical changes and uterine
contractions that occur between 20-36 weeks of pregnancy.
and is more commonly given as tocolytic drug.
➔ ▪ MgS04- is safe to use , has less side effects, excreted by
the kidneys and crosses the placenta , it increases uterine
perfusion & has therapeutic effects on the newborn .
➔ ADVERSE REACTIONS in Magnesium Sulfate
●
Flushing
●
feelings of increased warmth
PHARMACOLOGY
31
●
perspiration
pregnancy induced hypertension, this condition can have a
●
dizziness
devastating effect both on the mother and her baby. There are two
●
watch out for MgS04 toxicity such as
categories of gestational hypertension, pre eclampsia and
respiratory
eclampsia both have pharmacological treatment involved to
depression
,
cardiac
arrest,
depressed reflexes
NURSING INTERVENTIONS DURING TOCOLYTIC
THERAPY:
prevent further complications that may lead to seizure of the
mother and death of her unborn child.
FIRST LINE THERAPIES FOR MILD PRE ECLAMPSIA
➔ Methyldopa
1.
Monitor VS , FHR and uterine activity
2.
Monitor I&O (report UO=less than 30mL/hr. )
➔ Hydralazine
3.
Assess breath & bowel sounds @ least q4h
➔ Labetalol
4.
Assess DTR (deep tendon reflex)
➔ widely used and safe for pregnant mothers
5.
Assess pain and uterine contractions
6.
Weigh daily at the same time
7.
Monitor serum MGS04
●
●
Maintain therapeutic level @4-7mg/dL
Ca Gluconate=as antidote given @ 1 gram IV
over 3 mins
●
Observe the newborn for 24-48 hrs for MgS04
effects if drug is given to the mother before
delivery.
➔ Additional drug alternatives are: prazosin, nifedipine
,clonidine.
➔ Beta Blockers are safe, but potential for impaired fetal
growth if used early in pregnancy.
➔ MgS04= used for severe pre-eclampsia for the
prevention of eclampsia.
ADVERSE REACTIONS
➔ FOR METHYLDOPA
●
.Peripheral Edema
●
.anxiety
➔ The desired outcome of tocolytic therapy is to delay
●
nightmares
birth long enough to allow time for corticosteroids to
●
drowsiness
reach maximum benefit.
●
headache ‘
➔ If the baby is delivered prematurely, we need to help the
●
dry mouth
lungs of the baby by giving betamethasone or
●
drug-induced fever
dexamethasone.
●
mental depression
CORTICOSTEROID THERAPY IN PRETERM LABOR
➔ 24-34 weeks =@ risk for preterm delivery and should
➔ FOR HYDRALAZINE
●
headaches
➔ MOA of beta and dexa is to accelerate fetal lung
●
Nausea & vomiting
maturation & lung surfactant development decreasing
●
nasal congestion
incidence of RDS (respiratory distress syndrome)
●
dizziness
increasing survival of preterm infants.
●
tachycardia
●
palpitation
●
angina pectoris
●
*no known direct effect on fetus
receive betamethasone or dexamethasone
➔ Betamethasone dose= 12mg/IM every 12 hours for 2
doses
➔ Dexamethasone dose=6mg IM every 12 hrs for 4 dose
➔ SIDE EFFECTS OF BETAMETHASONE:are rare
➔ FOR MAGNESIUM SULFATE
●
Early signs of increased Magnesium levels
●
seizures
●
headache
●
vertigo
●
lethargy
●
edema
●
flushing
●
hypertension
●
feelings of increase warmth
●
increased sweating
●
perspiration
●
petechiae
●
thirst
●
ecchymoses
●
sedation
facial erythema
●
heavy eyelids
●
slurred speech
●
hypotension
●
.decreased DTR ( deep tendon reflex)
●
decreased muscle tone
●
includes:
➔ Therapeutic Magnesium levels = 4-7 mEq/L.
Gestational Hypertension is also one major complication of
pregnancy wherein the pregnant mother is experiencing sudden
increase in her pre-pregnant blood pressure and is termed as
➔ ▪Loss of patellar reflexes=first sign of Magnesium
Toxicity
➔ ▪And the toxic level of MgS04 is already 8-10mEq/L
PHARMACOLOGY
32
➔ ▪Respiratory Depression =can also be manifested if
the level of MgS04 in the blood is already= 10-15mEq/L
➔ And cardiac arrest may occur if the MgS04 level in
the blood becomes- 20-25 mEq/L.
ANALGESIA & SEDATION
SEDATIVE –HYPNOTICS
➔ SECOBARBITAL
NURSING INTERVENTION
●
DOSE : PO 100mg/1 dose
●
MOA: To decrease anxiety during the latent
phase of labor.
➔ FOR MgS04:
●
Provide continuous electronic fetal monitoring
●
●
Monitor fetal toxicity
●
Have antidote always available at bedside (Ca
●
Maintain patient in left lateral recumbent
●
Z-tract technique= use for IM injection of
MgS04 and rotate sites of injection bec.this
●
●
●
●
➔ PROMETHAZINE HYDROCHLORIDE
A
phenothiazine
antihistamine
and
Monitor BP,PR,RR. Monitor DTR, I&O
every hour.
sedation and reduce nausea & vomiting in
labor.
Monitor Temp.Breath and bowel sounds every
4 hours
●
Do not give Subcutaneously.
Check urine for protein every hour
●
DOSAGE: 25- 100mg/PO QID PRN for
anxiety
Monitor serum MgS04 level range should be
➔ HYDROXYZINE
Assess for epigastric pain, headache, visual
●
Anxiolytic antiemetic antihistamine use as
a preoperative and postoperative adjunct for
disturbances
sedation.
➔ FOR Hydralazine:
●
●
Monitor BP frequently
●
Observe for maintenance of diastolic BP
between 90 and110mm Hg as ordered.
●
ONSET: immediate (5mins.)
antiemetic often given with opiods to increase
between 4-7mEq/L
●
●
●
drug is painful & irritating
DOSE: IV initial 100mg then in increments of
25-50 mg as indicated
position
●
is a short acting barbiturates and sedative for
latent phase of labor
Gluconate@ 1gram/IV over 3 minutes
●
rapidly crosses the placenta
➔ PENTOBARBITAL
Observe for the level of consciousness and
headache
NARCOTICS AGENT
➔ FENTANYL CITRATE
●
●
Monitor I and O
●
Monitor Fetal Heart Rate
ONSET: 15-30 minutes
A synthetic opiate that is 50-100 times as
potent as MS04 that provides mild to moderate
sedation and pain relief during labor, also used
as adjunct to regional anesthesia.
●
This drug crosses the placenta and is excreted in
breast milk.
●
➔
the 1st stage is dilating stage, cervical effacement and
neonates of mothers who received this drug
cervical dilatation that occurs simultaneously. The
●
▪DOSAGE & ROUTE: IM/IV
second stage begins with complete cervical dilation and
●
50-100 mcg give IV over 1-2 mins, may repeat
ends with delivery of the newborn. During the third
stage there is placental separation and expulsion, and the
q2hrs PRN.
●
fourth stage is post partum w/c is the 4 hours after the
delivery of the placenta. Pharmacological interventions
➔
Watch out for respiratory depression in
Don’t give rapidly as it may result in muscle
rigidity
➔ BUTORPHANOL TARTRATE
maybe needed but selected only to minimize side effects
●
DOSAGE & ROUTE: IM/IV
for the patient and more importantly to the fetus.
●
1-2 mg q4h PRN
Analgesia and sedation are systemic drugs used during
●
It is a mixed opioid agonist-antagonist used for
labor
and
delivery
and
these
are as follows:
sedative-hypnotics, narcotic agonist, mixed narcotic
agonist-antagonists. The sedative tranquilizer drugs
are most commonly given for false or latent labor or with
relief of moderate to severe pain
●
Onset is 5-10 mins
●
Peak is 4-5 mins duration
➔ NALBUPHINE HYDROCHLORIDE
ruptured membranes without true labor. These drugs
●
DOSAGE & ROUTE: IV
are also given to reduce the anxiety level of the patient
●
10mg q3-6h PRN
towards upcoming true labor and delivery. These drugs
●
It is a mixed opioid agonist antagonist narcotic
will promote rest and relaxation.
●
▪Onset is 2-3 mins
PHARMACOLOGY
33
●
▪Peak:2-3 mins
●
▪Duration:3-6 hours
●
Provide a restful environment and side rails up
when patient is non ambulatory
●
NURSING INTERVENTIONS FOR PAIN-CONTROL
DRUGS
Monitor Fetal Heart Tone
NURSING HEALTH TEACHINGS FOR PAIN CONTROL
DRUGS
➔ Offer analgesia appropriate for the stage and phase of
➔ Advise the patient concerning
labor and anticipated method of delivery.
➔ Document the administration of drugs per agency
policy.
➔ Provide
appropriate
safety
measures after drug
administration.
a.
drugs ordered
b.
route of administration & reason
c.
expected effects of drug on labor
d.
potential drug effects on the mother and
➔ Check a compatibility chart for any mixing of drugs
neonate
➔ Verify that correct antidote drugs are available.
➔ Inform patients that most drugs used for pain relief in
labor and delivery are not given per-orem , because GI
NURSING INTERVENTION FOR SEDATIVE
HYPNOTICS
functions slowly during labor, thereby drug absorption
is decreased making the oral route ineffective.
➔ Counsel the patient about safety precautions to be used
➔ Do NOT give if active labor is imminent.
➔ Monitor Fetal Heart Rate and expect decrease variability
while receiving the drug like positioning in bed, use of
side rails, assistance with ambulation.
NURSING INTERVENTION FOR PHENOTHIAZINE
DERIVATIVES
➔ PROMETHAZINE
●
●
●
If administered IV give @ the onset of uterine
contractions. Administer @ a rate not to exceed
Oxytocin alongside prostaglandins are also called uterotrophic
25mg/min
drugs. Oxytocin is synthesized in the hypothalamus and is
Monitor
maternal
heart
rate
after
transported to nerve endings in the posterior pituitary gland. The
administration
hormone is released by the nerve endings and capillaries absorb the
Monitor the amount the patient receives in 24
substance and carry it into the general circulation where it
hrs
facilitates uterine smooth muscle contractions. When the
➔ HYDROXYZINE
pregnant client reaches post term above 37 weeks but with no
●
Administer deep IM only (Z-tract technique)
labor contractions, oxytocin per intravenous can be given as
●
DO NOT give via IV or Subcutaneously
ordered by the physician to stimulate uterine contractions thus
NURSING INTERVENTION FOR NARCOTIC
AGONIST AND MIXED NARCOTIC AGONISTANTAGONIST
This is not generally given before active labor. ▪
➢ ANTIDOTE: Naloxone
●
Give slowly per IV @ the beginning of a
contraction and over several minutes to
decrease the amount of drug perfused to the
fetus via the placenta.
●
Assess RR, must be greater than 12 before
administration
●
DRUGS FOR CERVICAL RIPENING
DINOPROSTONE GEL
➔ FENTANYL
●
this procedure is termed as induction of labor.
Provide a restful environment and side rails up
➔ This
is
a
naturally
occurring
form
of
PROSTAGLANDIN used to open an unfavorable
cervix
➔ At or near term in women needing labor induction.
Must be at room temperature and administered
➔ Using sterile technique.
➔ Patient must remain in the recumbent position 15-30
minutes following administration and 2 hours after
insertion of the gel.
when patient is non ambulatory
●
Monitor Fetal Heart Tone
➔ BUTORPHANOL TARTRATE
●
Have Naloxone available
●
Monitor for maternal and neonatal respiratory
depression.
●
Assess RR, must be greater than 12 before
administration
PHARMACOLOGY
34
DINOPROSTONE VAGINAL INSERTS
➔ IM : 3-10 units after the delivery of the placenta
➔ Assess cervical dilatation and effacement
OXYTOCIN
➔ At the time of insertion, after insertion, ask the patient
to remain in a lying position for 30 mins-2 hours.
➔ Monitor Fetal Heart Tone and uterine stimulation.
DRUGS THAT ENHANCES UTERINE CONTRACTION
CARBOPROST TROMETHAMINE
➔ C/I (Contraindications)
1.
Proven CPD (Cephalopelvic Disproportion)
2.
Fetal intolerance of labor
3.
Hypersensitivity
4.
Anticipated CS (cesarean section)
➔ PHARMACOKINETICS :
➔ DOSAGE: IM initially @ 0.25mg and repeat every
●
absorbed through IM.
15-30 mins as needed
➔ MAXIMUM DOSAGE: 4 doses if patient is
●
widely
distributed
in
circulation.
➔ This is a naturally occurring prostaglandin that
●
stimulates directly uterine smooth muscles.
●
secondary to uterine atony.
➔ To be given deep IM , don’t forget to aspirate prior to
Excretion: Urine
➔ PHARMACODYNAMICS:
●
injection.
Metabolism: 1-9 mins rapidly metabolized in
the liver ▪
➔ Also used as a treatment for postpartum hemorrhage
IM : onset 3-6 mins
➢ Peak: 40 mins
➔ This is CONTRAINDICATED before DELIVERY of
➢ Duration:2-3 hrs
PLACENTA.
➔ Use cautiously in patient with HYPERTENSION,
●
IV: onset within 1 min
➢ Duration:1 hr
ACUTE RENAL DISEASE, CARDIAC DISEASE,
➔ THERAPEUTIC EFFECT:
and ASTHMA.
DRUG
REACTION
FOR
CARBOPROST:
●
To induce or augment labor contractions ▪
●
To treat uterine atony
To stimulate milk letdown
MOA: Promotes uterine contraction by
1.
Diarrhea
●
2.
Nausea & Vomiting
●
3.
Fever
4.
Abdominal Pain With Cramps
increasing
➔ MOA/INDICATION: For prevention of postpartum
subinvolution,
and
intracellular
concentrations
of
Calcium in uterine myometrium.
METHYLERGOMETRINE MALEATE (Methergine)
hemorrhage,
Distribution:
extracellular fluid. Minute amounts in fetal
hypertensive
➔ ADVERSE
Absorption: not well absorbed per orem .Well
post
abortion
hemorrhage
➔ Acts on the smooth muscle of the uterus producing
sustained contractions and shortening the 3rd stage of
labor.
➔ NOT routinely given per IV bec. of an increase in BP
and cerebrovascular accidents.
➔ ROUTE & DOSAGE: IM 0.2 mg after delivery then
orally @ 0.2 mg 3-4 x daily up to 7 days postpartum.
➔ ▪SIDE EFFECTS :
●
Hypertension
●
dysrhythmias,
●
uterine hyperstimulation
●
tachysystole (6 or more uterine contractions
on 20 minutes.
➔ ADVERSE REACTIONS :
●
Seizures
●
water intoxication
●
(characterized
➔ MOA- used to induce labor during pregnancy and to
control post partum hemorrhage and to prevent uterine
atony post delivery.
Lactated Ringer’s Solution
➔ Connect as a piggyback line.
➔ TO CONTROL POSTPARTUM HEMORRHAGE
&
vomiting,
➔ NURSING INTERVENTIONS for OXYTOCIN
●
Have tocolytic drugs such as Terbutaline and
oxygen readily available
●
Monitor Maternal Pulse and BP, uterine
activity and FHR during administration
●
Monitor I&O
●
Maintain a patient in a sitting or lateral
recumbent position to promote placental
➔ DOSAGE: FOR INDUCTION OF LABOR =
incorporate 10 units(1 ampule) to IVF 1Liter of
nausea
hypertension, tachycardia, cardiac arrhythmias
PROTOTYPE DRUG: OXYTOCIN
➔ DRUG CLASS: Oxytocic agent
as
infusion.
●
Monitor for signs of uterine rupture(extreme
pain in uterus)
●
Use an IV pump to administer the drug.
and FOR POST DELIVERY CONTRACTIONS
incorporate 10-40 units in an IVF (Intravenous Fluid)
PHARMACOLOGY
35
➔ Pharmacologic measures include: use of stool softener
and laxative stimulants.
➔ SIDE EFFECTS and ADVERSE REACTIONS
●
Abdominal cramps
until 6 weeks postpartum,
●
Nausea and Vomiting
pharmacologic and nonpharmacologic measures commonly used
●
Diarrhea
during postpartum period have 5 primary purposes:
●
Rash
The
period
from
delivery
1.
To prevent uterine atony & postpartum hemorrhage,
2.
To relieve pain from uterine contractions, perineal
wounds and hemorrhoids,
3.
To enhance or suppress lactation, production and release
LAXATIVES
➔ GOAL OF CARE
●
days postpartum.
of milk by the mammary glands,
4.
To promote bowel function,
5.
To enhance immunity.
NURSING INTERVENTIONS:
➔ Docusate Sodium & Sennosides
PAIN RELIEF FOR UTERINE CONTRACTION
➔ A few days postpartum there are afterbirth pains from
uterine ischemia during contractions. Non steroidal
agents may be used to control postpartum discomforts
and pain narcotic agents are reserved for more severe
pain such as in cesarean section or extensive perineal
lacerations.
➔ CODEINE and MEPERIDINE - are systemic
analgesics that can cause decreased alertness.
1.
Store at room temperature.
2.
If in liquid prep, give it with milk or fruit juice
to mask the bitter taste.
3.
to ensure safety.
➔ MORPHINE SULFATE and CODEINE SULFATE
should be assessed for bowel function and respirations
because it can cause constipation and respiratory
depression.
➔ IBUPROFEN and KETOROLAC - are used to
control postpartum discomfort and pain.
➔ NSAIDs - non steroidal antiinflammatory drugs.
➔ These NSAIDs are effective in relieving mild to
pain
cause
by
postpartum
uterine
contractions, episiotomy, and perineal wounds
NURSING INTERVENTIONS for NSAIDs
1.
To minimize GI distress, best taken with food that has an
empty stomach.
2.
Assess for GI bleeding (dark, bloody stool, blood in
urine, coffee ground emesis).
3.
NSAIDs inhibit platelet synthesis and may prolong
bleeding time.
4.
Avoid alcohol, aspirin, corticosteroids (may increase
the risk for GI toxicity).
DRUGS THAT PROMOTES POSTPARTUM BOWEL
FUNCTIONS
➔ Constipation may be common to patient’s in the
postpartum period because peristalsis is decreased due to
the residual effect of progesterone on the smooth
muscle.
➔ Maybe more experienced by cesarean delivery.
Take with a full glass of water.
➔ BISACODYL
1.
Store tablets & suppositories below 77 degrees
& avoid excess humidity.
2.
Do not crush tablets.
3.
Do not administer w/in 1-2 hrs of milk or
antacid because enteric coating may dissolve
➔ Nurse: observe the patient as she cares for her newborn
moderate
➢For patient to have bowel movement by 2-4
resulting in abdominal cramping & vomiting.
4.
Take with a full glass of water.
➔ MINERAL OIL
1.
Do not give with or immediately after meals. ▪
2.
Give with fruit juice or a carbonated drink to
disguise the bitter taste
➔ MAGNESIUM HYDROXIDE
1.
Shake the container well.
2.
Do not give 1-2 hrs before or after oral drugs
because of the effects on absorption.
3.
Take with a full glass of water.
4.
Give 1-2 hrs after any oral antibiotics
➔ ▪SENNA
1.
Protect from light and heat.
➔ SIMETHICONE
1.
Administer after meals and at bedtime
2.
If chewable tablets are ordered, instruct the
patient to chew tablets thoroughly before
swallowing and to follow with a full glass of
water.
HEALTH TEACHINGS TO LAXATIVES
➔ Advise patients that stool softeners are given to enable
bowel movement without straining.
➔ Advise patients that measures to prevent and treat
constipation includes drinking 6-8 glasses of fluid per
day. Ingesting high fiber rich food, increasing
ambulation.
➔ Advise patients regarding temperature and storage
requirements for particular drugs.
PHARMACOLOGY
36
➔ Caution patient that prolonged, frequent, or excessive
use may result in electrolyte imbalance or dependence on
the drug
PORACTANT
➔ ROUTE & DOSAGE: 2.5 mL/kg per dose divided in 2
equal amounts administer each half amount to each
➔ Advise patients that most laxatives contain sodium.
Instruct them to check with their physician if they are on
a low sodium diet before using any laxative.
main bronchus
➔ Porcine-derived surfactant to be administered for
prophylactic and treatment of RDS in premature
NURSING
INTERVENTIONS
FOR
SYNTHETIC
SURFACTANT:
1.
patent endotracheal tube for administration and
Labor is determined to be preterm if it occurs before 37 weeks age
specified alterations in positioning the infant throughout
of gestation, tocolytic therapy is administered to delay labor and
delivery if there are no complications. But if preterm labor cannot
be halted, premature delivery of the newborn is inevitable, which
puts the newborn at risk for health problems. Premature neonates
are
at
risk
for
respiratory
distress,
hypothermia,
hypoglycemia, and hyperbilirubinemia, and they may have also
feeding difficulties. There are drugs administered on these preterm
the procedure.
2.
The concept of EINC (Essential Immediate Newborn Care)
was introduced to you during your exposure to NCM 107
concept which deals with immediate newborn care and part of
Monitor infant’s VS before, during,and after surfactant
therapy.
3.
Maintain adequate respiratory status
4.
Monitor ABGs and obtain a chest radiography study
5.
Don’t
perform
ET
suction
immediately
after
administration of surfactant unless signs of airway
neonates to help them with these major complications from being
preterm babies.
Maintain a patent airway= All surfactants require a
obstruction are present.
6.
Position and reposition the infant as needed for equal
distribution of surfactant throughout the lungs.
7.
Support and educate parents.
are drugs administered to full term healthy neonates.
DRUGS ADMINISTERED TO FULL TERM HEALTHY
NEONATES
DRUGS ADMINISTERED TO PRETERM NEONATES
ERYTHROMYCIN OPHTHALMIC OINTMENT
this WHO protocol to reduce maternal and infant mortality rate
SYNTHETIC SURFACTANT
➔ This is the common anti-infective administered to a
➔ ▪ When preterms are born they still posses an immature
lung development and breathing control, decrease airway
muscle tone and surfactant level thus the neonate may
suffer from RDS (Respiratory Distress Syndrome)
EXOGENOUS
SURFACTANT
THERAPY
FOR
manifest as eye edema and inflammation that lasts about
➔ This is use in Crede’s Prophylaxis
after delivery ,place 1cm of this drug without touching
the tip of the ointment in the newborn’s eyes.
➔ ROUTE & DOSAGE: 4mL/kg per dose divided into 4
equal amounts
Bovine-derived
surfactant
to
be
administered for prophylactic and treatment of
Drugs must be given by health care personnel
with
using
protection
against
gonococcal
and
chlamydial
PHYTONADIONE
➔ This is a synthetic Vitamin K, a fat soluble vitamin given
RDS in premature infants
experienced
➔ USES: Prevention of ophthalmic neonatorum &
conjunctivitis
➔ USES & CONSIDERATIONS:
●
➔ Side effects include chemical conjunctivitis that would
➔ DOSAGE & ROUTE :administered within 1 hour
BERACTANT
●
against eye infections.
24-48 hours.
PREVENTION & TREATMENT OF RDS
●
newborn’s eyes. It is given as a prophylactic treatment
ventilators
for
to newborns to prevent vitamin K deficiency.
➔ Administered as single dose injection.
prevention or rescue in treatment of RDS.
➔ Side Effects : pain on injection site
Administered through Fr.5 catheter inserted
➔ Allergic reactions urticarial and rash have been reported.
into an ET tube
➔ DOSAGE & ROUTE: 0.5-1 mg into vastus lateralis
CALFACTANT
➔ ROUTE & DOSAGE: 3mL/kg per dose divided in 2
equal amounts
w/in 1 hr after birth.
➔ This is an anticoagulant for prevention of hemorrhagic
disease of the newborn.
➔ It is readily absorbed by IM injection
➔ Calf-derived surfactant to be administered for
prophylactic and treatment of RDS in premature infants
PHARMACOLOGY
37
DRUG ADMINISTERED TO NEWBORNS
above. This is a naturally occurring event and part of the
normal life cycle of women.
HEPATITIS B INJECTION
➔ The menopause has three stages: perimenopause or pre
➔ DOSAGE & ROUTE : 0.5mL IM within 12 hours
after birth in the vastus lateralis of the newborn.
INTERVENTIONS
FOR
FULL
TERM
infant while preparing medications.
erythromycin
ointment
before
associated
with
available to help menopausal women cope up with these
reactions
on
the
neonate
COMBINED HORMONAL CONTRACEPTIVES
➔ Norethindrone
➔ Norethindrone acetate
administration of phytonadione and hepB vaccine.
any
symptoms
FIRST GENERATION:
➔ Wear gloves when administering medications.
➔ Monitor
carries
major hormonal changes.
Do not delay skin to skin contact between mother and
➔ Administer
life
menopause and certain pharmacological treatments are
HEALTHY NEONATES
➔
which certain physiological events occur. This event in a
woman's
➔ It protects the newborn from Hepatitis B
NURSING
menopause, menopause and postmenopause during
after
administration.
➔ Ethynodiol Diacetate
➔ These are the earliest progestin formulations to be used
in oral contraceptives
SECOND GENERATION:
➔ Norgestrel
Women are a special group of the world's population; they have
specific special health care needs throughout their reproductive
and post-reproductive life cycle. A woman's reproductive cycle
begins with menarche until menopause. In order to achieve a
healthy reproductive well being, certain medications are needed
➔ Levonorgestrel
THIRD GENERATION:
➔ Desogestrel
➔ Norgestimate
across her reproductive years until cessation of menstruation.
The new-generation progestins have a higher efficacy rating and
Menopause also brings major physiological changes associated
fewer effects on lipid and carbohydrate metabolism compared with
with this and to help women cope up with these changes , certain
f1st and 2nd generations.
drugs are available as prescribed by the physician. In this module ,
you will learn the different pharmacologic products that maybe
used throughout the reproductive and menopausal life cycle of
women.
➔ This lesson is about hormonal contraceptives available to
women during her reproductive years , all of these
contraceptives contains a synthetic version of estrogen
and a compound known as progestin. EE (Ethinyl
estradiol) is the most commonly used synthetic estrogen
found in combined hormonal contraceptives.
➔ There are some cases when women is not capable of
reproduction, and this is termed as infertility or the
inability to conceive a child after 12 months of
unprotected sexual intercourse. There are two types of
infertility, we have primary infertility if a couple has
never conceived or has never carried a pregnancy to term.
Secondary infertility describes a couple who has
conceived and brought a pregnancy to term but is unable
to conceive afterwards. After the age of 40 the chance of
achieving pregnancy for women decreases by 5%. In both
men and women as they get older, fertility rates also
decrease. However , women have a higher risk of being
infertile as their age progresses.
➔ Menopause is defined as the cessation of menstruation
in women, it normally occurs at a varying age of 35 and
➔ DRSP - Drospirenone is a fourth generation progestin
➔ It can increase K level altering water and electrolyte
imbalance.
MECHANISM OF ACTION
➔ The estrogen component of Combined Hormonal
Contraceptives inhibits ovulation by preventing
the formation of a dominant follicle. When a
dominant follicle does not mature, Estrogen remains at a
consistent level and is unable to reach the peak level
needed to stimulate LH (Leutenizing Hormone) surge.
When the LH surge is suppressed, ovulation is prevented
and pregnancy does not occur.
ROUTE OF DELIVERY :
➔ Commonly given in ORAL ROUTE in which pill is
ingested
daily
that
is
absorbed
by
the
GI
(Gastrointestinal) tract and metabolized by the liver.
➔ TRANSVAGINAL
➔ TRANSDERMAL - these are other routes of
administration
➔ ADVANTAGE: avoids GI absorption
➔ SE: nausea and vomiting
➔ Heart and circulatory risk
➔ COMBINED HORMONAL CONTRACEPTIVES
PHARMACOLOGY
38
●
Are one of the most commonly used methods
of reversible contraception in the world.
●
It has high degree of effectiveness and relatively
safe
DRUGS TO PROMOTE FERTILITY
CC ( Clomiphene Citrate )
➔
is a selective estrogen that induces ovulation , so women
ET ( Estrogen Therapy)
➔ HT used for women post hysterectomy
PROTOTYPE DRUG FOR MENOPAUSE
➔ ESTROGEN REPLACEMENT
●
and 1.25mg/d
●
can be capable of releasing mature ovum for possible
➢ Distribution: widely distributed and
➔ This is the most commonly used ovulation stimulant.
bounds to sex hormone
➔ CC is given in a 50 mg oral dose on days 5 through 9 of
➢ Metabolism: unknown
the menstrual cycle.
➢ Excretion: urine and bile
●
up to 6 cycles.
menopause and vaginal dryness
CC is readily absorbed from the GI tract.
➢ develops and maintain female genital
partially metabolized in the liver and excreted
in the feces via biliary elimination.
●
system
●
Has a half life of about 5 days
MOA - is unknown
●
Hypothesized to compete with estrogen at
SIDE EFFECTS:
➢ nausea and vomiting
➔ ▪PHARMACODYNAMICS:
●
THERAPEUTIC EFFECTS/USES:
➢ for moderate to severe symptoms of
➔ ▪PHARMACOKINETICS
●
PHARMACOKINETICS:
➢ Absorption: well absorbed PO
union of sperm cells by male counterparts.
➔ The dose can be increase to 100 mg and maybe repeated
ROUTE & DOSAGE: ▪PO at 0.3, 0.45,0.675
➢ breast tenderness
➢ leg cramps
➢ bleeding
receptor sites
➔ SIDE EFFECTS
●
Breast discomfort
●
Fatigue
●
Dizziness
●
Depression
●
Nausea
●
Increased appetite
●
Dermatitis
●
Urticaria
●
Anxiety
●
Heavier menses
●
Abdominal bloating
➔ ADVERSE REACTION
●
Bloating
●
Stomach or Pelvic Pain
●
Photophobia
●
Diplopia
●
Decreased visual acuity
DRUGS USED FOR MENOPAUSE
HT ( Hormonal Therapy)
➔ Drug of choice for menopause.
➔ It is used only for the relief of symptoms of menopause
like:
Men just like women also have some problems with their
reproductive health. Alterations in male's capacity to reproduce
can be associated with a range of developmental, endocrine,
infectious, inflammatory, malignant, and psycho emotional
processes. The drug family clearly associated with
male
reproductive process is androgen.
Androgens or male sex hormones are responsible in the control
of sexual processes, accessory sexual organs, cellular metabolism
and bone and muscle growth. Testosterone, is an anabolic steroid
that you learned in anatomy and physiology, which is the principal
sex hormone in men. Small amounts of testosterone are also being
synthesized by the ovaries in women. The normal plasma
concentration in males are 270 to 1070 ng/dL but it slowly
declines 1% per year after the age of 30. In this lesson you will
learn about pharmacological intervention intended for men's
reproductive health well being.
DRUGS RELATED TO MALE REPRODUCTIVE
DISORDERS
TESTOSTERONE (ANDROGEN)
●
Hot flashes
●
Vaginal dryness
●
Sleep disorders
EPT ( Estrogen – Progestin Therapy)
➔ HT used for women with intact uterus
➔ ▪ Controls the development and maintenance of sexual
processes, accessory sexual organs, cellular metabolism
and bone and muscle growth
➔ PHARMACOKINETICS:
●
Absorption: well absorbed in IM
●
Distribution: 98% distributed to system
PHARMACOLOGY
39
●
Metabolism: 10-100 minutes
6.
Antiulcer (Cimetidine)
●
Excretion: in urine and bile
7.
Sedatives (Alcohol, Coccaine, Cannabis)
➔ ▪ PHARMACODYNAMICS:
●
IM: Onset is unknown
●
Peak: unknown
●
Duration: 2-4 weeks
➔ Therapeutic Effects/Uses ▪
●
MOST
1.
secondary sex characteristics.
➔ MOA: Binds to androgen receptors, producing multiple
anabolic and androgenic effects.
➔ S/E: Abdominal pain, nausea, diarrhea, constipation
➔ ADVERSE REACTIONS:
●
Acne
●
Urinary urgency
●
Gynecomastia ▪
●
Red skin
●
Jaundice
●
Depression
●
Habituation
●
Allergic reaction
DRUGS USED IN OTHER MALE REPRODUCTIVE
DISORDERS
PHOSPHODIESTERASE
FOR
ERECTILE DYSFUNCTION
Develops and maintains male sex organs and
,increased salivation.
COMMON
Avanafil
●
50-200 mg (not affected by food)
●
Onset: 15-30 mins
●
Duration: 4-6 hrs
●
Use once in 24 hrs
●
SE: abdominal symptoms like diarrhea, upset
stomach, heartburn
2.
3.
Sildenafil
●
20 mg, works best on an empty stomach
●
Onset = 30-60 mins.
●
Duration = 4 hours
●
Most common
Vardenafil
●
10 mg, less effective with a high fat meal.
●
S/E: abdominal symptoms like diarrhea, upset
stomach, heartburn
●
Onset : 25-30 mins
●
Duration : 4-5 hrs
●
Use once in 24 hours
DELAYED PUBERTY
➔ Puberty is considered delayed when testicle enlargement
followed by penile growth and pubic hair development
has not begun by age 14. Delay in growth maybe a
normal part of the maturation process but the cause
could also be androgen deficiency or a deficiency of
growth hormone.
➔ 14 years and up = treatment can be done. ▪
➔ Testosterone Cypionate 50 mg / IM every month for
3-6 months or less before epiphyseal closure
➔ Vitamins are organic substances that are necessary for
normal metabolic functions and for tissue growth and
healing. The body needs only small quantity of vitamins
daily, which can be obtained through the diet.
SEXUAL DYSFUNCTION IN MALES
➔ A well-balanced diet has all of the vitamins and minerals
ED ( Erectile Dysfunction)
➔ The intake of vitamins should be increased by people
➔ is the inability to achieve or maintain an erection
satisfactory for sexual performance. It happens when not
enough blood flows to the penis during sexual
stimulation. This may be caused by psycho emotional
problems, diabetes, hypertension ▪
➔ PHOSPHODIESTERASE INHIBITORS - facilitates
erection by enhancing blood flow to the penis.
➔ The most commonly used treatment for ED.
needed for body functioning.
experiencing periods of rapid body growth; those who
are pregnant or breastfeeding; patients with debilitating
illnesses; those with malabsorptive issues, such as Crohn
disease (a type of inflammatory bowel disease (IBD); and
those with inadequate diets, which includes alcoholics
and some geriatric patients.
➔ Children who have poor nutrient intake and are
malnourished may need vitamin replacement. People on
“fad” or restrictive diets may have vitamin deficiencies, as
DRUGS THAT CAUSES SEXUAL DYSFUNCTIONS IN
may those who are unable to afford or do not select a
MALE:
wide variety of foods.
1.
Anticholinergics (ATS04)
2.
Antidepressants (Tricyclic)
3.
Antihistamines (Dipenhydramine)
4.
Antihypertensives (Angiotensin-Converting Enzymes) ▪
5.
Antipsychotics (Phenothiazines )
FAT SOLUBLE VITAMIN
The fat-soluble vitamins are A, D, E, and K. They are metabolized
slowly; can be stored in fatty tissue, liver, and muscle in significant
amounts; and are excreted in the urine at a slow rate. Vitamins A
and D are toxic if taken in excessive amounts over time.
PHARMACOLOGY
40
VITAMIN A
➔ Calcifediol is then converted to an active form, calcitriol,
➔ Vitamin A (retinol and beta-carotene) are essential for
bone growth and for maintenance of epithelial tissues,
skin, eyes, and hair. Vitamin A has antioxidant
properties. Studies show that women who take vitamin
A have a 20% decrease in breast cancer as opposed to
those who do not take vitamin A. However, excessive
doses can be toxic. During pregnancy, excessive amounts
of vitamin A (>6000 IU) might have a teratogenic effect
(i.e., it can cause birth defects) on the fetus
hormone, and along with parathyroid hormone (PTH)
and calcitonin, it regulates calcium and phosphorus
metabolism.
➔ Calcitriol and PTH stimulate bone reabsorption of
calcium and phosphorus.
➔ Excretion of vitamin D is primarily in bile; only a small
are low, more vitamin D is activated; when serum
➔ Vitamin A is absorbed in the gastrointestinal (GI) tract,
and 90% is stored in the liver; however, this function can
be inhibited with liver disease. Massive doses of vitamin
A can cause hypervitaminosis. Signs and symptoms
include hair loss, peeling skin, anorexia, abdominal pain,
lethargy, nausea, and vomiting. The upper limit (UL) for
vitamin A is 3000 mcg/daily = 10,000 IU). Vitamin A
toxicity affects multiple organs, especially the liver.
oil,
cholestyramine,
alcohol,
and
antihyperlipidemic drugs decrease the absorption of
vitamin A. Vitamin A is excreted through the kidneys
and feces
calcium levels are normal, activation of vitamin D is
decreased.
➔ The normal adult recommended dietary allowance
(RDA) of vitamin D is 1000 mg daily (600 IU/day).
Excess vitamin D ingestion (>4000 IU/day) results in
hypervitaminosis D and may cause hypercalcemia (an
elevated serum calcium level). Anorexia, nausea, and
vomiting are early symptoms of vitamin D toxicity.
VITAMIN E
➔ Vitamin E has antioxidant properties that protect
cellular components from being oxidized and protect red
blood cells (RBCs) from hemolysis. Vitamin E depends
on bile salts, pancreatic secretion, and fat for its
Pharmacodynamics
➔ Vitamin A is necessary for many biochemical processes.
It aids in the formation of the visual pigment needed for
night vision. This vitamin is needed in bone growth and
development, and it promotes the integrity of the
mucosal and epithelial tissues. An early sign of vitamin A
deficiency (hypovitaminosis A) is night blindness. This
may progress to dryness and ulceration of the cornea and
cause blindness. Vitamin A taken orally is readily
absorbed from the GI tract and peaks in 3 to 5 hours. Its
duration of action is unknown. Because vitamin A is
stored in the liver, the vitamin may be available to the
body for days, weeks, or months.
absorption.
➔ Vitamin E is stored in all tissues, especially the liver,
muscle, and fatty tissue. About 75% of vitamin E is
excreted in bile.
➔ The RDA of vitamin E in adults is 30 IU daily and
should not exceed the upper limit (UL) of 1000 mg/day
in oral intake.
➔ The dosage is determined by nutritional intake or degree
of deficiency by the health care provider. Side effects of
large doses of vitamin E may include fatigue, weakness,
nausea, GI upset, headache, bleeding, and breast
tenderness.
➔ Vitamin E may prolong the prothrombin time (PT), and
patients taking warfarin should have their PT monitored
VITAMIN D
closely. Iron and vitamin E should not be taken together
➔ Vitamin D has a major role in regulating calcium and
phosphorus metabolism, and it is needed for calcium
absorption from the intestines.
➔ Dietary vitamin D is absorbed in the small intestine and
requires bile salts for absorption. There are two
compounds of vitamin D: vitamin D2, ergocalciferol, a
synthetic fortified vitamin D, and vitamin D3,
cholecalciferol, a natural form of vitamin D influenced
by ultraviolet sunlight on the skin.
➔ Over-the-counter (OTC) vitamin D supplements usually
contain vitamin D3. Once absorbed, vitamin D is
converted
taken with calcium can reduce the incidence of fractures.
➔ Calcitriol, the active form of vitamin D, functions as a
amount is excreted in the urine. If serum calcium levels
Pharmacokinetics
Mineral
in the kidneys. Studies have suggested that vitamin D
to
calcifediol
(also
25-hydroxycholecalciferol) in the liver.
known
as
because iron can interfere with the body’s absorption
and use of vitamin E.
VITAMIN K
➔ Vitamin K occurs in three forms. Vitamin K1
(phytonadione) is the most active form and is a synthetic
type of vitamin K made by plants, and it represents the
bulk of dietary vitamin K. Vitamin
➔ K2 (menaquinone) is synthesized by probiotic bacteria
in the digestive tract. Vitamin K3 (menadione) is another
synthetic form of vitamin K.
➔ After vitamin K is absorbed, it is stored primarily in the
liver and in other tissues. Half of vitamin K comes from
the intestinal flora, and the remaining portion comes
from the diet.
PHARMACOLOGY
41
➔ The RDA for an adult male is 120 mcg/day, and for an
adult female the RDA is 90 mcg/day.
damage. IV administration of thiamine is recommended
for
➔ Vitamin K is needed for synthesis of prothrombin and
clotting factors VII, IX, and X. For oral anticoagulant
treatment
of
Wernicke-Korsakoff
syndrome.
Thiamine must be given before giving any glucose to
avoid aggravation of symptoms.
overdose, vitamin K1 (phytonadione) is the only vitamin
➔ Riboflavin may be given to manage dermatologic
K form available for therapeutic use and is most effective
problems such as scaly dermatitis, cracked corners of the
in preventing hemorrhage.
mouth, and inflammation of the skin and tongue. To
➔ Vitamin K is used for two purposes:
treat migraine headache, riboflavin is given in larger
●
as an antidote for oral anticoagulant overdose
●
to prevent and treat the hypoprothrombinemia
of vitamin K deficiency.
doses than for dermatologic concerns.
➔ Niacin is given to alleviate pellagra and hyperlipidemia,
for which large doses are required. However, large doses
➔ Spontaneous hemorrhage may occur with vitamin K
may cause GI irritation and vasodilation, resulting in a
deficiency due to lack of bile salts and malabsorption
flushing sensation. Pyridoxine is administered to correct
syndromes that interfere with vitamin K uptake (e.g.,
vitamin B6 deficiency. It may also help alleviate the
celiac disease).
symptoms of neuritis caused by isoniazid (INH) therapy
➔ Newborns are vitamin K deficient, thus a single dose of
for tuberculosis. Vitamin B6 is essential as a building
phytonadione is recommended immediately after
block of nucleic acids, in RBC formation, and in
delivery.
synthesis of hemoglobin.
➔ This practice is common in the United States but is
➔ Pyridoxine is used to treat vitamin B6 deficiency caused
controversial in other countries because it can elevate the
by lack of adequate diet, inborn errors of metabolism, or
bilirubin level and can cause hyperbilirubinemia with a
drug-induced
risk of kernicterus. Oral and parenteral forms of
penicillamine, or cyclosporine (or hydralazine) therapy.
phytonadione
It is also used to treat neonates with seizures refractive to
are
available;
intravenous
(IV)
administration is dangerous and may cause death
deficiencies
secondary
to
INH,
traditional therapy. Vitamin B6 deficiencies may occur in
alcoholics along with deficiencies of other B-complex
WATER SOLUBLE VITAMINS
vitamins. Patients with diabetes or alcoholism may
➔ Water-soluble vitamins are the B-complex vitamins and
benefit from daily supplementation. Pyridoxine is readily
vitamin C. This group of vitamins is not usually toxic
absorbed in the jejunum and is stored in the liver,
unless
muscle, and brain. It is metabolized in the liver and
taken
in
extremely
excessive
amounts.
Water-soluble vitamins are not stored by the body, so
consistent,
steady
supplementation
is
required.
Water-soluble vitamins are readily excreted in the urine.
Protein binding of water-soluble vitamins is minimal.
Foods that are high in vitamin B are grains, cereals,
breads, and meats. There are reports that B vitamins may
excreted in the urine.
FOLIC ACID
➔ Folic acid, a form of B Vitamin is absorbed from the
small
intestine,
and
the active form of folic
acid—folate—is circulated to all tissues.
promote a sense of well-being and increased energy as
➔ One third of folate is stored in the liver, and the rest is
well as decreased anger, tension, and irritability. Citrus
stored in tissues. It is excreted 80% in bile and 20% in
fruits and green vegetables are high in vitamin C. If the
fruits and vegetables are cut or cooked, a large amount of
vitamin C is lost.
VITAMIN B COMPLEX
urine.
➔ Folic acid is essential for body growth. It is needed for
DNA synthesis, and without folic acid, cellular division
is disrupted.
➔ Chronic
alcoholism,
poor
nutritional
intake,
Vitamin B1 (thiamine), vitamin B2 (riboflavin), vitamin B3
malabsorption syndromes, pregnancy, and drugs that
(nicotinic acid, or niacin), and vitamin B6 (pyridoxine) are
cause inadequate absorption (phenytoin, barbiturates) or
vitamins in the vitamin B–complex group that are water soluble.
folic acid antagonism (methotrexate, triamterene,
This is a common group of vitamins administered in the clinical
setting, especially to patients with alcoholism.
➔ Thiamine deficiency can lead to the polyneuritis and
cardiac pathology seen in beriberi or to Wernicke
encephalopathy that progresses to Korsakoff syndrome,
conditions most commonly associated with alcohol
abuse. Wernicke-Korsakoff syndrome is a significant
central nervous system (CNS) disorder characterized by
confusion, nystagmus, diplopia, ataxia, and loss of recent
memory. If not treated, it can cause irreversible brain
trimethoprim) are causes of folic acid deficiencies.
➔ Symptoms of folic acid deficiencies include anorexia,
nausea, stomatitis, diarrhea, fatigue, alopecia, and blood
dyscrasias
(megaloblastic
anemia,
leukopenia,
thrombocytopenia).
➔ These symptoms are usually not noted until 2 to 4
months after folic acid storage is depleted. Folic acid
deficiency during the first trimester of pregnancy can
affect the development of the CNS of the fetus.
➔ This may cause neural tube defects (NTDs) such as
spina bifida, defective closure of the bony structure of
PHARMACOLOGY
42
the spinal cord, or anencephaly, lack of brain mass
memory loss, mood changes, dementia, psychosis,
formation.
megaloblastic anemia with macrocytes (over enlarged
➔ The U.S. Public Health Services recommends that all
erythrocytes [RBCs]) in the blood, and megaloblasts
women who may become pregnant consume 400 mcg of
(over enlarged erythroblasts) in the bone marrow. To
supplemental folic acid each day in addition to the folate
correct vitamin B12 deficiency, cyanocobalamin in
they get with food.
crystalline form can be given intramuscularly for severe
➔ Synthetic folate is more stable than folic acid obtained
deficits. It cannot be given intravenously because of
from food: bioavailability is greater than 85% with
possible hypersensitive reactions. Cyanocobalamin can
synthetic folate and less than 59% for food-sourced folic
be given orally and is commonly found in multivitamin
acid. Some evidence suggests that 400 to 500 mcg (0.4 to
preparations. It can also be given as a subcutaneous
0.5 mg) of folic acid per day can decrease the incidence
injection.
of coronary artery disease (CAD).
➔
It is thought that folic acid decreases the amino acid
homocysteine in the blood, which may contribute to
heart disease.
➔ Excessive doses of folic acid may mask signs of vitamin
B12 deficiency, which is a risk in older adults.
➔ Patients taking phenytoin to control seizures should be
cautious about taking folic acid.
➔ This vitamin can lower the serum phenytoin level, which
could increase the risk of seizures; the phenytoin dose
would need to be adjusted in such patients.
➔ This is a complex interaction that is not fully
understood, but it is thought that 1 mg or less per day of
folic acid is safe in patients with controlled epilepsy.
VITAMIN B12
➔ Vitamin B12, like folic acid, is essential for DNA
synthesis. Vitamin B12 aids in the conversion of folic
acid to its active form. With active folic acid, vitamin
B12 promotes cellular division. It is also needed for
normal hematopoiesis (development of RBCs in bone
marrow) and to maintain nervous system integrity,
especially of the myelin. The gastric parietal cells produce
an intrinsic factor that is necessary for the absorption of
vitamin B12 through the intestinal wall. Without the
intrinsic factor, little or no vitamin B12 is absorbed.
After absorption, vitamin B12 binds to the protein
transcobalamin II and is transferred to the tissues. Most
vitamin B12 is stored in the liver and is slowly excreted,
and it can take 2 to 3 years for stored vitamin B12 to be
depleted and for a deficit to be noticed.
➔ Vitamin B12 deficiency is uncommon unless there is a
disturbance of the intrinsic factor and intestinal
absorption. Pernicious anemia (lack of the intrinsic
factor) is the major cause of vitamin B12 deficiency, but
deficiency can also develop in strict vegetarians who do
not consume meat, fish, or dairy products. Other
possible causes of vitamin B12 deficiency include
malabsorption syndromes (cancer, celiac disease, and
certain drugs), gastrectomy, Crohn disease, and liver and
kidney diseases. Vitamin B12 deficiency is commonly
seen with the use of metformin and proton pump
inhibitors (e.g., omeprazole). Symptoms may include
numbness and tingling in the lower extremities,
VITAMIN C
➔ Vitamin C (ascorbic acid) is absorbed from the small
intestine. Vitamin C aids in the absorption of iron and
in the conversion of folic acid. Vitamin C is not stored in
the body and is excreted readily in the urine. A high
serum vitamin C level that results from excessive dosing
of vitamin C is excreted by the kidneys unchanged.
Vitamin C is used in the treatment of scurvy, which is
rare in developed countries but seen in individuals who
consume few fruits and vegetables. Also, scurvy is seen in
people who are on restricted diets or who abuse alcohol
or drugs. The recommended daily allowance of vitamin
C (adult dose) is 75 mg/day for women and 90 mg/day
for men to prevent deficiency.
Pharmacokinetics
➔ Vitamin C is absorbed readily through the GI tract and
is distributed throughout the body fluids. The kidneys
completely excrete vitamin C mostly unchanged.
Pharmacodynamics
➔ Vitamin C is needed for carbohydrate metabolism and
protein and lipid synthesis. Collagen synthesis also
requires vitamin C because it is part of the intercellular
matrix that binds cells together and aids in wound
healing. Smoking decreases serum vitamin C levels.
Vitamin C in doses greater than 500 mg aids iron
absorption; however, it can decrease the effect of oral
anticoagulants.
➔ The use of large doses of vitamin C is questionable.
Large doses of any vitamin can cause toxicity. Most
authorities believe that vitamin C does not prevent the
common
cold,
cure advanced cancer, or treat
schizophrenia. Moreover, large doses of vitamin C can
cause nausea, abdominal cramps, and diarrhea. If taken
with aspirin or sulfonamides, it may cause crystal
formation in the urine. Vitamin C directly irritates the
intestinal mucosa in the GI tract. Large doses of vitamin
C can decrease the effect of oral anticoagulants. If large
doses of any vitamin are to be discontinued, a gradual
reduction of the dosage is necessary to avoid vitamin
deficiency.
weakness, fatigue, anorexia, loss of taste, diarrhea,
PHARMACOLOGY
43
➔ Copper is needed for the formation of RBCs and
connective tissues. Copper is a cofactor of many
enzymes, and its function is in the production of the
IRON
neuro-transmitters
➔ Iron (ferrous sulfate, gluconate, or fumarate) is vital for
hemoglobin regeneration. Sixty percent of the iron in
the body is found in hemoglobin, and one of the causes
of anemia is iron deficiency. A normal diet contains 5 to
20 mg of iron per day. Foods rich in iron include liver,
norepinephrine
and dopamine.
Excess serum copper levels may be associated with
Wilson disease, an inborn error of metabolism that
allows for large amounts of copper to accumulate in the
liver, kidneys, brain, and cornea (brown or green
Kayser-Fleischer rings).
lean meats, egg yolks, dried beans, green vegetables like
spinach, and fruit. Food and antacids slow the
absorption of iron, and vitamin C increases iron
absorption.
➔ During pregnancy, iron requirements increase due to the
expansion of maternal blood volume and production of
RBCs by the fetus. The iron needs of pregnant women
are too great to be met through their diet, therefore
supplementation is needed. About 27 mg/day are
recommended during pregnancy and for 2 to 3 months
after delivery.
➔ The dose of iron for infants up to 12 months old is 11
mg/day, and for children from 1 to 8 years of age, it is 7
to 10 mg/day. Males from 9 to 50 years of age require 8
to 11 mg/day. Females 9 to 13 years of age require 8
mg/day; 14 to 18 years of age, 15 mg/day; 19 to 50 years
of age, 18 g/day; and women over 50 years of age require
8 mg/day.
Pharmacokinetics
➔ Iron is absorbed by the intestines and enters the plasma
as heme, or it may be stored as ferritin. Although food
decreases absorption by 25% to 50%, it may be necessary
to take iron preparations with food to avoid GI
discomfort. Vitamin C at doses greater than 500 mg may
slightly increase iron absorption, whereas tetracycline,
quinolone antibiotics (ciprofloxacin, levofloxacin, etc.),
and antacids can decrease absorption.
Pharmacodynamics
➔ Iron replacement is given primarily to correct or control
iron-deficiency anemia, which is diagnosed by a
laboratory blood smear. Positive findings for this anemia
are microcytic (small), hypochromic (pale) erythrocytes
(RBCs). Clinical signs and symptoms include fatigue,
weakness, shortness of breath, pallor, and, in cases of
severe anemia, increased GI bleeding. The dosage of
ferrous sulfate for prophylactic use is 300 to 324 mg/day.
➔ The onset of action for iron therapy takes days, and its
peak action does not occur for days or weeks; therefore,
the patient’s symptoms are slow to improve. Increased
hemoglobin and hematocrit levels occur within 3 to 7
days.
COPPER
PHARMACOLOGY
44
➔ Monitor serum blood levels of any suspected vitamin or
mineral deficiency.
➔ Advise patients to take the prescribed amount of
vitamins.
➔ Counsel patients to read vitamin labels carefully and
discuss with a health care provider prior to taking any
vitamin or supplement.
➔ Advise patients to consult with a health care provider or
pharmacist regarding interactions with prescription and
over-the-counter medications.
➔ Discourage patients from taking a large dose of vitamins
over a long period unless prescribed for a specific
purpose by a health care provider. To discontinue
long-term use of high-dose vitamin therapy, a gradual
decrease in vitamin intake is advised to avoid vitamin
deficiency.
➔ Inform patients that missing vitamins for 1 or 2 days is
not a cause for concern because deficiencies do not occur
VITAMINS
Assessment
➔ Check the patient for vitamin deficiency before the start
of therapy and regularly thereafter.
➔ Explore such areas as inadequate nutrient intake,
debilitating disease, and gastrointestinal (GI) disorders.
➔ Obtain a 24- and 48-hour diet history analysis.
➔ When possible, obtain levels to assess serum blood levels
Nursing Diagnoses
➔ Nutrition, Imbalanced related to inadequate intake of
food sources of vitamins
for some time.
➔ Advise patients to check expiration dates on vitamin
containers before purchasing them.
➔ Potency of vitamins is reduced after the expiration date.
➔ Counsel patients to avoid taking mineral oil with
vitamin A on a regular basis because it
➔ interferes with absorption of the vitamin; mineral oil
also interferes with vitamin K absorption.
➔ If needed, take mineral oil at bedtime.
➔ Explain to patients that there is no scientific evidence
that large doses of vitamin C will cure a cold.
➔ Alert patients not to take large doses of vitamin C with
aspirin or sulfonamides because crystals
may
form in the kidneys and urine.
➔ Knowledge, Deficient related to food sources of vitamins
➔ Alert patients to avoid excessive intake of alcoholic
➔ Decision Making, Readiness for Enhanced related to
beverages. Alcohol can cause vitamin B–complex
food choices and vitamin supplementation
Planning
➔ The patient will eat a well-balanced diet.
➔ The patient with vitamin deficiency will take vitamin
supplements as prescribed.
➔ The patient will demonstrate knowledge of vitamins
contained in food sources.
Nursing Interventions
➔ Administer vitamins with food to promote absorption.
➔ Store vitamins in light-resistant containers.
➔ Use the supplied calibrated dropper for accurate dosing
when administering vitamins in drop
➔ form. Solutions may be administered mixed with food or
drink.
➔ Administer vitamins intramuscularly for patients who
are unable to take vitamins by the oral
➔ route (e.g., those with GI malabsorption syndrome).
➔ Recognize the need for vitamin E supplements for
infants receiving vitamin A to avoid the risk of hemolytic
anemia.
deficiencies.
➔ Advise patients to eat a well-balanced diet. Vitamin
supplements are not necessary if the person is healthy
and receives proper nutrition on a regular basis.
➔ Educate patients about foods rich in vitamin A,
including milk, butter, eggs, and leafy green and yellow
vegetables.
➔ Advise patients that nausea, vomiting, headache, loss of
hair, and cracked lips (symptoms of hypervitaminosis A)
should be reported to the health care provider. Early
symptoms of hypervitaminosis D are anorexia, nausea,
and vomiting.
Cultural Considerations
➔ Food and food choices have strong cultural roots.
Determine the patient’s preferred and culturally
meaningful foods, and incorporate them into the food
and supplement plan.
➔ Use interpreters as appropriate.
➔ Glucose-6-phosphate
dehydrogenase
(G-6-PD)
deficiency is common among people of Arabic and
Chinese heritage.
PHARMACOLOGY
45
Evaluation
➔ Evaluate the patient’s understanding of the purpose of
Osmotic Pressure
➔ is the force required to prevent the movement of water
vitamins and their correct use.
➔ Evaluate the effectiveness of the patient’s diet for
inclusion of appropriate amounts and types of food.
Have the patient periodically keep a diet chart for a full
week to determine typical nutrition.
by osmosis across a selectively permeable membrane.
Hydrostatic Pressure
➔ It is the pressure exerted against the wall of the blood
vessel by the blood inside it.
➔ Determine whether the patient with malnutrition is
receiving appropriate vitamin therapy.
➔ Approximately 60% of a typical adult weight consist of
fluids (water and electrolytes).
All routes of fluid intake and loss must be considered when
assessing fluid balance. General guidelines can be used as the basis
for establishing fluid needs.
➔ The recommended water intake for a healthy adult is
about 2300 to 2900 mL per day; oral intake accounts for
1200 to 1500 mL, solid foods about 800 to 1100 mL,
and oxidative metabolism about 300 mL daily.
➔ Patients lose water daily through various routes: kidneys,
skin, lungs, and GI tract.
➔ The kidneys, the major organ regulating fluid loss,
produce 1200 to 1500 mL of urine daily.
➔ Insensible water loss is continuous and occurs daily
through the skin and lungs without awareness and is not
measurable.
➔ Sensible water loss occurs through the lungs/respiration
(500 mL/day) and perspiration/skin (500 to 600
mL/day) and through the GI tract/feces (200 mL/day)
and is measurable.
➔ The minimum urinary output for an adult is 0.5 to 1
mL/kg/h or 35 to 70 mL/h for a 70-kg patient.
➔ Daily water requirements differ according to the
patient’s age and medical problems.
➔ Intravenous fluids (IVFs) are ordered based on an
evaluation of the patient’s fluid and electrolyte balance,
fluid requirements, and fluid needs.
IMPORTANT TERMINOLOGIES
WATER DISTRIBUTION IN THE BODY
Osmosis
➔ is the movement of water (a solvent) across a selectively
permeable membrane, such as the plasma membrane.
Diffusion
➔ is the movement of a solute from an area of higher
concentration to an area of lower concentration within a
solvent. At equilibrium, there is a uniform distribution
of molecules.
Osmolality
➔ It is the concentration of solutes in 1 liter of solution
Three compartments:
1.
Intracellular (inside the cell)
2.
Intravascular (arteries, veins, capillaries)
3.
Interstitial (spaces between the cells, outside of the
vascular compartment)
EXTRACELLULAR: Intravascular and Interstitial.
●
Contains about 1/3 of total body water.
INTRACELLULAR:
●
Contains about 2/3 of total body water
PHARMACOLOGY
46
Body fluids are located in two fluid compartments:
1.
Body fat (obese people have less fluid than thin people
because fat cells contain little water).
The intracellular space (fluid in the cells)- located
●
2.
3.
primarily in the skeletal muscle mass.
Percentages of Body Water
The extracellular space (fluid outside the cells).
A. Intravascular space (15%)- fluid inside the
blood vessel containing plasma; about 3L.
B. Interstitial space (5%)- contains the fluid that
surrounds the cell; about 11 to 12 L. E.g.:
Lymph
C. Transcellular
Cerebrospinal,
intraocular,
space
(1-2%)
pericardial,
E.g.:
synovial,
and pleural fluids; digestive
enzymes
➔ Body fluid normally shifts between the two major
compartments in an effort to maintain an equilibrium
between the spaces.
➔ Third-space fluid shift refers to loss of fluid into a
space that does not contribute to equilibrium between
the ICF or ECF.
➔ An early clue of a third-space fluid shift is a decrease in
urine output despite adequate fluid intake (occurs in
ascites, peritonitis, bowel obstruction, and massive
bleeding into a joint of body cavity).
ELECTROLYTES
➔ Active chemicals (cations which carry positive charge,
and anions which carry negative charge)
WATER & ELECTROLYTES
➔ Under normal healthy conditions, the body loses water
and electrolytes daily through urine, perspiration, feces.
➔ Fluids are replenished by absorption of water in the GI
tract from the liquids and foods that are consumed.
➔ In many disease states (e.g., vomiting, diarrhea, GI
suctioning, hemorrhage, drainage from a wound, nausea,
anorexia, fever, excess loss from a disease e.g.,
uncontrolled DM)
Routes of Gains and Losses
➔ Gain
➔ Sodium has the greatest concentration in the ECF, and
it regulates the volume of body fluid.
➔ Retention of sodium is associated with fluid retention,
and excessive loss of sodium is usually associated with
decreased volume of body fluid.
➔ ECF has a low concentration of potassium and can
tolerate only small changes in its concentration.
Therefore release of large stores of intracellular
potassium typically caused by trauma to the cells and
tissues, can be extremely dangerous
Factor that influence body fluids:
1.
Age (younger people have a higher percentage of body
fluids than older people).
2.
Gender (men have approximately more body fluid than
female).
●
Dietary intake of fluid, food or enteral feeding
●
Parenteral fluids
➔ Loss
●
Kidney: urine output
●
Skin loss: sensible, insensible losses
●
Lungs
●
GI tract
●
Other
INTRAVENOUS ADMINISTRATION
➔ Refers to the introduction of fluids directly into the
venous bloodstream.
➔ Large volumes of fluids can be rapidly administered into
the vein and there is usually less irritation.
➔ The most rapid of all parenteral routes because it
bypasses all barriers to drug absorption.
➔ Drugs may be given direct injection with a needle in the
vein.
PHARMACOLOGY
47
➔ More commonly administered intermittently or by
PARENTERAL NUTRITION
continuous infusion through an established peripheral
or central I.V line
Peripheral line
INTRAVENOUS SOLUTIONS
➔ Consist of water (the solvent) containing one or more
types of dissolved particles (solutes).
➔ Most commonly dissolved solutes in IV solutions are:
sodium chloride, dextrose, and potassium chloride.
➔ The solutes that dissolve in water and dissociate into ion
Central line
particles are called Electrolytes. These ions give water
the ability to conduct electricity.
➔ The solutes: Na+, and Cl- , K+, and ClOSMOSIS
➔ Fluid shifts through the membrane from the region of
low solute concentration to the region of high solute
concentration until the solutions are of equal
concentration
IV SITE SELECTION
DIFFUSION
➔ The natural tendency of a substance to move from an
area of higher concentration to one of lower
concentration.
➔ E.g.: Exchange of oxygen and carbon dioxide between
the pulmonary capillaries and alveoli; movement of
sodium from the ECF to the ICF.
PHARMACOLOGY
48
Used as Replacement fluids for:
➔ conditions of cellular dehydration
Precaution
➔ Administering them too rapidly might cause a shift of
fluids being drawn from the intravascular space to the
other compartments
If there is no available stock
➔ How to prepare 0.45 sodium chloride?
➔ How to prepare 0.2 sodium chloride?
Isotonic solution
HYPERTONIC SOLUTION
➔ If I.V solution and the blood have approximately the
same osmolality.
Hypotonic solution
➔ Solutions that have fewer dissolved particles than the
blood.
Hypertonic solution
➔ Solutions that have higher dissolved particles than the
blood.
➔ Normal blood serum osmolality = 295 to 310
milliosmoles/L (mOsm/L)
➔ Parenteral nutrition solutions
➔ D5 % 0.45 sodium chloride
➔ D5 % 0.9 sodium chloride
➔ (Na Cl)
➔ Dextrose 50% (D50)
To meet the caloric requirements (must be administered into
central veins so that they can be diluted by rapid blood flow).
Precautions:
➔ Have the potential to pull fluid from the intracellular
and interstitial compartments → cellular DHN and
vascular volume overload.
OSMOLALITY
➔ Causing phlebitis and spasm with infiltration and
➔ It is the concentration of solutes in 1 liter of solution.
(Clayton)
➔ The solute or particle concentration of a fluid (Fauci)
extravasation in peripheral veins. Generally > than
approximately 600 to 700 mOsm/L should NOT be
administered in peripheral veins
Normal blood serum osmolality
➔ 295 to 310 milliosmoles/L (Clayton).
➔ 275–290 mOsmol/kg (Fauci)
ISOTONIC SOLUTION
➔ 0.9 % sodium chloride (Na Cl)
●
(Osmolality of 308 mOsm/L)
➔ Lactated Ringer’s (LR)
●
D5%0.2 Na Cl (initial)
Used as Replacement fluids for:
➔ The patient with intravascular fluid deficit (e.g., acute
blood loss from hemorrhage, GI bleeding, or from an
accident)
➔ hypovolemic, hypotensive patients to increase vascular
volume to support blood pressure
Management:
➔ Fluid overload (potentially pulmonary edema), especially
if the patient has CHF
HYPOTONIC SOLUTION
IV SOLUTION: CRYSTALLOIDS
➔ include dextrose, saline, lactated Ringer's solution
➔ used for replacement and maintenance fluid therapy
IV SOLUTION: COLLOIDS
➔ volume expanders
➔ 0.2 % or 0.45 % sodium Chloride (Na Cl)
PHARMACOLOGY
49
DEXTRAN
E. Platelets (PLTS), Platelet Concentrate (PC) or
Random Donor Platelet Concentrate (RD-PC)
➔ not a substitute for whole blood because it does not have
●
any products that carry oxygen
established bleeding in thrombocytopenic
patients.
HETASTARCH
➔ Nonantigenic volume expander
➔ can decrease platelet & hematocrit count
●
Prepared from a single unit of whole blood.
●
Due to storage at RT it is the most likely
component to be contaminated with bacteria.
PLASMANATE
●
Therapeutic dose for adults is 6 to 10 units.
●
Some patients become "refractory" to platelet
➔ commercially prepared, used instead of plasma or
therapy.
albumin to replace body protein
●
A. Packed RBCs – contain whole blood without plasma
●
Expiration is 5 days as a single unit, 4 hours if
pooled.
IV SOLUTION: BLOOD PRODUCTS
●
Used to prevent spontaneous bleeding or stop
●
Store at 20-24 C (RT) with constant agitation.
●
D negative patients should be transfused with
Used to treat symptomatic anemia and routine
D negative platelets due to the presence of a
blood loss during surgery
small number of RBCs
Hematocrit is approximately 80% for nonadditive (CPD), 60% for additive (ADSOL).
●
Allow WB to sediment or centrifuge WB,
remove supernatant plasma.
●
Advantages:
➢ ess chance of circulatory overload
➢ -less risk of reaction to plasma antigen
➢ -possible
decrease
in
risk
in
transmitting serum hepatitis
B. Whole blood
●
used in acute blood loss
●
not used in anemia unless severe
IV SOLUTION: LIPIDS
C. Lipids
●
F.
●
One bag from ONE donor
●
Need 6-10 for therapeutic dose
Pooling Platelets
●
6-10 units transferred into one bag
●
Expiration = 4 hours
used to balance nutritional needs
D. Washed Red Blood Cells (W-RBCs)
●
Washing removes plasma proteins, platelets,
WBCs and micro aggregates which may cause
febrile or urticarial reactions.
●
Patient requiring this product is the IgA
deficient patient with anti-IgA antibodies.
●
Prepared by using a machine which washes the
cells 3 times with saline to remove and WBCs
●
Two types of labels
➢ Washed RBCs - do not need to QC
for WBCs.
➢ Leukocyte Poor WRBCs, QC must
be done to guarantee removal of 85%
of WBCs. No longer considered
effective method for leukoreduction
●
Expires 24 hours after unit is entered
FRESH FROZEN PLASMA
➔ Used to replace labile and non-labile coagulation factors
in massively bleeding patients OR treat bleeding
associated with clotting factor deficiencies when factor
concentrate is not available.
➔ Must be frozen within 8 hours of collection.
➔ Expiration
●
frozen - 1 year stored at <-18 C.
●
frozen - 7 years stored at <-65
●
C.thawed - 24 hours
●
Fresh Frozen Plasma – Volume 200-250cc
CRYOPRECIPITATE (CRYO), FACTOR VII OR
ANTI-HEMOPHILIC FACTOR (AHF)
➔ Storage Temperature
PHARMACOLOGY
50
●
Frozen -18 C or lower
➔ Check IV site for infiltration.
●
Thawed - room temperature
➔ Prepare and administer Kayexalate.
➔ Expiration:
➔ Instruct clients taking potassium-wasting diuretics or
●
Frozen 1 year
cortisone preparation to eat potassium rich -foods
●
Thawed 6 hours
(banana, citrus fruits, vegetables, nuts)
●
Pooled 4 hours
➔ Best to be ABO compatible but not important due to
small volume
➔ Cryoprecipitate – volume 15 ccs
NURSING INTERVENTIONS
➔ Monitor vital signs and report abnormal findings
➔ Monitor urine output
➔ Monitor weight daily
➔ Check for signs and symptoms of fluid volume deficit
(dehydration: thirst, dry mucous membrane, poor skin
turgor)
➔ Sodium (135- 145 mEq/L)
➔ Major cation in the ECF
➔ Hyponatremia
➔ Hypernatremia
FUNCTIONS
➔ Major electrolyte that regulates body fluids
➔ Promotes transmission and conduction of nerves
➔ Check for manifestations of fluid excess: cough, moist
rales
➔ Monitor laboratory results
➔ Monitor type of fluid given
➔ Monitor IV injection site
➔ Calcium (4.5-5.5 mEq/L)
➔ Hypocalcemia
➔ Hypercalcemia
FUNCTIONS
➔ Promote normal nerve and muscle activity
FUNCTIONS
➔ Potassium (3.5-5.3 mEq/L)
➔ Necessary for transmission- conduction of nerve
Impulses & for the contraction of skeletal, cardiac &
smooth muscles
➔ Promotes glycogen storage in the liver
➔ increase cardiac contraction
➔ Maintains normal permeability and promotes blood
clotting (converts Prothrombin to Thrombin)
➔ Needed for formation of bone and teeth
NURSING INTERVENTIONS
➔ Helps regulate osmolality of cellular fluids
➔ Monitor VS: Monitor pulse rate if client is taking
DRUGS USED TO CORRECT HYPERKALEMIA
Digoxin. Bradycardia is a sign of Digitalis toxicity
➔ IV Sodium Bicarbonate
●
increases serum pH
➔ 10% Calcium gluconate
●
decreases irritability of myocardium
➔ Insulin and glucose
●
moves potassium back into the cells
➔ Sodium polystyrene
●
sulfonate (kayexaIate) - cation exchanger
➔ Administer IV fluid with Calcium slowly. Diluent: D5W
and Saline solution.
➔ Check IV for infiltration. Calcium may cause necrosis
➔ Monitor ECG.
➔ Instruct client to avoid overuse of antacids/ laxatives.
➔ Take oral calcium with meals or after meals to increase
absorption.
➔ Suggest that the client consume foods high in calcium
(milk and milk products).
Potassium Chloride- 40 meq/20 ml or 2meq/ml
Sodium Bicarbonate- 50 meq/50 ml or 1meq/ml
➔ Magnesium (1.5-2.5 mEq/L
NURSING INTERVENTIONS
➔ Give oral potassium with sufficient amount of water or
juice
➔ Dilute I.V Potassium Chloride(KCl) in theIV bag and
mix thoroughly; DO NOT give via IM or give as IV
bolus or push
➔ Monitor urine output, serum potassium and ECG
➔ Sister cation to potassium
➔ Hypomagnesemia
➔ Hypermagnesemia
FUNCTIONS
➔ Promotes transmission of neuromuscular activity
➔ Mediator of neural transmission in CNS
➔ For metabolism of carbohydrates and protein
PHARMACOLOGY
51
●
cell growth, cellular function,
●
enzyme activity,
●
Carbohydrates,
carboxylic
acid,
protein
synthesis
●
muscular contraction,
●
wound healing,
●
immune competence,
●
& GIT integrity.
➔ Different Types of Nutritional Support
●
Oral, Enteral, Parenteral
ORAL FEEDING
➔ Many patients require nutritional supplementation due
to malnutrition or anorexia (e.g., a deficiency of certain
nutrients, vitamins, or minerals).
➔ Factors that can affect appetite:
●
psychological stress about a patient’s illness and
problems
with
family,
finances,
and
employment
➔ If the patient can swallow and has a working GI tract,
oral nutritional supplementation between meals can
help increase caloric intake.
ENTERAL FEEDING
➔ Enteral nutrition (EN) involves the delivery of nutrition
or fluid via a tube into the GI tract, which requires a
functional, accessible GI tract.
➔ Depending on the different pathologies present, EN may
be used for short-term nutritional supplementation,
such as with reduced appetite or swallowing difficulties,
or
long-term
nutritional
supplementation
for
malabsorption disorders or increased catabolism
➔ Nutrients are substances that nourish and aid in the
development of the body. Nutrients provide energy,
promote growth and development, and regulate body
processes. Inadequate nutrient intake can cause
malnutrition. Patients experiencing chronic or critical
illnesses that result in surgery or hospitalization are at
risk for malnutrition. Without adequate nutritional
support, the body’s metabolic processes slow down or
stop. This can greatly diminish organ functioning and
have a poor response on the patient’s immune system
NUTRITIONAL SUPPORT
➔ Nutrients needed for
ENTERAL SOLUTIONS
The four groups of enteral solutions:
➔ polymeric
(milk-based,
blenderized
foods
and
commercially prepared whole nutrient formulas);
➔ modular formulas (protein, glucose, polymers, and
lipids);
PHARMACOLOGY
52
➔ elemental/monomeric formulas (predigested nutrients
that are easier to absorb); and
➔ specialty formulas designed to meet specific nutritional
needs in certain illnesses such as liver failure, pulmonary
disease, or HIV infection
COMPLICATIONS OF ENTERAL
➔ DEHYDRATION
●
Diarrhea is a common complication that can
lead to dehydration.
●
METHODS OF DELIVERY
Are prescribed for the critically ill and for those
to control the flow at a slow rate over 24 hours
●
are administered every 3 to 6 hours over 30 to
60 minutes by gravity drip or infusion pump.
At each feeding, 300 to 400 mL of solution is
Intermittent
infusion
is
considered
●
balance in most patients
➔ ASPIRATION PNEUMONITIS
●
It can occur when the contents of the tube
feeding enter the patient’s lungs from the GI
tract.
Oral feedings, and with this method, 250 to
●
respiratory failure. An important nursing
through a syringe into the tube four to six
intervention is to check the agency’s policy for
times a day.
This method takes about 15 minutes each
feeding, but it may not be tolerated well by the
specific guidelines prior to initiating EN.
●
contents before initiating enteral feeding and
given in a short period.
thereafter every 4 hours between feedings.
The bolus method may cause nausea, vomiting,
Usually, if the residual is greater than 150 mL
aspiration, abdominal cramping, and diarrhea
(check the agency policy), the nurse holds the
normally tolerate the rapidly infused solution,
method
is
reserved
feeding, and the residual is checked again in 1
for
hour. If the residual still exceeds this amount,
ambulatory patients
the provider is notified. Large residuals mean
➔ CYCLIC METHOD
●
the patient may have an obstruction or a
is another type of continuous feeding infused
problem that is important to correct prior to
over 8 to 16 hours daily (day or night).
●
Administration during daytime hours is
suggested for patients who are restless or for
those who have a greater risk for aspiration.
●
continuing the feeding
➔ DIARRHEA
●
the
ambulatory.
day
for patients who are
Due to rapid administration of feedings,
contamination of the formula, low-fiber
The nighttime schedule allows more freedom
during
It is imperative that the nurse check for gastric
residual by gently aspirating the stomach
patient because a massive volume of solution is
this
Consequences range from coughing and
wheezing to infection, tissue necrosis, and
400 mL of solution is rapidly administered
therefore
one of the most serious and potentially
life-threatening complications of tube feedings.
an
➔ BOLUS METHOD
●
Unless contraindicated, it is recommended that
30 to 35 mL/kg/day be maintained for fluid
inexpensive method for administering EN
●
Fluid intake is monitored, and if appropriate,
feedings.
administered.
●
cause
fluid is added to the patient’s daily regimen of
➔ INTERMITTENT ENTERAL FEEDING
●
also
maintain serum iso-osmolality.
The enteral feedings are given by an infusion
pump such as the Kangaroo pump, which is set
●
can
draw water out of the cells in an attempt to
who receive feedings into the small intestine.
●
formulas
dehydration, and hyperosmolar solutions can
➔ CONTINUOUS FEEDINGS
●
High-protein
formulas, tube movement, and various drugs
●
Check for drugs that can cause diarrhea; these
may be antibiotics or sorbitol in liquid
medications.
●
Diarrhea can usually be managed or corrected
by decreasing the rate of infusion,
PHARMACOLOGY
53
●
Diluting the solution with water, changing the
100 to 150 mL, stop the infusion for 1 hour
solution, discontinuing the drug, increasing the
and recheck.
patient’s daily water intake, or administering an
●
●
angle at all times during infusion of tube
Constipation is another common problem that
feedings. If elevating the head of the bed is
frequently occurs. It can be easily corrected by
contraindicated, position the patient on the
changing the formula, increasing water, or
right side.
requesting a laxative
●
●
through the tube, use a 30 mL flush of water at
gastrointestinal
the beginning and end of administration; flush
with 15 mL of water between administration
Determine urine output and record it for
of each drug
future comparisons.
●
●
Obtain the patient’s weight and use it for
diarrhea, decrease the enteral feeding flow rate,
Listen for bowel sounds. Report diminished or
and as diarrhea lessens, slowly increase the
absent bowel sounds immediately to the health
feeding rate.
care provider. Also palpate the abdomen for
●
distension.
●
to full strength. Determine whether side effects
of drugs could be causing diarrhea.
➔ NURSING DIAGNOSIS
●
Fluid Volume, Deficient related to inadequate
●
●
Diarrhea related to enteral feedings
●
Aspiration related to enteral feedings via a
provider.
●
Nutrition, Imbalanced: Less than Body
Patients should be weighed at the same time
nutrients or tolerate oral intake
each day with the same scale and the same
➔ PLANNING
amount of clothing.
The patient will not aspirate during enteral
especially
those
given
●
via
bag.
The patient will receive adequate nutritional
●
support through enteral feedings.
●
➔ NURSING INTERVENTION
●
listen by stethoscope for air movement in the
stomach. (Follow agency guidelines.)
●
➔
PATIENT TEACHING
●
throat, and abdominal cramping.
➔ CULTURAL CONSIDERATION
●
the need for adequate nutrition, and find ways
feeding. When the residual is more than 100 to
recheck the idual. If it is still over 100 to 150
mL, notify the health care provider.
●
Check the continuous route for gastric residual
every 4 to 6 hours. If the residual is greater than
Respect cultural beliefs concerning refusal to
receive enteral or parenteral nutrition. Explain
Determine gastric residual before the enteral
150 mL, hold the feeding for 1 hour and
Instruct patients to report any problems related
to enteral feedings, such as diarrhea, sore
Check the tube placement by aspirating gastric
secretions or by injecting air into the tube to
The nutritional solution should be at room
temperature
The complication of diarrhea related to enteral
feedings will be managed
Change the feeding bag daily. Do not add the
new solution to the old solution in the feeding
gastrointestinal route.
●
Weigh the patient to determine weight gain or
loss. Compare with the baseline weight.
Requirements related to an inability to absorb
feedings,
Give additional water during the day to prevent
dehydration. Consult with the health care
gastrointestinal route
●
Monitor vital signs and report abnormal
findings.
fluid intake or excess fluid loss
●
The enteral solution may be diluted, with the
provider’s order, and then gradually increased
Assess baseline laboratory values and compare
these with future laboratory results
●
Monitor for adverse effects of enteral feedings,
such as diarrhea. To manage or correct
future comparisons.
●
Flush the feeding tube as appropriate: for
mL every 4 hours. When administering drugs
Assess the patient’s tolerance of enteral feeding,
disturbance(nausea, cramping, diarrhea).
●
continuous,
and after; for continuous feeding, flush with 30
place.
possible
bolus,
intermittent feeding, flush with 30 mL before
Confirm that the feeding tube is securely in
including
ordered:
intermittent, or cyclic.
➔ ASSESSMENT
●
Deliver enteral feedings according to the
method
NURSING PROCESS: ENTERAL FEEDING
●
Raise the head of the bed to a 30- to 45-degree
enteral solution that contains fiber.
that nutritional needs can be met.
●
Use an interpreter as appropriate.
➔ EVALUATION
●
Determine that the patient is receiving the
prescribed nutrients daily and is free of
complications associated with enteral feeding
PHARMACOLOGY
54
PARENTERAL NUTRITION (PN), TOTAL
PARENTERAL NUTRITION (TPN), &
HYPERALIMENTATION (HA)
●
glucose concentration
●
➔ Is the administration of nutrients by a route other than
the GI tract (e.g., the bloodstream).
➔ Delivered if a patient is not eligible for EN because of a
nonfunctioning GI tract or intestinal failure,
➔ Indications for patients who require PN are those with
bowel
obstruction,
prolonged
Infection, related to PN solution due to high
paralytic
ileus,
inflammatory bowel disease, or severe pancreatitis, and
those who require bowel rest following complex GI
surgery. Also, patients with greater nutritional needs
sometimes require PN, such as those who have sustained
severe trauma or burns and the severely malnourished.
➔ Solutions for parenteral nutrition include amino acids,
carbohydrates, electrolytes, fats, trace elements, vitamins,
Breathing
Pattern, Ineffective related to
complication from insertion of subclavian line
●
Knowledge, Deficient related to PN therapy
➔ PLANNING
●
The patient’s nutrient needs will be met via
PN.
●
Infection will be avoided as evidenced by the
patient remaining fever free.
➔ NURSING INTERVENTION
●
Check the full set of vital signs and report
changes.
●
Determine body weight and compare it with
the baseline weight.
●
Monitor laboratory results—especially white
blood cell count, electrolytes, protein, and
and water
glucose —and report abnormal findings.
●
Compare laboratory results with baseline
findings to assess any changes.
●
Measure fluid intake and output. Fluid volume
deficit or excess may occur due to the
hyperosmolar content of the PN solution
●
Monitor temperature changes for possible
infection or a febrile state.
●
Use aseptic technique when changing dressings
and solution bags.
●
NURSING PROCESS: PARENTERAL NUTRITION
➔ ASSESSMENT
●
Obtain
baseline
vital
signs
for
your agency’s policy.
●
Initially, glucose levels may be high.
●
Refrigerate PN solution that is not in use.
High glucose concentration is an excellent
future
comparisons.
●
Confirm baseline weight. •
●
Determine laboratory results (electrolytes,
glucose, protein [prealbumin], and white
blood cell levels frequently change during
medium for bacterial growth.
●
comparisons. •
●
ordered level to avoid hyperglycemia. •
●
avoid hypoglycemia.
●
●
a deep breath, holding it, and bearing down).
Always clamp tubing during bag and tubing
Carefully read the label on the bag of PN
Compare the ingredients to the health care
changes to prevent air embolus.
●
➔ NURSING DIAGNOSES
●
Fluid Volume, Imbalanced related to excess
fluid infusion, renal dysfunction, or osmotic
●
nutritional support
and
symptoms
of
Follow your agency’s policy for dressing and
tubing changes. •
●
Do not draw blood from or administer
medications through the central line, and do
not check central venous pressure via the PN
solution
Nutrition, Imbalanced related to altered
signs
findings. •
diuresis resulting from hyperosmolar PN
●
for
neck veins, or chest rhonchi—and report any
Assess the PN insertion site for erythema,
edema, swelling, tenderness, and drainage.
Check
overhydration—coughing, dyspnea, engorged
provider’s order. •
●
During tubing and dressing changes, have the
patient perform a Valsalva maneuver (taking
Check urine output and report abnormal
solution.
If PN finishes before the next time it is due to
be administered, hang a bag of dextrose 10% to
findings.
●
Monitor the flow rate of PN. Start with 60 to
80 mL/hour, and increase slowly to the
parenteral nutrition [PN] therapy). Early
laboratory results are useful for future
Check the blood glucose level according to
line.
●
Results could be invalid
➔ PATIENT TEACHING
PHARMACOLOGY
55
●
Provide emotional support to patients and
family before and during
●
PN therapy.
●
Be available to discuss the patient’s concerns or
refer the patient to the appropriate health care
provider.
●
Instruct patients to notify their health care
provider immediately if they experience
discomfort or reactions.
●
Keep the patient informed of the progress and
effectiveness of PN
➔ CULTURAL CONSIDERATION
●
Respect the patient’s cultural beliefs about
refusing PN. •
●
Explain reasons for adequate nutrition, and
find ways to meet nutritional needs. •
●
Use an interpreter as appropriate.
➔ EVALUATION
●
Evaluate the patient’s positive and negative
response to PN therapy.
●
Determine periodically whether the patient’s
serum electrolytes, protein, and glucose levels
are within desired ranges.
●
Evaluate nutritional status by weight changes,
energy level, feelings of well-being, symptom
control, and healing.
●
Evaluate patient and family understanding of
the purpose and possible complications of PN
therapy
●
PHARMACOLOGY
56