General Pharmacological Principles Module A. Objectives The student will be able to: List three sources of drugs. List the components of a proper medication.

General Pharmacological Principles

Module A

Objectives• The student will be able to:

• List three sources of drugs.• List the components of a proper medication order.• Define the commonly used abbreviations.• List the routes of medication delivery.• Define "parental administration" and list three

types of parental administration.• List the four routes of medication delivery via

inhalation.• List three types of nebulizers used to deliver

respiratory medication.• Given a route of administration, explain the safety

requirements associated with drug administration.

Objectives• The student will be able to:

• Explain two ways to confirm proper patient identification prior to giving a medication.

• State the change in pulse rate needed to terminate a respiratory treatment.

• Describe how the effectiveness of bronchodilators can be objectively measured?

• List the items that should be documented in the patients chart following each treatment.

• Describe the procedure you would follow in the event of an adverse reaction.

• Define terms typically found on a package insert for a drug.

• Describe how most drugs are metabolized and excreted.

Web Site

• www.prenhall.com/colbert

• Animations

• Videos

• Updates

• Glossary & Drug Pronunciations

• Extended Concepts

• Chapter Quiz

• Reference & Additional Readings

Definition of Pharmacology

• Pharmacology - The study of drugs (chemicals) including their origins, properties, and interactions with living organisms.

Are these drugs?

• Aspirin

• Mint

• Vodka

• Vitamins

• Black Cohosh

Drug Sources

• Chemical synthesis• Most common• Recombinant DNA

• Animal

• Plant

• Mineral

FDA

• Federal agency

• Regulates drug testing

• Approves new drugs

• http://www.fda.gov/

Drug Approval

• Can take up to 12 years and over 200 million dollars.

• Only 1 in 10,000 chemicals are approved.

Steps for Drug Approval

• Identify the chemical structure• Animal studies – toxicology studies• Investigational New Drug Approval

• Phase I: Healthy volunteers• Phase II: Volunteers who have the disease• Phase III: Large multi-center study

• New Drug Application – NDA is filed with the FDA and upon approval it is released for general use. Reporting system in place for 6 months

Source of Drug Information

• PDR – Physician Desk Reference

• USP – United States Pharmacopoeia

• National Formulary

• Hospital Formulary

• FDA Website!• http://www.fda.gov/

Study of Drugs

• Generic and Trade Names

• Classification

• Indications

• Actions

• Adverse reactions (side effects)

• Contraindications

• Dosage

Naming Drugs

• Chemical Name: Reflects the chemical structure. • 4-(5-cyclopentyloxy-carbonylamino 1-methyl-

indo-3 ylmethyl)

• Code Name: Name assigned by a manufacturer to an experimental chemical that shows potential as a drug (SCH 1000).

Naming Drugs

• Generic Name: Based on the drugs chemical structure.• Assigned by the USAN Council

• Example: isoproterenol

• Trade Name: Name given by the manufacturer.• A generic drug can have 2 or more trade

names.• Also called brand name.

• Example: Isuprel

Trade Names

•Beta Blockers•propranolololol•atenolololol•metoprolololol

•Neuromuscular blocking agents

•pancuroniumium•vecuroniumium•atracuriumium

•Names of drugs contains clues

•Slo-Bid•Nasalcort•DuoNeb

Prescriptions for Medication Orders• Patient’s Name• Date• Name of the drug• Dosage of drug and amount

• Concentration if appropriate

• Route of administration (delivery device)• Frequency or Schedule

• Number of days if appropriate

• Any additional instructions• Peak flows before and after therapy• Monitor tidal volume during IPPB treatment

• Signature of Physician

Examples:

• John Smith 12/23/89IPPB therapy with 0.25 mL of 1% Bronkosol and 3 mL Normal Saline four times a day x 3 days. Dr. James Jones

• Jack Doe 3/30/99SVN therapy with 0.3 mL of 5% Alupent and 2 mL of Normal Saline every four hours around the clock. Peak flow before and after treatment. Dr. James Jones

Example

• Karen Johnson 4/28/96

MDI Proventil 2 puffs three times a day. Administer with spacer Dr. James Jones

Abbreviations

• Lots of changes over the last few years.

• Due to errors in prescribing, many abbreviations have been eliminated based upon JCAHO recommendations (handout).

• Many institutions have specific rules that go beyond JCAHO recommendations (handout).

Frequency Abbreviations

• BID: Twice a day

• TID: Three times a day

• PRN: When necessary, as needed

• STAT: Immediately

EliminatedEliminated Frequency Abbreviations

• Some others that have been eliminatedeliminated: • QOD: Use “Every other day”• QD: Use “daily”• QID: Four times a day• Q4: Every four hours• Q3: Every three hours• Q2: Every two hours • Q4 ATC: Every four hours around the clock• Q4 WA: Every four hours while awake• Q4 PRN: Every four hours as needed• H.S: Use at “bedtime”

Other commonly used abbreviations:

• NS: Normal Saline

• : With

• : Without• a.c.: Before Meals• p.c.: After Meals• mL: Milliliters• gtt: drop• qs: Quantity sufficient (as much as

required)• PO: By mouth, orally

cc

• MDI: Metered Dose Inhaler• IPPB: Intermittent Positive Pressure Breathing• SVN: Small Volume Nebulizer• SPAG: Small Particle Aerosol Generator• Rx: Prescription or “take”• IM: Intramuscularly• IV: Intravenous• DPI: Dry Powder Inhaler• Tx: Treatment

Other commonly used abbreviations:

• NPO: Nothing by mouth

• OTC: Over the Counter

• FDA: Food and Drug Administration

• PDR: Physician Desk Reference

• BS: Breath Sounds

• PF: Peak Flow

• PEFR: Peak Expiratory Flow Rate

Other commonly used abbreviations:

Other Eliminated Eliminated Abbreviations

• D/C: (eliminated) Discontinued

• cc (eliminated): Cubic Centimeters

5 “Rights”

• Right Drug• Right Dose• Right Patient

• Patient’s wrist band

• Right Time• Right Route• Also

• Expiration Date• Allergies• Timely documentation

Routes of Medication Delivery

• Oral (Enteral) Route• Tablet• Capsule• Pill• Powder• Solutions• Elixirs• Syrups• Emulsions/gels

Routes of Medication Delivery

• Parenteral Route (route comprising routes that bypass the alimentary tract, i.e. injectable)• Intradermal• Subcutaneous• Intramuscular• Intravenous• Intra-arterial• Intra-spinal• Intraosseous (into the tibia or sternum)

Routes of Medication Delivery

• Topical• Transdermal• Creams and gels

• Sublingual (under the tongue)• Enteral

• Rectal• Inhalation

• MDI• Aerosol (SVN, USN)• DPI• IPPB

Routes of Medication Delivery

• Aerosol Therapy• Small volume nebulizers• Ultrasonic nebulizers• Large volume nebulizers

• SPAG• Heart Nebulizer

• IPPB• Metered Dose Inhalers• Dry Powder Inhalers

SMALL VOLUME NEBULIZER (SVN) LARGE VOLUME NEBULIZER

SMALL PARTICLE AEROSOL GENERATOR (SPAG)

METERED DOSE INHALER (MDI)

DRY POWDER INHALER (DPI)

Continuous Nebulization•Occasionally, the nebulized medication must be administered over an extended period of hours instead of minutes. •A nebulizer can be adapted to other oxygen delivery equipment to facilitate this process.

Advantage of Aerosolized Agents

• Dosage is smaller.

• Less side effects and less severe side effects.

• Rapid Onset.

• Drug delivery is targeted to the respiratory system.

• Painless, safe and convenient.

• Patients can administer medication themselves.

Medications Given by RCP

• Bronchodilators

• Mucolytics

• Steroids

• Non-Steroidal Anti-inflammatory• Mast Cell Stabilizers• Leukotriene Inhibitors

• Anti-Infective Agents

Medications given by RCP

• Nicotine Replacement Therapy

• Artificial Surfactants

• Topical Anesthetics• Lidocaine

• Gases• Oxygen• Nitric Oxide• He/O2 (Heliox)

• Morphine (?)

Objectives

• State the change in pulse rate needed to terminate a respiratory treatment.

• Describe how the effectiveness of bronchodilators can be objectively measured?

• List the items that should be documented in the patients chart following each treatment.

• Describe the procedure you would follow in the event of an adverse reaction.

• Define terms typically found on a package insert for a drug.

• Describe how most drugs are metabolized and excreted.

• What is the difference between Q4 PRN, Q4 WA, and PRN?

• Q4 PRN: Every four hours as needed • Q4 WA: Every four hours while awake• PRN: When necessary, as needed

Drug Metabolism and Excretion

• Pharmacokinetics: The movement (kinesis) of the drug throughout the body. • Absorption

• Limited by disintegration• Bioavailability: The amount of drug that has been absorbed

into the circulation.

• Distribution• Metabolism

• Liver

• Elimination• Kidney

• GI Tract (feces), Skin, Pulmonary System

Definition of Terms

• Selectivity – The extent to which a drug acts at one specific site or receptor.

• When binding occurs:• Ion channel open/closed• Biochemical

messengers are activated.

• Normal cellular function is turned on or off.

Definition of Terms

• Racemic – A drug which contains two isomersisomers (same chemical components, only bonded differently).

• Agonist – A drug or chemical that binds to a corresponding receptor and initiates a cellular effect or response – Example: 2 agonist• Agonists have an affinity for a receptor site.

• Antagonist - A drug which binds with a receptor butbut do not cause activation of the receptor.• Explains why some drug’s action is less effective or

blocked in the presence of another drug.

Definition of Terms

• Drug Affinity – A measure of the tendency of a drug to combine with a particular receptor site.

• Drug Potency – The amount of drug required to produce the response desired.• A more potent drug would require a lower

dose to proved a desired effect.

• Drug Efficacy – The peak or maximum biologic effect.

Definition of Terms• Tolerance - Increasing amounts of drug are

needed to produce the same effect. • Loss of effectiveness.• Tachyphylaxis - A rapidlyrapidly decreasing response to a

drug following administration of the initial doses.

• Desensitization - Loss of tissue responsiveness that can occur with drug exposure.

• Placebo - An inactive substance resembling a medication that may be given experimentally or for its psychological effects

Definition of Terms

• Additive – The sum of the effects of two drugs given together is equal to each of them given separately but at the same time (1+1 = 2).

• Synergism – The joint effect of two drugs is greater than the algebraic sum of their individual effects (1+1 = 3). • albuterol + ipratropium bromide

• Potentiation - The effect of two drugs given together where one drug has no effect but increases the response of the other drug (1 + 0 = 2)

Definition of Terms

• Half Life of a drug – The time required to eliminate 50% of the drug from the body after absorption and distribution are complete.

• Loading Dose – Administration of an initial higher level of the drug to facilitate a steady state (maximal saturation of the receptors in the body).

• Maintenance Dose – Additional drug which is administered after the loading dose that is used to maintain the steady state.

Definition of Terms

• Side Effect – Unwanted symptoms which occur after drug administration• Also called adverse drug reaction (ADR)

• Cumulation – Occurs when a drugs rate of removal or inactivation is slower than the rate of administration. This can result in toxicity.

• Emetic - A substance that induces vomiting.• Activated Charcoal – Used to decrease absorption.

• Teratogenicity – A drug’s potential to damage a fetus in utero when given to a pregnant women.

Definition of Terms

• Systemic Effect - Throughout the body

• Local Effect - Restricted to a specific area (drugs given by aerosol to the lungs)

Definition of Terms

• Therapeutic Index = LD50

ED50

• LD 50 - “Lethal Dose 50”• The dose that is lethal to 50% of the test

population of animals

• ED 50 – “Effective Dose 50”• The dose that is therapeutically effective in

50% of the test population of animals

Therapeutic Index

• The higher the therapeutic index, the safer the drug.

• The lower the therapeutic index, the greater the chance of toxicity.

• theophylline, lidocaine and digitalis all have low therapeutic indexes.

• LD50 400 mg = 2

ED50 200 mg

Safety Requirements for Drug Administration

• Always check the patient’s chart.

• Always check the patient’s name band for proper identification.

• Check the medication label before preparing medication.

• Check dates on the medication for expiration date.

Safety Requirements for Drug Administration

• Check medication color for change.

• Check the dosage of medication ordered and know the normal and safe range.

• Always wash hands before preparing and giving a medication.

• Check previous notes to determine the patients previous response to the medication.

Safety Requirements for Drug Administration

• Document the HR before, during and after the therapy.• If the heart rate increases more than 20 beats from

the baseline, STOP THE TREATMENTSTOP THE TREATMENT and notify your clinical instructor/preceptor.

• Document patient assessment findings (breath sounds, respiratory pattern, use of accessory muscles, peak flows if using a bronchodilator) before an after therapy.

• Assure patient safety before leaving the room.• Bedrails up, patient restraint, call button in

patient’s reach.

• Document clearly, concisely and accurately.

Safety Requirements for Drug Administration

• If you make an error when documenting:• Put one line through the charting.• Initial.• Write “error”.• Continue to chart correct information.

• Never use white-out!

Nosocomial Infection

• Hospital Acquired Infection• Hand Washing #1!!

Adverse Reaction

• Stop the treatment immediately.

• Stay with the patient and notify the nurse.

• When the patient is out of immediate danger, contact your Clinical Instructor or Preceptor.

• Document the adverse reaction, the patients vital signs at the time you left the room, personnel you contacted and any order change by the physician.

Adverse Reaction

• If the physician changed the medication order or therapy, document all changes on the respiratory therapy treatment sheet.

• Report the incidence at change of shift; discuss with next therapist taking care of the patient.

What To Do With an Improper Order

• As a student• Contact your clinical instructor/preceptor

• The clinical instructor or preceptor will then follow the steps outlined below.

• As a therapist• Contact the physician• Contact the department supervisor• Contact the department manager• Contact the medical director of the RC

department

Take Home Message

• SAFETY!

• SAFETY!

• SAFETY!

• Remember: “To Err is human,” but to err in drug administration can be very dangerous!