What is the difference between OTC and prescription drug therapy?
Prescription Drugs:
1.
Legal drugs are obtained by prescription or over the counter.
2. To obtain prescription drugs you must have an order.
3. Advantage to prescription is that health care provider gets to examine the patient
and determine a diagnosis.
4. They then can maximize the amount of therapy you need by order the proper
amount of meds.
5. Also the provider can teach you on how to use the meds and what side effects to
expect
For OTC drugs:
1.
They do not require physicians order.
2.
Most patients treat themselves safely if they follow the directions.
3.
If not followed OTC can have serious adverse effects.
4.
Patients prefer to take OTC drugs, because they can be obtained much easier.
5.
No appt. so they save money and time.
Downfall in obtaining OTC:
1. Is that assistance with choosing the proper drug can be challenging
2. OTC may also interact with foods, herbal products, prescription meds and other OTC
drugs.
3. Patients may not be aware that some drugs can impair their ability to function safely.
4. Self treatment is sometimes ineffective and the potential for harm may increase if
the disease is allowed to progress
What are Alternative Therapies?
1.
They involve natural plant extracts, herbs, vitamins, minerals, dietary supplements,
and many techniques considered by some to be unconventional.
2.
Unconventional therapies are acupuncture, hypnosis, biofeedback, and massage
They different in chemical structure because:
1.
When using you must be aware of allergic reactions.
2.
Most herbals contain a mixture of ingredients, many of which have not been
identified.
3.
It is not unusual to find dozens of different chemicals in teas and infusions made
from the flowers, leaves or roots of a plant
4.
People with food or medicine allergies should consult a doctor before taking herbal
products
5.
Always take the smallest amount possible when you start taking. Even less then
recommended dose to see if allergic to it.
6.
7.
Because it says natural does not mean that it is safer or better.
Some herbal products contain ingredients that may serve as agonists or antagonists
to prescription drugs.
8.
If taking Warfin (Coumadin), digoxin (Lanoxin) you should not take herbal products
9.
Most therapeutic herbals have powerful chemicals but that does not make them
safe.
What are the procedures in clinical trials?
1.
2.
Preclinical investigationExtensive lab research where scientists perform many tests on human and microbial
cells.
3. Studies are performed in several species of animals to examine the effectiveness of
different doses and to look for adverse effects.
4. Tests are long so that the can see what harm is done. Because lab tests do not
always reflect the way a human responds.
5.
Preclinicals are always inconclusive.
6. Animal test may overestimate or underestimate actual risk to humans
Clinical investigation1. 3 different stages termed clinical phase trials.
2.
Longest part of drug approval
3. Perform on healthy volunteers to determine dosage and effects.
4. Then large groups with same disease are given meds.
5. Investigators then look for the concerns such as drug effective, worsens other
conditions, interacts unsafely with existing meds or affects one type of patient
Clinical phase trials-
1.
Essential component of drug evaluations due to variability of responses among
patients.
2.
If drug seems to be effective with out serious side effects approval will be
accelerated or the drug may be used immediately.
3.
If shows promise but has precautions are noted the process is delayed until
company remedies concerns.
4.
In any case NDA must be submitted before a drug is allowed to proceed to next
stage
NDA Review1.
3rd stage of drug approval
2.
Clinical phase 3 trials and animal testing may continue depending on the results
from Preclinical testing
3.
FDA is permitted 6 months to review NDA
4.
If NDA approved process continues to final stage.
5.
If rejected process is suspended until noted concerns are addressed by company.
6.
Average NDA review time is 17-24 months
Postmarketing surveillance1.
Final Stage, begins after clinical trials and NDA completed
2.
The purpose for stage 4 is to survey for harmful drug effects in a larger population
3.
Some effects take longer to appear and not identified until a drug is circulated to
large numbers of people. Example: Troglitazone (Rezulin) Placed in market 1997 and
in 1998 Britain banned it after discovering at least one death and several cases of
liver failure in diabetic patients. Noticed also in US and was later recalled in 2000
Bioterrorism- defined as the intentional use of infectious biological agents, chemical
substance or radiation to cause widespread harm or illness.
Public has become more aware of threat because Centers for Disease Control and US
department of defense have stepped up efforts to inform, educate and prepare the
public for disease outbreaks.
Nursing Responsibilities
Joint Commission on Accreditation of Healthcare Organizations (JCAHO) has required
hospitals to develop disaster plans to conduct periodic emergency drills to determine
readiness
1.
Nurses are central to the effort.
2. Education- nurses need to maintain current knowledge and understanding of
emergency management relating to bioterrorist activities.
3. Resources- nurses must maintain current listing of health and law enforcement
contacts and resources in their local community that would assist in the event of
bioterrorist activity
4. Diagnosis and treatment- nurses must be aware of the early signs and symptoms of
chemical and biological agents and their immediate treatment
5. Planning-nurses should be involved in developing emergency management plans
What should you as the nurse know prior to giving medications to your patients?
1. What drug is ordered
• Name (generic and trade) and drug classification
• Intended or proposed use
• Effects on the body
• Contraindications
• Special considerations (age, weight, body fat distribution)
• Side effects
2. Why the medication has been prescribed for this particular patient
3. How the medications is supplied by the pharmacy
4. How the medication is to be administered including dosage ranges
5. What nursing process considerations related to the medication apply to this patient
Before administering the meds the nurse must obtain and process information regarding the
patient’s medical history, physical assessment, disease processes and learning needs and
capabilities.
It is vital that the nurse be prepared to recognize and respond to potential adverse
effects of meds
Signs of allergic reactions vary in severity and include:
1.
Skin rash with or without itching
2. Edema
3. Nausea
4. Diarrhea
5. Runny nose
6. Reddened eyes with tearing
If reaction alert personnel and apply labels to chart, MAR and place bracelet on patient.
Also know the 5 Rights:
• Right Patient
• Right Medication
• Right Dose
• Right Route of Administration
• Right Time of Delivery
Lastly do the three checks of drug administration!!!!
1.
Checking the drug with the MAR or the medication information system when
removing it from the medication drawer, refrigerator or controlled substance
locker
2.
Checking the drug when preparing it, pouring it, taking it out of the unit dose
container or connecting the IV tubing to the bag
3.
Checking the drug before administering it to the patient
What drugs are used for the relief of constipation?
Bulk Forming:
1.
Calcium polycarbophil (Fibercon, Fiberall, Mitrolan)
• PO 1g qd PRN
2. Methylcellulose (Citrucel)
• PO 5-20 ml tid in 8-10 oz water
3. Psyllium mucilloid (Metamucil, Naturacil)
• PO 1-2 tsp in 8oz water qd PRN
Saline and Osmotic:
4. Magnesium hydroxide (Milk of Magnesia)
• PO 20-60 ml qd PRN
5. Polyethylene glycol =(MiraLax)
• PO 17g in 8oz of liquid qd for 2-4 days
6. Sodium biphosphate (Fleet Phospho-Soda)
• PO 15-30 ml mixed in water qd PRN
Stimulant:
7. Bisacodyl (Dulcolax)
• PO 10-15 mg qd PRN
8. Castor Oil (Emulsoil, Neoloid, Purger)
• PO 15-60 ml qd PRN
9. Phenoplhthalein (ExLax, Feen-a-mint, Correctol)
• PO 60-240 mg qd PRN
Stool Softner/Surfactant:
10. Docusate (Surfak, Dialose, Colace)
• PO 50-500 mg qd
Miscellaneous Agent:
11. Mineral Oil
• PO 45 ml BID
Constipation is best prevented and treated with a combination of adequate exercise, a highfiber diet, an adequate intake of fluids, and the occasional use of laxatives
Prolonged use of stimulant laxatives can create abnormal changes in the lining of the large
intestine caused by deposits of a pigment (a condition called melanosis coli). Also, stimulant
laxatives can become addictive, leading to the development of lazy bowel syndrome, which in
turn causes the large intestine to become dependent on the laxatives. For all these reasons,
stimulant laxatives should be used only for brief periods of time to treat constipation. They
are useful for preventing constipation in people who are taking drugs that will almost
certainly cause constipation, such as opioids. Stimulant laxatives are often used to empty
the large intestine before diagnostic procedures are performed.
What is Addiction?
Addiction is an overwhelming compulsion that drives someone to repetitive drug-taking
behavior despite serious health and social consequences.
Substance abuse depends on multiple complex, interacting variables like:
1.
Agent or drug factors- cost, availability, dose, mode of administration (e.g. oral, IV,
inhalation), speed of onset/termination and length of drug use.
2. User factors- genetic factors (e.g. metabolic enzymes, innate tolerance) propensity
for risk-taking behavior prior experiences with drugs, disease that may require a
scheduled drug
3.
Environmental factors- social/community norms, role models, peer influences,
educational opportunities
In the case of legal prescriptions it might start with needing the meds at first and then
grow to become addicted
Dependence- When a person has an overwhelming desire to a take a drug and cannot
stop, this is referred to as substance dependence. (Physical or psychological)
Physical dependence- refers to an altered physical condition caused by the nervous
system adapting to repeated substance use
Psychological dependence- this produces no signs of physical discomfort after the
agent is discontinued
Potency- a drug that is more potent will produce a therapeutic effect at a lower dose,
compared to another drug in the same class.
Example- Drug X and drug Y, which both produce a 20mm drop in blood pressure. If
drug Y produced this effect at a dose of 10 mg, and drug X at 60 mg then drug Y is said
to be more potent.
Efficacy- is the magnitude of maximal response that can be produced from a particular
drug.
Example- Ibuprofen (200mg) and aspirin (650mg). Ibuprofen is obviously more potent.
Although both relieve pain etc. they both then have the same efficacy. If pain is severe
neither would relieve the pain. So that would require a med with a higher efficacy which
would be a narcotic.
Efficacy is almost always more important than potency.
Therapeutic levels (range)- drug concentration between the minimum effective
concentration and the toxic concentration
Example- if patient has a severe headache and is given half of an aspirin tablet, the
plasma level will remain below the minimum effective concentration and the patient will
not experience pain relief. 2 or 3 tablets will increase the plasma level of aspirin into
therapeutic range and pain will subside.
Scheduled drugs- are classified according to their potential for abuse.
Schedule 1 drugs have the highest potential for abuse!!!
Schedule 1- Abuse, Physical and Psychological- High dependency. Example- heroin, LSD,
marijuana and methaqualone (limited or no therapeutic use)
Schedule 2- Abuse, Physical and Psychological- high dependency. Example- morphine,
PCP, cocaine, methadone and methamphetamine (used therapeutically w/prescription:
some drugs no longer used)
Schedule 3- Abuse, Physical Moderate; Psychological High dependency. Example:
anabolic steroids, codeine and hydrocodone w/aspirin or Tylenol and some barbiturates
(used therapeutically w/prescriptions)
Schedule 4- Abuse, Physical, Psychological low dependency. Example: Darvon, Talwin,
Equanil, valium and xanax (used therapeutically w/ prescription)
Schedule 5- Abuse, Physical, Psychological lowest dependency. Example: over the
counter cough medicines w/codeine (used therapeutically w/o prescription)
What’s the responsibility of the nurse when teaching patient’s about their
medications?
1.
Therapeutic use and outcomes
2. Monitoring side and adverse effects. Some side effects do not need to be reported
to the doctor. Other more serious side effects like extreme nausea or vomiting,
bleeding, or extreme dizziness should be reported
3. Medication administration- Ex. Know how much to take, how often to take, special
requirements for taking( empty stomach etc)
4. Other monitoring and special requirements- Meds that you should not take with this
medicine, foods or beverages you must not take)
Know the actions that most medications produce in the body-
For instance- a drug taken by mouth must cross over plasma membranes of the GI tract to
enter the bloodstream. To leave it must cross back over those same membranes to get to
the target cell.
A drug given by enteral route is broke down by the stomach acid and digestive enzymes.
Enzymes in the liver and other organs may change the drug molecule to make it lest active.
There are four processes in pharmacokinetics (actions of drugs in body):
1.
Absorption- process of the movement of a substance from its site of
administration, across body membranes, to circulating fluids. Absorption is the
primary pharmacokinetics factor determining the length of time it takes a drug to
produce it effect. Of course, the more rapid the absorption the fast the onset.
Drugs administered IV fastest onset of action, drugs in elixir or syrup faster than
tabs. Also higher doses are absorbed faster and more rapid onset. Acids are
absorbed in acids and bases are absorbed in bases. Also drug-drug, or food-drug
interactions may influence absorption. Ex: tetracyclines w/ food or drugs containing
calcium, iron or magnesium can delay absorption of antibiotic. High fat meals can
slow delay of absorption w/ oral meds taken w/meal.
Most drugs, with the exception of a few topical medications, intestinal antiinfective
and some radiologic contrast agents must be absorbed to produce an effect.
2.
Distribution- how drugs are transported throughout the body. The fastest
determining distribution is the amount of blood flow to body tissue. The heart,
liver, kidneys and brain receive the most blood supply. Skin, bone and adipose tissue
receive a lower flow. Therefore it is more difficult to deliver high concentration of
drugs to these areas. Physical properties of the drub influence how it moves thru
the body. Lipid solubility is an important part because it determines how quickly a
drug is absorbed, mixes within the bloodstream, crosses membranes and becomes
localized in body tissues. Lipid soluble agents are not stopped by the barriers that
usually stop water soluble drugs. So they are completely distributed to body
tissues. Drug and other chemicals compete w/ each other for plasma protein binding
sites. Example of displaced medicine from plasma protein is Coumadin (warfarin),
99% binds to plasma but when you take aspirin or tagamet(cimetidine) it displaces
the warfarin and causes it to raise blood levels enhancing risk of hemorrhage. The
brain and placenta have special barriers that do not allow chemicals of meds to
cross. They are the blood-brain barrier and fetal placental barrier.
3.
Metabolism- also called biotransformation is the process of chemically converting a
drug to a form that is usually more easily removed from the body. The liver is the
primary site of drug metabolism, although the kidneys and cells of the intestinal
tract also have high metabolic rates. During metabolism, the addition of side chains,
known as conjugates makes drug more water-soluble and more easily excreted by
the kidney. Prodrugs have no pharmacologic activity unless they are first
metabolized to their active form by the body. Examples are benazepril (lotensin)
and losartan (Cozaar). Few drugs have the ability to increase metabolic activity in
the liver which is called enzyme induction. One that does this Phenobarbital causes
the liver to synthesize more microsomal enzymes. By doing so it will increase the
rate of its own metabolism as well as that of other drugs. In these patients higher
doses of meds may be required. Hepatic enzyme activity is reduced in infants and
elderly patients. Patients with severe liver damage (cirrhosis) will require low drug
dosage because of the decreased metabolic activity.
4.
Excretion- drugs removed from the body. The rate at which meds are excreted
determines their concentration in the blood stream and tissue. This is important
because the concentration of drugs in bloodstream determines their duration of
action. Liver disease or renal failure often increases the duration of drug action in
the body because they interfere w/ natural excretion. Primary site of excretion is
the kidneys. Certain drugs may be excreted more quickly if the ph of the filtrate
changes. Weak acids like aspirin are excreted faster when the filtrate is slightly
alkaline. Weakly basic drugs such as diazepam (valium) are excreted faster with a
slightly acidic filtrate because they are ionized in this environment. To speed renal
excretion of acidic drugs like aspirin a nurse would administer sodium bicarbonate
which will make the aspirin more basic to excrete faster. Diazepam can be enhanced
by giving ammonium chloride to acidify the filtrate. Kidney disease of course does
not excrete meds and may keep them an extended time. These doses must be
reduced to avoid toxicity. There is also respiratory excretion and glandular
excretion. Example of respiratory is after anesthesia the faster the breathing the
faster the removal. For glandular Iv drugs are excreted thru salvia. Another
example would be someone who has eaten garlic may then sweat out the garlic thru
perspiration.
Know the nursing process as it relates to your responsibilities when administering
drugs1. Assessment- Initial contact w/patient and continues with every interaction
thereafter. Baseline is gathered so that it can be looked over when patient revisits.
Get subjective date and objective date.
2. Nursing diagnoses- provide patient goals and possible outcomes, planning
interventions to meet these goals or outcomes and to help nurse evaluate the
effectiveness of the care given.
3. Planning- this go with the strategies or interventions to establish goals and
outcomes. It is the formal written process that communicates w/ all members of the
health care team what the nurse will do to assist the patient in meeting goals.
4. Interventions- designed to meet the patient’s needs and ensure safe effective care.
As the nurse is providing the care ongoing assessment is happening and new data is
compared to the earlier data.
5. Evaluation- Nursing diagnoses are reviewed while taking into consideration the
patient’s response to care.
Know about opioids medicationsOpioids-also known as narcotic analgesics are prescribed for severe pain, persistent cough
and diarrhea. Natural substance obtained from the unripe seeds of poppy plants such as
opium, morphine, and codeine and Synthetic drugs like propoxyphene (Darvon), meperideine
(Demerol), oxycodone (oxycontin) fentanyl (duragesic, sublimaze), methadone (dolophine)
and heroin. Oral opioids begin w/in 30 minutes and may last all day. Parenteral produce
immediate effects. Feelings from opioids are extreme pleasure, profound sedation, and
constricted pupils, increase in the pain threshold and respiratory depression. Addiction can
occur very quickly. Withdrawal is very unpleasant although not life threatening. Methadone
is a narcotic used to treat opioids addiction. Although it is also addictive it does not
produce the same degree of euphoria as other opioids and its effects are longer lasting.
Heroin addicts are given methadone to prevent unpleasant withdrawal symptoms. Since
methadone is oral patients are no longer exposing to serious risks associated w/intravenous
use like hepatitis and AIDS. Patients can sometimes say on methadone for a lifetime.
Cultural competency- the nurse must keep in mind the following variable when treating
patients in different ethnic groups
1.
Diet- every culture has a unique set of foods and spices which have the potential to
affect pahrmacotherapy. For example, Asian diets tent to be high in carbs and low in
protein and fat. African American diets are higher in lipid content.
2. Alternative therapies- many cultures believe in using herbs or other therapies along
with modern meds. Many Chinese go to herbalists to treat their illnesses. Native
Americans collect, store and use herbs to treat and prevent disease. Hispanic
culture uses spices and herbs to maintain a balance of hot and cold which promotes
wellness. Massage, heat and tea infusions are used by many cultures.
3. Beliefs of health and disease- each cultures have distinct ways to view sickness
and health. Native Americans seek tribal medicine man or Hispanics from a
curandero (folk healer) African Americans use healing through the use of lying of
hands.
4. Genetic Differences- DNA sequences, hundreds of structural variants in metabolic
enzymes have been discovered. Some of these appear more frequently in ethnic
groups and have an impact on pharmacotherapeutics.
How do you administer, IM, IV, sub Q, oral, intradermal, sublingual etc?
1.
Enteral route- includes drugs given orally, thru nasogastric or gastrostomy. Oral is
the most common.
2.
Sublingual/Buccal- tab not swallowed, but kept in mouth. Rapid onset. Sublingual is
under tongue and Buccal is between the gum and cheek. Slower absorption.
3.
Topical- applied to the skin or membranous linings of the eyes, ear, nose,
respiratory tract, urinary tract, vagina or rectum. (Dermatologic preparations,
Inhalations, Instillations and Irrigations). Many of these produce a local effect.
4.
Transdermal- patches deliver meds. Example is Nitro pad for angina pectoris.
Although they have a certain amount of drug rate of delivery varies.
5.
Ophthalmic- is used for the eye and surrounding structures. Used for dryness,
infections, glaucoma and dilation.
6.
Otic- used for ear, including infections and soft blockages of auditory canal.
7.
Nasal-used for both local and systemic. Mucosa provides excellent absorptive
surface for certain meds. Advantages are easy usage and avoidance of first pass
effect and digestive enzymes. Although can have potential for damage to cilia.
8.
Vaginal- used for local infection and to relieve vaginal pain and itching. Before
inserting patient must empty bladder
9.
Rectal- used for either local or systemic. It is safe and effective for patients who
are comatose or who are experiencing nausea and vomiting.
What is the medication that causes oily stools and can also be used for weight loss?
1.
Anorexiants (amphetamine and dextroamphetamine (Dexedrine) - are used to
reduce appetite; however they are addictive and are rarely prescribed today.
Attempts to produce drugs that promote weight loss by blocking lipid absorption
resulted in orlistat (xenical) which acts to block fat absorption in the GI tract. But
orlistat may also decrease absorption of other substance including fat soluble
vitamins and warfarin (Coumadin). To avoid having severe GI effects such as flatus
with discharge, oily stool, abdominal pain and discomfort patients should restrict
their fat intake.
How do you holistically take care of your patient?
What is PUD, how do you treat this illness, what can be done to prevent it? An ulcer is
an erosion of the mucosa layer of the GI tract, usually associated w/inflammation and
mostly occurs in the duodenum. PUD is a lesion located in either the stomach (gastric) or
intestine (duodenum). Factors causing PUD:
1.
Close family history of PUD
2. Blood group O
3. Smoking tobacco
4. Beverages and food containing caffeine
5. Drugs, particularly glucocorticoids, aspirin and NSAIDS
6. Excessive psychological stress
7. Infection w/ H. pylori
Treatment should be eliminating the factors that are causing it. But for those
requiring meds use:
1.
H2 receptor antagonists- suppresses the volume and acidity of stomach acid
2. PPI’s- blocks the enzyme responsible for secreting hydrochloric acid
3. Antacids-alkaline substances that have been used to neutralize the stomach acid
4. Antibiotics- elimination of organism causing the ulcer to heal more rapidly and to
remain in remission longer.
The goal is to provide immediate relief, promote healing of the ulcer and future
recurrence of the disease. The choice of meds depends on the source of disease,
severity of symptoms and OTC versus prescription drugs.