• Food and Drug Administration
• State and Local Agencies
• Nurse Practice Acts
• Agency/Hospital Policies

• Medication-category/class
• Mechanism of Action
• Therapeutic Effect
• Side Effects
• Adverse Effects
• Toxic Effects
• Medication Interactions
• Precautions/Contraindications
• Preparation, dosage, administration
• Nursing Implications

• What the body does to medications
• What medications do to the body
• Different forms of medications
• Different routes for administering medications

• Pharmaceutics
• Pharmacokinetics - what the body does to the drug (absorption, distribution, metabolism, excretion)
• Pharmacodynamics - what the drug does to the body
• Pharmacotherapeutics - good effects of the drug on the body
• Toxicology - bad effects of the drug on the body

• Absorption - movement of drug into the bloodstream
• Distribution - drug transport to sites of action
• Metabolism - chemical conversion of drug into metabolites that can be excreted
• Excretion - elimination of drug from the body

Absorption

• Movement of drug into the bloodstream
• Affected by:

• Route of Administration (local vs. systemic)
• Form (liquid, capsule, etc.)
• Drug Solubility (water or fat soluble)
• Blood Flow
• Body Surface (stomach has a lot of surface area)
• Food (food in stomach can slow absorption as long as 2 hours)
• pH

Distribution

• Drug transport to sites of action
• Factors affecting:

• Cardiovascular Health
• Local blood flow (at target area)
• Membrane permeability
  -Blood-Brain Barrier (water soluble medications can't get into brain)
• Protein-binding capacity (medication binds to protein albumin, only portion that is unbound is therapeutic)

• Biotransformation: chemical conversion of drug into metabolites that can be excreted (enzymes break down medication into metabolites, usually in liver)
• The slower the metabolism, the greater the risk of toxicity
• Factors affecting metabolism: liver function, other medications, health status
• First Pass Effect - medications that are deactivated in the liver before reaching systemic circulation; must be delivered parenterally to avoid GI tract

• Elimination of the drug
• Primarily through kidneys (BUN & creatinine clearance indicators of kidney function, hydration helps body eliminate drugs)
• Also through liver, lungs, bowel, sweat, mammary glands (constipation can increase medication effects)

• Onset -  when drug concentration to reaches a high enough blood level for its effects to appear.
• Peak - When the concentration of medication is highest in the blood
• Duration - period of time in which the medication has a pharmacological effect (before it is metabolized and excreted)
• Half-life - the amount of time it takes for half of the drug to be eliminated
• Therapeutic Range - a range of therapeutic concentrations
• Therapeutic Level - the concentration of a drug in the blood serum that produces the desired effect without toxicity
• Trough Level - when the drug is at its lowest concentration, right before the next dose is due
• Peak Level - when the drug is at its highest concentration (when the rate of absorption is equal to the rate of elimination)

• Route (oral vs. IV)
• Age, Weight, Gender (important in children, fat distribution)
• Environment (heat or cold)
• Nutritional/Hydration (fiber, constipation, diarrhea, when you ate)
• Pathological States (disease)
• Genetic Factors (racial groups - diuretics work better in African-Americans, opiods work differently in Asians)
• Psychological Factors (placebo effect, mind can heal the body)

• MAO Inhibitors and Tyramine (found in aged foods)
• Coumadin and Green Leafy Vegetables (Vitamin K - antidote to Coumadin)
• Milk (don't take w/tetracyline)
• Grapefruit (don't take w/calcium channel blockers)
• Potassium (w/Lasix encourage potassium rich foods; don't take w/ACE inhibitors)
• Full or Empty Stomach

• Physiologic Changes
• Mechanical/Cognitive
• Polypharmacy

■  Delayed but more complete
■  Gastric pH is less acidic because of decreased acid production in the stomach.
■  Decreased gastric pH delays absorption of medications absorbed in acid environments.
■  Because of decreased intestinal motility, drugs remain in the system longer, allowing for more absorption.

■  Low albumin level could create a problem with plasma protein binding.
■  Increased risk of toxicity due to multiorgan slowdown.
■  Altered because of less lean mass
■  Less body water, greater body fat
■  Dehydration, poor nutrition, and electrolyte imbalances decrease absorption.

■  Presence of diseases may decrease metabolism of the drug.
■  Changes due to age, higher blood concentration, and less excretion cause greater chances of toxicity.
■  Some drugs interfere with the liver’s ability to metabolize another drug.

■  Decreased glomerular filtration rate inhibits excretion from the kidneys.
■  Diminished renal function inhibits excretion, thereby increasing the risk of toxicity.

• Leaders in the family or community
• Health beliefs and practices
• Past use of medicine
• Use of herbal treatments, folk remedies, or supplements
• Dietary habits

• Mechanisms of Actions
• Primary Effects
• Secondary Effects
• Drug Interactions

• Receptor Activity
  -Agonist (mimics receptor)
  -Antagonist (blocks receptor)
  -Partial Agonist
• Examples/Classifications: beta blockers, antihistamines, anticoagulant, corticosteroids, beta-adrenergic agonist, ACE inhibitors

• Pallative - makes patient comfortable, ofen in end-stage of illness
• Supportive - maintains integrity of body functions while patient is recovering
• Chemotherapeutic - destroys disease-producing microorganisms or cells; eg. antibiotics for infection, anti-neoplastic druge for cancer
• Restorative - returns the body to or maintains the body at optimal levels of health; eg. vitamin  and mineral supplements
• Acute - intensive treatment for critically ill
• Maintenance - treatment of chronic illnesses such as hypertension
• Supplemental/Substitutive - supplies body with a substance needed to function; eg. insulin
• Prophylactic - intended to prevent illness; eg. antibiotic therapy before surgery, vaccines

• Side Effects - unintended, often predictable, physiological effects that are usually well tolerated by patients. They occur at the usual prescribed dose and may be immediate (e.g., dizziness) or delayed (e.g., constipation).
• Adverse Reactions - harmful, unintended, usually unpredicted reactions to a drug administered at the normal dosage.
• Teratogens - Drugs known to cause developmental defects in pregnancy
• Allergic Reactions - immune system identifies a medication as a foreign substance that should be neutralized or destroyed
• Anaphylactic Reaction - life-threatening allergic reaction that occurs immediately after administration. The allergic response produces sudden constriction of bronchioles, edema of the larynx and pharynx, severe shortness of breath, wheezing, and severe hypotension
• Idiosyncratic Reaction - an unexpected, abnormal, or peculiar response to a medication. Idiosyncratic reactions may take the form of extreme sensitivity to a medication, lack of response, or a paradoxical (opposite of expected) response, such as agitation in response to a sedative.
• Cumulative Effect/Overdosing - the increased response to repeated doses of a drug that occurs when the rate of administration is greater than the rate of metabolism and excretion.

• Antagonistic - (1+1 < 2) one drug interferes with the actions of another and decreases the resultant drug effect—that is, the combined effect is less than that of one drug given alone.
• Synergistic - (1 + 1 > 2) the effect of both drugs together is greater than the individual effects
• Additive - (1 + 1 = 2) the effect of a combination of drugs with similar actions is equivalent to the sum of the individual effects of the same drugs given alone
• Drug Incompatibilities - when multiple drugs are mixed together, causing a chemical deterioration of one or both drugs.

• Tolerance - a decreasing response to repeated doses of a medication
• Dependence - a person’s physical reliance on, or need for a drug
• Addiction - a person’s psychological reliance on, or need for a drug
• Drug Misuse - nonspecific, indiscriminate, or improper use of drugs
• Drug Abuse - inappropriate intake of a substance by amount, type, or situation, continuously or periodically
• Illicit Drugs - also known as street drugs, are drugs sold illegally.

• Oral
• Sublingual
• Buccal
• Topical
• Enteral (in stomach but not in mouth)
• Parenteral (outside of the digestive system)

• liquids, elixirs, syrups
• suspension solutions
• powders
• capsules
• tablets
• coated tablets
• enteric coated tablets
• sustained or extended release

• Applied directly to body surface/body cavities
• Skin, Instillation, Inhalation

• lotions, creams, ointments
• eye, ear medications

• inhalation, vaginal, rectal, nasal

• Transdermal patches

• Intradermal
• Subdermal
• Intramuscular
• Intravenous

• Over the Counter
• Herbal Medications
• Dietary Supplements
• Alternative
• Complementary/Integrative
• Nursing Diagnosis
  -Readiness for Enhanced Knowledge
  -Knowledge Deficit
  -Risk for Injury

• Generic Name (acetaminophin, ibuprofen)
• Chemical Name (actylsalicylic acid)
• Brand/Trade Name (Tylenol, Bayer, Motrin, Advil)

• Usage
• Body System
• Chemical or Pharmacologic
• Federal Classifications
  -Controlled Substance
  -Pregnancy

• Generic and Brand Name
• Therapeutic Actions
• Indications
• Pharmacokinetics
• Contraindications/Adverse Effects
• Interactions
• Route/Dosage
• Nursing Implications

• Assessment - subjective and objective data, medication history, medical history, allergies, admitting diagnosis
• Assess before, during, and after medication administration

• Knowledge Deficit
• Risk for Injury
• Ineffective Management of Therapeutic Regimen
• Noncompliance
• Risk for Aspiration
• Ineffective Health Maintenance

• Medication Reconciliation
• Take vitals, check labs (don't delegate)
• Know and use your resources (drug book, pharmacist)
• Contact the physician for clarification, concerns, questions
• Know what can be crushed, opened, stored
• Watch for drugs with similar names
• Watch for multiple units of same medications (eg. shouldn't need to give more than 4 pills)
• Teach patient about meds
• Don't administer meds you did not prepare
• Dont give unlabeled meds

• Watch for high alert medications
• Identify patient using two identifiers (name, DOB, check wristband, medical record number)
• Seven Rights
• Three Checks
• Check for allergies
• Check for swallowing issues
• Honor patient's concerns
• Document!
• Don't use abbreviations

TRAMPED

• Right Time
• Right Route
• Right Amount (dose)
• Right Medication
• Right Patient
• Right Effect
• Right Documentation

Do TRAMP and compare against MAR

1 - when you retrieve and prepare medications

2 - after you prepare medications as you are putting bottles/packages back in drawer

3 - at the bedside before you administer medications

• Check the patient
• Consult a drug reference source for side effects to the medication
• Identify type of error
• Notify nurse manager or supervisor
• Notify physician and obtain orders
• Incident Report
• Full disclosure to patient