drug presentation in nursing

Warning: The NCBI web site requires JavaScript to function. more...

An official website of the United States government

The .gov means it's official. Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you're on a federal government site.

The site is secure. The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

• Publications
• Account settings
• Browse Titles

NCBI Bookshelf. A service of the National Library of Medicine, National Institutes of Health.

Open Resources for Nursing (Open RN); Ernstmeyer K, Christman E, editors. Nursing Pharmacology [Internet]. 2nd edition. Eau Claire (WI): Chippewa Valley Technical College; 2023.

Nursing Pharmacology [Internet]. 2nd edition.

• About Open RN

Chapter 1 Pharmacokinetics & Pharmacodynamics

1.1. pharmacokinetics & pharmacodynamics introduction, learning objectives.

• Discuss the processes of pharmacokinetics

• Use multiple professional resources, including technology, to identify pertinent information related to drugs

• Describe the processes of pharmacodynamics

• Consider pharmacodynamic differences across the life span

• Differentiate among prescription drugs, over-the-counter drugs, herbals, and dietary supplements

Safe medication administration is a vital component of the nursing role. Every day, nurses make critical decisions regarding the safety, appropriateness, and effectiveness of the medications administered to their clients. Examples of decisions that a nurse might make during client care are as follows:

• Is my client’s heart rate within the correct range to receive this beta-blocker medication?
• Does my client have adequate renal function prior to administering this dose of antibiotic?
• Is this pain medication effective in controlling my client’s discomfort?

To make safe decisions regarding medication administration, the nurse must have a strong understanding of  pharmacology , the science dealing with actions of drugs on the body. Symptom management and a client’s overall well-being are strongly connected to the appropriate administration of medications prescribed in a client’s treatment plan. Before a student nurse reviews a medication order, checks a medication administration record, or removes a medication from a dispensing machine, it is essential to have a foundational understanding of how medications interact with the human body. This chapter will review basic concepts related to pharmacokinetics and pharmacodynamics.

1.2. PHARMACOKINETICS

Pharmacokinetics – examining the interaction of body and drug.

Pharmacokinetics  is the term that describes the four stages of absorption, distribution, metabolism, and excretion of drugs. Drugs  are medications or other substances that have a physiological effect when introduced to the body. There are four basic stages a medication goes through within the human body: absorption, distribution, metabolism, and excretion. This entire process is sometimes abbreviated  ADME .

Absorption  is the first stage of pharmacokinetics and occurs after medications enter the body and travel from the site of administration into the body’s circulation.  Distribution  is the second stage of pharmacokinetics. It is the process by which medication is spread throughout the body.  Metabolism  is the third stage of pharmacokinetics and involves the breakdown of a drug molecule.  Excretion  is the final stage of pharmacokinetics and refers to the process in which the body eliminates waste. Each of these stages is described separately in the following sections of this chapter.

Research scientists who specialize in pharmacokinetics must also pay attention to another dimension of drug action within the body: time. Scientists do not have the ability to visualize where a drug is going or how long it is active. To compensate, they use mathematical models and precise measurements of blood and urine to determine where a drug goes and how much of the drug (or breakdown product) remains after the body processes it. Other indicators, such as blood levels of liver enzymes, can help predict how much of a drug is going to be absorbed.

Principles of chemistry are also applied while studying pharmacokinetics because the interactions between drugs and body molecules represent a series of chemical reactions. Understanding the chemical encounters between drugs and biological environments, such as the bloodstream and the oily surfaces of cells, is necessary to predict how much of a drug will be metabolized by the body.

Pharmacodynamics  refers to the effects of drugs in the body and the mechanism of their action. As a drug travels through the bloodstream, it exhibits a unique  affinity  for a drug-receptor site, meaning how strongly it binds to the site. Drugs and receptor sites create a lock and key system (see Figure 1.1 [ 1 ]) that affect how drugs work and the presence of a drug in the bloodstream after it is administered. This concept is broadly termed as drug  bioavailability .

Pharmacodynamics: Drug and Receptor Binding

The bioavailability of drugs is an important feature that chemists and pharmaceutical scientists keep in mind when designing and packaging medicines. However, no matter how effectively a drug works in a laboratory simulation, the performance in the human body will not always produce the same results, and individualized responses to drugs have to be considered. Although many responses to medications may be anticipated, a person’s unique genetic makeup may significantly impact their response to a drug.  Pharmacogenetics  is defined as the study of how people’s genes affect their response to medicines.[ 2 ]

1.3. ABSORPTION

The first stage of pharmacokinetics is known as  absorption . Absorption occurs after drugs enter the body and travel from the site of administration into the body’s circulation. Medications can enter the body through various routes. Common routes to administer medications include the following examples:

• Oral (swallowing an aspirin tablet)
• Enteral (administering medication into the gastrointestinal tract via a nasogastric tube)
• Rectal (administering an acetaminophen suppository)
• Intranasal (spraying allergy medication into the nose)
• Inhalation (breathing in asthma medication from an inhaler)
• Intramuscular (injecting an influenza vaccine into the deltoid muscle)
• Subcutaneous (injecting insulin into the subcutaneous tissue in the abdomen)
• Transdermal (wearing a nicotine patch that is absorbed through the skin)
• Intravenous (administering antibiotics directly into a vein)

First-Pass Effect

When a medication is administered orally or enterally, absorption may be significantly hindered in the gastrointestinal (GI) tract. For example, when medications made of protein are introduced into the GI tract, they can be quickly deactivated by enzymes as they pass through the stomach and duodenum. If some of the drug is absorbed from the intestine into the bloodstream, part of the absorbed portion may be broken down by liver enzymes, whereas the remaining part escapes into the general circulation. The portion of the drug that enters the general circulation will either become protein-bound (and thus inactive) or remain free to circulate and create an action at a receptor site. This entire process that results in reduced concentration of active drug available in an individual’s circulation is known as the  first-pass effect . Due to the first-pass effect, prescribing providers and nurses administering medications must understand that several doses of an oral medication may be needed before enough free drug stays active in the circulation to exert the desired effect. These metabolic effects are further described in the “ Metabolism ” section later in this chapter.

Alternate Routes

A workaround to the first-pass effect is to administer medication using alternate routes to the GI tract. Examples of alternative routes that avoid the first-pass effect include transdermal, nasal, inhalation, injection, or intravenous administration of medication. Alternative routes of medication administration bypass the first-pass effect by entering the bloodstream directly or via absorption through the skin or lungs. For example, pain relievers may be administered directly into the bloodstream (referred to as intravenous medications) so they are quickly available for distribution to tissues within the body.

Alternative routes of medication have other potential considerations. For example, injections are often painful and cause a break in the skin, an important barrier to infection. They can also be costly and difficult to administer daily, may cause localized side effects, or contribute to unpredictable fluctuations in medication blood levels.

Transdermal application of medication is an alternate route that has the primary benefit of slow, steady drug delivery directly to the bloodstream, without passing through the liver first. See Figure 1.2 [ 1 ] for an image of a client self-administering a transdermal patch. Drugs delivered transdermally enter the blood via a meshwork of small arteries, veins, and capillaries in the skin. This makes the transdermal route of drug delivery particularly useful when a medication must be administered over a longer period of time to control symptoms. For example, transdermal application of fentanyl, a pain medication, can provide effective pain management over a several hours; a scopolamine patch can control motion sickness over the duration of a cruise ship vacation; and a nitroglycerin patch is used to prevent chronic chest pain. Despite their advantages, transdermal patches have a significant drawback in that only very small drug molecules can enter the body through the skin, making this application route inappropriate for some types of medications.

Applying Transdermal Patch

Inhaling drugs through the nose or mouth is another alternative route for rapid medication delivery that bypasses the liver. See Figure 1.3 for an image of a client self-administering an inhaler.[ 2 ] Metered-dose inhalers have been a mainstay of asthma therapy for several years, and nasal steroid medications are often prescribed for allergy and sinus problems.

Adult Using Inhaler

EMERGING DISCOVERIES AND RECENT DEVELOPMENTS

Researchers are currently exploring alternative methods of drug delivery such as the use of inhaled insulin powders. Afrezza® is an example of an inhaled insulin approved by the Food and Drug Administration (FDA) to assist with blood sugar control. This technology stems from novel uses of chemistry and engineering to manufacture insulin particles of just the right size for absorption. If too large, the insulin particles could lodge in the lungs; if too small, the particles will be exhaled.[ 3 ]

Life Span Considerations

Neonate & pediatric.

Gastric absorption in neonates and pediatric clients varies from adults. In infants, the acid-producing cells of the stomach are immature until around the age of one to two years. Additionally, gastric emptying may be decreased because of slowed or irregular peristalsis (coordinated muscle movements of the intestines).

The liver of infants and children is not fully mature, resulting in a decrease in first-pass elimination and subsequently higher drug levels in the bloodstream.[ 4 ]

OLDER ADULT

As a natural result of aging, older adults will experience decreased blood flow to tissues within the GI tract. In addition, there may be changes in the gastric (stomach) pH that may alter the absorption of certain medications. Older adult clients may also experience variations in available plasma proteins, which can impact drug levels of medications that are highly protein-bound.

Consideration must also be given to the use of subcutaneous and intramuscular injections in older clients experiencing decreased cardiac output because decreased drug absorption of medications can occur when peripheral circulation is decreased. Additionally, as adults age, they often have less subcutaneous fat, resulting in decreased absorption of medication from transdermal patches that require adequate subcutaneous fat stores for proper absorption.[ 5 ]

The box below summarizes route considerations that a nurse should consider when administering medication.

Route Considerations

Oral (PO) or Enteral (NGT, GT, OGT) Ingestion

• Oral route is a convenient route for administration of solid and liquid formulations.
• Additional variables that may influence the rate and extent of absorption include enteric coating or extended-release formulations, acidity of gastric contents, gastric emptying rate, dietary contents, and presence of other drugs.
• First-pass effect: Blood containing the absorbed drug passes through the liver, which can deactivate a substantial amount of the drug and decrease its bioavailability (the percentage of dose that reaches the systemic circulation).

Parenteral Injection

• Subcutaneous and intramuscular administration: Injections can be difficult for clients to self-administer at home or to administer on a daily basis. They can be costly and painful. Injections also cause a break in skin that is an important barrier to infection, can cause fluctuation in drug levels, and can cause localized side effects to skin, such as bruising, redness, bleeding, and swelling.
• Intravenous (IV): IV drugs are fully available to tissues after administration into the bloodstream, offering complete bioavailability and an immediate effect. However, this route requires intravenous access that can be painful to the client and also increases risk for infection. Medications must be administered in sterile fashion, and if two products are administered simultaneously, their compatibility must be verified. There is also an increased risk of toxicity to the kidneys or liver.

Pulmonary Inhalation

• Inhalation allows for rapid absorption of drugs in gaseous, vaporized, or aerosol form through the lung tissue.

• Absorption of particulates/aerosols depends on particle/droplet size, which influences depth of entry through the pulmonary tree to reach the alveoli.

• The ability of the client to create successful inhalation, especially in the presence of bronchospasm, may also influence depth of entry in the pulmonary tree.

Topical and Transdermal Application

• Topical creams, lotions, and ointments are generally used for local effect; transdermal patch formulations are used for systemic effect.

• Absorption through the buccal or sublingual membranes may be rapid and is used for systemic effect.

• Absorption through skin is generally slower but produces a steady, long-term effect that avoids the first-pass effect. However, absorption of medication is affected by blood flow to the skin.[ 6 ] For this reason, heat and cold applications should not be used over transdermal medications.

1.4. DISTRIBUTION

Distribution.

The second stage of pharmacokinetics is the process known as  distribution . Distribution is the process by which a drug is dispersed throughout the body’s blood and tissues. After a drug enters into systemic circulation by absorption or direct administration, it will pass from vascular spaces to tissues where a drug-receptor interaction will occur, creating the effect of the drug.

Drugs are designed to primarily cause one effect, meaning they bind more strongly to one specific receptor site and predictably cause or block an action. However, side effects and adverse effects can occur when the drug binds to other sites in addition to the target tissue, causing an unintended action. These side effects can range from tolerable to unacceptable and can result in the discontinuation of the medication. For example, a person might take the pain reliever ibuprofen (Advil) to treat a sore leg muscle, and the pain may be subsequently relieved, but there may also be stomach irritation as a side effect.

The distribution of a drug throughout the body is dependent on many body-related factors such as blood flow, tissue differences, plasma protein-binding, the blood-brain barrier, and the placental barrier.

The circulatory system transports medications throughout the body in the bloodstream. Many factors can affect the blood flow and delivery of medication, such as decreased blood flow (due to dehydration), blocked vessels (due to atherosclerosis), constricted vessels (due to uncontrolled hypertension), or weakened pumping by the heart muscle (due to heart failure). As an example, when administering an antibiotic to a client with diabetes who has an infected toe, it may be difficult for the antibiotic to move through the blood vessels all the way to the area of the toe that is infected because of blocked vessels in the legs and feet due to atherosclerosis.

Tissue Differences

Distribution occurs most rapidly into tissues with a greater number of blood vessels that allow high blood flow (such as the lungs, kidneys, liver, brain). Distribution occurs least rapidly in tissues with fewer numbers of blood vessels (such as fat), resulting in low blood flow. However, lipophilic drugs (i.e., drugs that dissolve in lipid environments) disproportionately distribute into adipose tissue in obese subjects.

The permeability of capillaries is tissue-dependent. Capillaries of the liver and kidney are porous, allowing for greater permeability. Distribution rates are relatively slower or nonexistent into the central nervous system because of the tight junction between capillary endothelial cells and the blood-brain barrier.

Protein-Binding

After a drug enters the bloodstream, a portion of it exists as free drug, dissolved in plasma water, but a portion of it becomes bound to proteins. This is important because only free and unbound drugs will pass from the bloodstream to tissues where drug-receptor interactions will occur, thus producing the first effects of a medication. The other portion of the drug that becomes “protein-bound” is inactive while it is bound. For many drugs, these bound forms can account for 95-98% of the total.[ 1 ]

Protein binding can also act as a reservoir as the drug is released slowly, causing a prolonged action. When considering drug distribution, it is important to consider both the amount of free drug that is readily available to tissues, as well as the protein binding that causes the drug to be released over time.

Albumin is one of the most important proteins in the blood. Albumin levels can be decreased by several factors such as malnutrition and liver disease. Therefore, clients with low albumin levels may experience differences in the desired actions of administered medication because of the consequence effect on protein-binding and distribution.

Competition for plasma binding can also impact the effects of drugs. For example, aspirin and warfarin are anticoagulants that compete for the same plasma protein-binding site. Administering both drugs at the same time will increase the amount of unbound drug, thereby increasing their effects and increasing the client’s risk for bleeding.[ 2 ]

As an analogy of how protein binding affects the distribution of medications, consider passengers at a bus stop going to their destination. See Figure 1.4 [ 3 ] for an image of a bus related to this analogy. Many passengers (i.e., drug molecules) want to take a ride on the bus. Everyone is eager to get to their destination (i.e., receptor sites) and tries to find a seat. Some passengers are stronger than others and take all the seats first (such as drug molecules with greater protein-binding ability). When there aren’t enough seats on the bus, some passengers are left at the bus stop and become “free” to move around or walk to their destination. In a similar way, “free” drug molecules that are not protein-bound circulate freely in the bloodstream. The “free” passengers in this analogy may go directly to their destination, or they may stop at other locations along the route. In a similar manner, “free” drug molecules produce the first intended or unintended effects in the body when they attach to receptors. Furthermore, similar to the passengers who had seats on the bus and then later got off at their destination, the medication molecules attached to proteins are eventually released and attach to the receptor sites.

Protein-Binding Like Available Seats on a Bus

Blood-Brain Barrier

Medications destined for the central nervous system (the brain and spinal cord) face an even larger hurdle than protein-binding; they must also pass through a nearly impenetrable barricade called the  blood-brain barrier . This blockade is built from a tightly woven mesh of capillaries that protect the brain from potentially dangerous substances, such as poisons or viruses. Only certain medications made of lipids (fats) or those with a “carrier” can get through the blood-brain barrier.

Scientists have devised ways for medications to penetrate the blood-brain barrier. For example, the brand-named medication Sinemet® is a combination of two drugs: carbidopa and levadopa. Carbidopa is designed to carry the levadopa medication across the blood-brain barrier, where it enters the brain and is converted into dopamine to exert its effect on symptoms related to Parkinson’s disease.

Some medications inadvertently bypass the blood-brain barrier and impact an individual’s central nervous system function as a side effect. For example, diphenhydramine is an antihistamine used to decrease allergy symptoms. However, it can also cross the blood-brain barrier, depress the central nervous system, and cause the side effect of drowsiness. In the case of a person who has difficulty falling asleep, this drowsy side effect may be useful, but for a person trying to carry out daily activities, drowsiness can be problematic.

Placental Barrier

The placenta links mother and fetus, and the blood-placental barrier regulates transfer of molecules between maternal and fetal circulation to protect the fetus. Drug transporters are involved in transport of drugs through the placenta, affecting potential drug distribution to the fetus.[ 4 ] The placenta is known to be permeable to some medications, and furthermore, some drugs can cause significant harm to the fetus. However, many medications have not been specifically studied in pregnant clients and their effects on the fetus are unknown.

For this reason, it is always important to consider the potential effects of medication on the fetus if it is administered to a client who is pregnant or who may become pregnant. Nurses play a critical role in notifying the health care provider regarding potential safety concerns if medication can be distributed to the fetus. Nurses must always check a recent, evidence-based drug reference before administering medications to a client who is pregnant or may become pregnant. This imperative is implied in the remaining chapters.

Fat content in infants and children is decreased because of greater total body water. Additionally, protein-binding capacity is decreased, and the developing blood-brain barrier allows more drugs to enter the central nervous system.[ 5 ]

At the same body mass index, older adults, on average, tend to have more body fat than younger adults. This increased body fat can result in a longer duration of action for many medications that accumulate in fatty tissues. Serum albumin also decreases, resulting in more active free drug circulating within the body. For these reasons related to distribution, many older adult clients require lower dosages of medication.[ 6 ]

1.5. METABOLISM

After a drug has been absorbed and distributed throughout the body, it is broken down by a process known as  metabolism  so that it can be excreted from the body. Drugs undergo chemical alteration by various body systems to create compounds that are more easily excreted.

As previously discussed in this chapter, medications that are swallowed or otherwise administered into the gastrointestinal tract are inactivated by the intestines and liver, known as the first-pass effect. Additionally, everything that enters the bloodstream, whether swallowed, injected, inhaled, absorbed through the skin, or produced by the body itself, is metabolized by the liver. See Figure 1.5 [ 1 ] for an image of the liver. These chemical alterations are known as biotransformations. The biotransformations that take place in the liver are performed by liver enzymes.

Biotransformations occur by mechanisms categorized as either Phase I (modification), Phase II (conjugation), and in some instances, Phase III (additional modification and excretion.)[ 2 ]

Phase I biotransformations alter the chemical structure of the drug. Many of the products of enzymatic breakdown, called metabolites, are less chemically active than the original molecule. For this reason, the liver is referred to as a “detoxifying” organ. An example of a Phase I biotransformation is when diazepam, a medication prescribed for anxiety, is transformed into desmethyldiazepam and then to oxazepam. Both these metabolites produce similar physiological and psychological effects of diazepam.[ 3 ]

In some instances, Phase I biotransformations change an inactive drug into an active form called a “prodrug.” Prodrugs improve a medication’s effectiveness. They may also be designed to avoid certain side effects or toxicities. For example, sulfasalazine is a medication prescribed for rheumatoid arthritis. It is prodrug that is not active in its ingested form but becomes active after Phase I modification.

Phase II biotransformations involve reactions that couple the drug molecule with another molecule in a process called conjugation. Conjugation typically renders the compound pharmacologically inert and water-soluble so it can be easily excreted. These processes can occur in the liver, kidney, lungs, intestines, and other organ systems. An example of Phase II metabolism is when oxazepam, the active metabolite of diazepam, is conjugated with a molecule called glucuronide so that it becomes physiologically inactive and is excreted without further chemical modification.[ 4 ]

Following Phase II metabolism, Phase III biotransformations may also occur, where the conjugates and metabolites are excreted from cells.[ 5 ]

Factors Affecting Metabolism

Critical factors in drug metabolism are the type and concentration of liver enzymes. The most important enzymes for medical purposes are monoamine oxidase and cytochrome P450. These two enzymes are responsible for metabolizing dozens of chemicals.[ 6 ]

Drug metabolism can be influenced by a number of factors. One major disruptor of drug metabolism is depot binding. Depot binding is the coupling of drug molecules with inactive sites in the body, resulting in the drug not being accessible for metabolism. This action can also affect the duration of action of other medications susceptible to depot binding. For example, tetrahydrocannabinol (THC), the main psychoactive component of marijuana, is highly lipid-soluble and depot binds in the adipose tissue of users. This interaction drastically slows the metabolism of the drug, so metabolites of THC can be detected in urine weeks after the last use.[ 7 ]

Another factor in drug metabolism is enzyme induction. Enzymes are induced by repeated use of the same drug. The body becomes accustomed to the constant presence of the drug and compensates by increasing the production of the enzyme necessary for the drug’s metabolism. This contributes to a condition referred to as tolerance and causes clients to require ever-increasing doses of certain drugs to produce the same effect. For example, clients who take opioid analgesics over a long period of time will notice that their medication becomes less effective over time.[ 8 ]

In contrast, some drugs have an inhibitory effect on enzymes, making the client more sensitive to other medications metabolized through the action of those enzymes. For example, monoamine oxidase inhibitors (MAOIs) are prescribed as antidepressants because they block monoamine oxidase, the enzyme that breaks down serotonin and dopamine, thus increasing the concentration of these chemicals in the central nervous system. However, this can cause problems when clients taking an MAOI also take other medications that increase the levels of these chemicals, such as dextromethorphan found in cough syrup.[ 9 ]

Additionally, drugs that share metabolic pathways can “compete” for the same binding sites on enzymes, thus decreasing the efficiency of their metabolism. For example, alcohol and some sedatives are metabolized by the cytochrome P450 enzyme and only a limited number of these enzymes exist to break these drugs down. Therefore, if a client takes a sedative after drinking alcohol, the sedative is not well-metabolized because most of cytochrome P450 enzymes are filled by alcohol molecules. This results in reduced excretion and high levels of both drugs in the body with enhanced effects. For this reason, the co-administration of alcohol and sedatives can be deadly.

Clinical Significance

When administering medication, nurses must know how and when the medication is metabolized and eliminated from the body. Most of the time, the rate of elimination of a drug depends on the concentration of the drug in the bloodstream. However, the elimination of some drugs occurs at a constant rate that is independent of plasma concentrations. For example, the ethanol contained in alcoholic beverages is eliminated at a constant rate of about 15 mL/hour regardless of the concentration in the bloodstream.[ 10 ]

Half-life  refers to the rate at which 50% of a drug is eliminated from the body. Half-life can vary significantly between drugs. Some drugs have a short half-life of only a few hours and must be given multiple times a day, whereas other drugs have half-lives exceeding 12 hours and can be given as a single dose every 24 hours. See Figure 1.6 [ 11 ] for an illustration of half-life affecting the blood concentration of medication over time.

Half-Life Affecting Blood Concentration of Medication Over Time

Half-life affects the duration of the therapeutic effect of a medication. Many factors can influence half-life. For example, liver disease can prolong half-life if it is no longer effectively metabolizing the medication. Information about half-life of a specific medication can be found in evidence-based medication references. For example, in the “Clinical Pharmacology” section of the  DailyMed  reference for  furosemide,  the half-life is approximately two hours.

Depending on whether a drug is metabolized and eliminated by the kidneys or liver, impairment in either of these systems can significantly alter medication dosing, frequency of doses, anticipated therapeutic effect, and even whether a particular medication can be used at all. Nurses must work with other members of the health care team to prevent drug interactions that could significantly affect a client’s health and well-being. Nurses must be alert for signs of a toxic buildup of metabolites or active drugs, particularly if the client has liver or kidney disease, so that they can alert the health care provider. In other cases, drugs such as warfarin and certain antibiotics are dosed and monitored by pharmacists, who monitor serum levels of the drugs, as well as kidney function.

The developing liver in infants and young children produces decreased levels of enzymes. This may result in a decreased ability of the young child or neonate to metabolize medications. In contrast, older children may experience increased metabolism and require higher doses of medications once the hepatic enzymes are fully produced.[ 12 ]

Metabolism by the liver may significantly decline in the older adult. As a result, dosages should be adjusted according to the client’s liver function and their anticipated metabolic rate. First-pass metabolism also decreases with aging, so older adults may have higher “free” circulating drug concentrations and thus be at higher risk for side effects and toxicities.[ 13 ]

Critical Thinking Activity 1.5

Metabolism can be influenced by many factors within the body. If a client has liver damage, they may not be able to breakdown (metabolize) medications as efficiently. Dosages are calculated according to the liver’s ability to metabolize and the kidney’s ability to excrete.

When caring for a client with cirrhosis, how can this condition impact the dosages prescribed?

Note: Answers to the Critical Thinking activities can be found in the “ Answer Key ” section at the end of the book.

Did You Know?

Did you know that, in some people, a single glass of grapefruit juice can alter levels of drugs used to treat allergies, heart diseases, and infections? Fifteen years ago, pharmacologists discovered this “grapefruit juice effect” by luck, after giving volunteers grapefruit juice to mask the taste of a medicine. Nearly a decade later, researchers figured out that grapefruit juice affects the metabolizing rates of some medicines by lowering levels of a drug-metabolizing enzyme called CYP3A4 (part of the CYP450 family of drug-binding enzymes) in the intestines.

Paul B. Watkins of the University of North Carolina at Chapel Hill discovered that other juices like Seville (sour) orange juice—but not regular orange juice—have the same effect on the liver’s ability to metabolize using enzymes. Each of ten people who volunteered for Watkins’ juice-medicine study took a standard dose of felodopine, a drug used to treat high blood pressure, diluted in grapefruit juice, sour orange juice, or plain orange juice. The researchers measured blood levels of felodopine at various times afterward. The team observed that both grapefruit juice and sour orange juice increased blood levels of felodopine, as if the people had received a higher dose. Regular orange juice had no effect. Watkins and his coworkers have found that a chemical common to grapefruit and sour oranges, dihydroxybergamottin, is likely the molecular culprit. Thus, when taking medications that use the CYP3A4 enzyme to metabolize, clients are advised to avoid grapefruit juice and sour orange juice.[ 14 ]

1.6. EXCRETION

Excretion  is the final stage of a medication interaction within the body. The body has absorbed, distributed, and metabolized the medication molecules – now what does it do with the leftovers? Remaining parent drugs and metabolites in the bloodstream are often filtered by the kidney, where a portion undergoes reabsorption back into the bloodstream, and the remainder is excreted in the urine. The liver also excretes byproducts and waste into the bile. Another potential route of excretion is the lungs. For example, drugs like alcohol and the anesthetic gases are often eliminated by the lungs.[ 1 ]

Routes of Excretion

The most common route of excretion is through the kidneys. As the kidneys filter blood, the majority of drug byproducts and waste are excreted in the urine. The rate of excretion can be estimated by taking into consideration several client factors, including age, weight, biological sex, and kidney function. There are known sex differences in the three main renal functions of glomerular filtration, tubular secretion and tubular reabsorption. Renal clearance is generally higher in men than in women.[ 2 ]

Kidney function is measured by lab values such as serum creatinine, glomerular filtration rate (GFR), and creatinine clearance. If a client’s kidney function is decreased, then their ability to excrete medication is affected, and drug dosages must be altered for safe administration.

Renal disorders, such as chronic kidney disease, can reduce kidney function and hinder drug excretion. As kidney function decreases with age, drug excretion becomes less efficient, and dosing adjustments may be needed. Other medical conditions that impact blood flow to the kidneys can also affect drug elimination. For example, heart failure can affect systemic blood flow to the kidney, resulting in decreased filtration and elimination of drugs.

As the liver filters blood, some drugs and their metabolites are actively transported by hepatocytes (liver cells) to bile. Bile moves through the bile ducts to the gallbladder and then on to the small intestine. During this process, some drugs may be partially absorbed by the intestine back into the bloodstream. Other drugs are biotransformed (metabolized) by intestinal bacteria and reabsorbed. Unabsorbed drugs and byproducts/metabolites are excreted in the feces.

If a client has decreased liver function, their ability to excrete medication is affected, and drug dosages must be adjusted. Lab studies used to evaluate liver function are called liver function tests and include measurement of alanine transaminase (ALT) and aspartate aminotransferase (AST) enzymes that the body releases in response to damage to or disease of the liver.

Conditions that cause decreased blood flow to the liver can also affect the metabolism and excretion of drugs. For example, conditions such as shock, hypovolemia, or hypotension cause decreased liver perfusion and may require adjustment of dosages of medication.

Other Routes to Consider

Sweat, tears, reproductive fluids (such as seminal fluid), and breast milk can also contain drugs and byproducts/metabolites of drugs. This can pose a toxic threat, such as the exposure of an infant to breast milk containing drugs or byproducts of drugs ingested by the mother. Therefore, nurses must refer to a drug reference and contact a health care provider with any concerns before administering medications to a mother who is breastfeeding.[ 3 ]

Neonate & Pediatrics

Neonates and children have immature kidneys with decreased glomerular filtration, resorption, and tubular secretion. As a result, they do not excrete medications as efficiently from the body. Dosing for most medications used to treat infants and pediatric clients is commonly based on weight in kilograms, and a smaller dose is usually prescribed. In addition, pediatric clients may have higher levels of free circulating medication than anticipated and may become toxic quickly. Therefore, it is vital for nurses to diligently recheck dosages before administering medications and closely monitor infants and children for early identification of adverse effects and drug toxicity.[ 4 ]

Older Adult

Kidney and liver function often decrease with age, which can lead to decreased metabolism and excretion of medications. Subsequently, medication may have a prolonged half-life with a greater potential for toxicity due to elevated circulating drug levels. Some medications may be avoided or smaller doses recommended for older clients due to these factors, which is commonly referred to as “Start low and go slow.”[ 5 ]

Putting It All Together

Safely administering medications to clients is a significant concern and requires team effort by pharmacists, prescribing health care providers, and nurses. In addition to the factors described in this chapter, there are many other considerations for safe medication administration that are further explained in the “ Legal/Ethical ” chapter.

Critical Thinking Activity 1.6

When providing care for a client who has chronic kidney disease, how does this condition impact medication excretion?

Interactive Activity

“Pharmacokinetics Quiz” by E. Christman for Open RN is licensed under   CC BY 4.0

1.7. PHARMACODYNAMICS

Pharmacodynamics.

So far in this chapter, we have learned the importance of pharmacokinetics in how the body absorbs, distributes, metabolizes, and excretes a medication. Now let’s consider how drugs act on target sites of action in the body, referred to as  pharmacodynamics.

Mechanism of action  is a medical term that describes how a medication works in the body. For example, did you know that an osmotic laxative like magnesium citrate attracts and binds with water? The mechanism of action for this medication is it pulls water into the bowel, which softens stool and increases the likelihood of a bowel movement.

A drug’s mechanism of action may refer to how it affects a specific receptor. Many drugs bind to specific receptors on the surface of cells to cause an action. For example, morphine binds to a specific receptor that inhibits transmission of nerve impulses along the pain pathway and decreases a client’s feelings of pain.

Other medications inhibit specific enzymes for a desired effect. For example, earlier in this chapter we discussed how monoamine oxidase inhibitors (MAOIs) are prescribed as antidepressants because they block monoamine oxidase, the enzyme that breaks down serotonin and dopamine. This blockage increases the concentration of serotonin and dopamine in the central nervous system and increases a client’s feelings of pleasure.

Agonist and Antagonist Actions

Drugs have agonistic or antagonistic effects on receptor sites. An  agonist  binds tightly to a receptor to produce a desired effect. An  antagonist  competes with other molecules and blocks a specific action or response at a receptor site. See Figure 1.7 [ 1 ] for an illustration of how a beta-blocker, an antagonist cardiac medication, blocks specific action on the beta receptors of a cardiac cell.

Antagonist Action of Beta-Blockers on Beta Receptors of a Cardiac Cell

Agonistic and antagonistic effects on receptors for common classes of medications are further discussed in the “ Autonomic Nervous System ” chapter.

Critical Thinking Activity 1.7

Atenolol (Tenormin) is an antagonist medication. Does the nurse anticipate this will cause a specific action or block a specific action at a receptor site?

1.8. TYPES OF MEDICATIONS

There are a variety of drugs and substances that clients may utilize for symptom management or to enhance their wellness. Nurses document clients’ use of prescription medications, over-the-counter medications, herbal substances, and other supplements in the medical record. Some substances have a long half-life and have the potential to interact with new medications, so accuracy is vital. Ensuring an accurate medical record and knowledge of the different types of substances a client is taking is important for an effective nursing plan of care.

Prescription Medications

Drugs are prescribed by a licensed prescriber for a specific person’s use and regulated through the United States Food and Drug Administration (FDA). More information about FDA approval of medications is described in the “ Legal/Ethical ” chapter. Prescription medications include brand-name medications and generic medications.[ 1 ]

COMMON PREFIXES, SUFFIXES, AND ROOTS FOR CLASSES OF MEDICATION

Table 1.8 provides prefixes, suffixes, and roots associated with common prescription medications. As a nurse, familiarizing yourself with the content in the table can help you to quickly organize medications based on their name and recall their mechanism of action and identify potential interactions or side effects. This knowledge can improve your ability to safely administer medications and provide health teaching. Ultimately, this knowledge can lead to improved client outcomes, increased satisfaction, and a reduced risk of adverse events and medication errors.

Common Classes of Medications, Examples, Suffixes, and Roots

View in own window

Generic Medications

Generic medications can be safe and effective alternatives to their brand-name counterparts at a significantly reduced cost. By law, generic medications must have the same chemically active ingredient in the same dose as the brand name (i.e., they must be “bio-equivalent”). However, the excipients (the base substance that holds the active chemical ingredient into a pill form (such as talc) or the flavoring can be different. Some clients do not tolerate these differences in excipients very well. When prescribing a medication, the provider must indicate that a generic substitution is acceptable. Nurses are often pivotal in completing insurance paperwork on the client’s behalf if the brand-name medication is more effective or better tolerated by that particular client.[ 2 ]

When studying medications in nursing school and preparing for the NCLEX, it is important to know medications by their generic name because the NCLEX does not include brand names in their questions.

Over-the-Counter Medications

Over-the-counter (OTC) medications do not require a prescription. They can be bought at a store and may be used by multiple individuals. OTC medications are also regulated through the FDA. Some prescription medications are available for purchase as OTC in smaller doses. For example, diphenhydramine (Benadryl) is commonly prescribed as 50 mg every 6 hours, and the prescription strength is 50 mg. However, it can also be purchased OTC in 25 mg doses (or less for children.)[ 3 ]

Herbals and Supplements

Herbs and supplements may include a wide variety of substances including vitamins, minerals, enzymes, and botanicals. Supplements such as “protein powders” are marketed to build muscle mass and can contain a variety of substances that may not be appropriate for all individuals. Herbals and supplements are often considered complementary and alternative medications (CAM).  Complementary and alternative medications (CAM)  are types of therapies that are commonly used in conjunction with or as an alternate to traditional medical therapies. These herbal and supplement substances are not regulated by the FDA, and most have not undergone rigorous scientific testing for safety for the public. While clients may be tempted to try these herbals and supplements, there is no guarantee that they contain the ingredients listed on the label. It is also important to remember that there is a potential for adverse effects or even overdose if the herbal or supplement contains some of the same drug that was also prescribed to a client.[ 4 ] By understanding the use of CAM therapies, nurses can help their clients make informed decisions and take a holistic approach to their care. Additionally, being knowledgeable about CAM therapies can help nurses to better educate their clients on the potential benefits and risks associated with these therapies, which can help improve client outcomes and satisfaction.

Read additional information on complementary and alternative medicine at the  National Center for Complementary and Integrative Health (NCCIH) Database .

1.9. efficacy, dose-response, onset, peak, and duration.

Dosing considerations play an important role in understanding the effect that a medication may have on a client. During administration, the nurse must pay close attention to the desired effect and therapeutic response, as well as the safe dose range for any medication.

The nurse should have an understanding of medication  efficacy  in order to ensure its appropriateness. If a nurse is provided a variety of medication choices according to a provider’s written protocol, the nurse should select the option with the anticipated desired therapeutic response.

Additionally, the nurse must be aware of the overall  dose-response  based on the dosage selected. Dose response is the dose of medication required to achieve the desired response to the medication. As the dose increases, the response of the drug may increase, as well as the potential for toxicity. This response helps determine the therapeutic index of a drug, or the effective dose range. The measured response and dose are often graphed perpendicular to each other, with the slope of the graph’s curve representing therapeutic index (or overall dose-effect). It is important to note that some medications have a very small therapeutic window, and even small increases in dosages can result in toxic effects. See Figure 1.8 [ 1 ] for an illustration of a dose-response graph.

Dose-Response Graph

Onset, Peak, and Duration

Three additional principles related to the effect a medication has on a client are onset, peak, and duration.

Onset  of medication refers to when the medication first begins to take effect. Time of onset is affected by the route of administration. For example, a diuretic given intravenously will begin to take effect much faster than a diuretic administered orally because the intravenous route delivers the drug directly to the systemic circulation and avoids the first-pass effect.

Peak  refers to the maximum concentration of medication in the body, and the client shows evidence of greatest therapeutic effect. For example, a client taking ibuprofen can anticipate maximum pain relief in one to two hours when the medication reaches peak serum levels.

Duration  refers to the length of time the medication produces its desired therapeutic effect. For example, the duration of oral acetaminophen is four to six hours, at which time the client will likely require an additional dose for pain.

Duration, Dosing, and Steady State

Now let’s consider the implication of duration and dosing. Remember the duration of medication is correlated with the elimination. Half-life is the amount of time that it takes for half of the drug to be eliminated from the body.

If a medication has a short half-life (and is therefore eliminated more quickly from the body), the therapeutic effect is shorter. These medications may require repeated dosing throughout the day in order to achieve steady blood levels of active free drug and a sustained therapeutic effect.

Other medications have a longer half-life (and therefore are eliminated more slowly from the body, resulting in longer therapeutic duration) and may only be administered once or twice per day. For example, oxycodone immediate release is prescribed every 4 to 6 hours for the therapeutic effect of immediate relief of severe pain, whereas oxycodone ER (extended release) is prescribed every 12 hours for the therapeutic effect of sustained relief of severe pain.

Steady state  refers to the point at which the amount of drug entering the body is equal to the amount of drug being eliminated, resulting in a stable drug concentration.[ 2 ] When steady state is achieved, there is a state of equilibrium in the body and the concentration of the drug remains constant, resulting in optimal therapeutic effect.

Clinical Example

Consider this client care example and apply the principles of onset, peak, and duration: A 67-year-old female postoperative client rings the call light to request medication for pain related to the hip replacement procedure she had earlier that day. She notes her pain is “excruciating, a definite 9 out of 10.” Her brow is furrowed, and she is grimacing in obvious discomfort. As the nurse providing care for the client, you examine her postoperative medication orders and consider the pain medication options available to you. In reviewing the various options, it is important to consider how quickly a medication will work (onset), when the medication will reach maximum effectiveness (peak), and how long the pain relief will last (duration). Understanding these principles is important in effectively relieving the client’s pain and constructing an overall plan of care.

Critical Thinking Activity 1.9

1. At 0500, your client who had a total knee replacement yesterday rates his pain while walking as 7 out of 10. Physical therapy is scheduled at 0900. The client has acetaminophen (Tylenol) 625 mg ordered every four hours as needed for discomfort. What should you consider in relation to the administration and timing of the client’s pain medication?

2. Your client is prescribed NPH insulin to be given at breakfast and supper. As a student nurse, you know that insulin is used to decrease blood sugar levels in clients with diabetes mellitus. During report, you hear that the client has been ill with GI upset during the night, and the nursing assistant just informed you he refused his breakfast tray. While reviewing this medication order, you consider the purpose of the medication and information related to the medication’s onset, peak, and duration. When reviewing the drug reference, you find the NPH insulin has an onset of about 1 – 3 hours after medication administration. What should you consider in relation to the administration and timing of the client’s insulin?

1.10. THERAPEUTIC LEVELS

Now that the concepts of dose-response, onset, peak, and duration have been discussed, it is important to understand the therapeutic window and therapeutic index.

Therapeutic Window

For every drug, there exists a dose that is minimally effective (the Effective Concentration) and another dose that is toxic (the Toxic Concentration). Between these doses is the  therapeutic window , where the safest and most effective treatment will occur. For example, see Figure 1.9 [ 1 ] for an illustration of the therapeutic window for warfarin, a medication used to prevent blood clotting. Too much warfarin administered causes bleeding and vitamin K is required as an antidote. Conversely, not enough warfarin administered for a client’s condition can cause clotting. Think of the therapeutic window (the green area on the graph) as the “perfect dose,” where clotting is prevented and yet bleeding does not occur.

The effect of warfarin is monitored using a blood test called international normalized ration (INR). For clients receiving warfarin, nurses vigilantly monitor their INR levels to ensure the dosage appropriately reaches their therapeutic window and does not place them at risk for bleeding or clotting.

Peak and Trough Levels

Now let’s apply the idea of therapeutic window to the administration of medications requiring the monitoring of peak and trough levels, which is commonly required in the administration of specific IV antibiotics. The dosage of these medications is  titrated , meaning adjusted for safety, to achieve a desired therapeutic effect for the client. Titration is accomplished by closely monitoring the peak and trough levels of the medication. A drug is said to be within the “therapeutic window” when the serum blood levels of an active drug remain consistently above the level of effective concentration (so that the medication is achieving its desired therapeutic effect) and consistently below the toxic level (so that no toxic effects are occurring).

A  peak  drug level is drawn after the medication is administered and is known to be at the highest level in the bloodstream. A  trough  level is drawn when the drug is at its lowest in the bloodstream, right before the next scheduled dose is given. Medications have a predicted reference range of normal values for peak and trough levels. These numbers assist the pharmacist and provider in gauging how the body is metabolizing, protein-binding, and excreting the drug and are used to adjust the prescribed dose to keep the medication within the therapeutic window. When administering IV medications that require peak or trough levels, it is vital for the nurse to plan the administration of the medication according to the timing of these blood draws.[ 2 ]

Therapeutic Index

The  therapeutic index  is a quantitative measurement of the relative safety of a drug. It is a comparison of the amount of drug that produces a therapeutic effect versus the amount of drug that produces a toxic effect.

• A large (or high) therapeutic index number means there is a wide therapeutic window between the effective concentration and the toxic concentration of a medication, so the drug is relatively safe.
• A small (or low) therapeutic index number means there is a narrow therapeutic window between the effective concentration and the toxic concentration. A drug with a narrow therapeutic range (i.e., having little difference between toxic and therapeutic doses) often has the dosage titrated according to measurements of the actual blood levels achieved in the person taking it.

For example, phenytoin has a narrow therapeutic index between the effective and toxic concentrations. Clients who start taking phenytoin to control seizures have frequent peak and trough drug levels to ensure they achieve steady state with a therapeutic dose to prevent seizures without reaching toxic levels.

Critical Thinking Activity 1.10

Mr. Parker has been receiving gentamicin 80 mg IV three times daily to treat his infective endocarditis. He has his gentamicin level checked one hour after the end of his previous gentamicin infusion was completed. The result is 30 mcg/mL. Access the information below to determine the nurse’s course of action.

View information on therapeutic drug levels.

(After accessing the information, be sure to select “click to keep reading” in order to view drugs that are commonly checked, their target levels, and what abnormal results mean.)

Based on the results in the above client scenario, what action will the nurse take based on the result of the gentamicin level of 30 mcg/mL?

1.11. EVALUATING EFFECTS

Evaluating the effects.

The nurse is responsible for assessing the client, monitoring lab values, and recognizing side effects and/or adverse effects of medications. Drug dosages should be verified to ensure all are within recommended safe ranges according to the client’s current status, as well as for their potency.

Potency  refers to the amount of the drug required to produce the desired effect. A drug that is highly potent may require only a minimal dose to produce a desired therapeutic effect, whereas a drug that has low potency may need to be given at much higher concentrations to produce the same effect. Consider the example of opioid versus nonopioid medications for pain control. Opioid medications often have a much higher potency in smaller doses to produce pain relief; therefore, the overall dose required to produce a therapeutic effect may be much less than that for other analgesics.

The nurse preparing to administer medications must also be cognizant of drug selectivity and monitor for potential side effects and adverse effects.  Selectivity  refers to the separation between the desired and undesired effects of a drug. Drugs that are selective will search out target sites to create a specific drug action, whereas nonselective drugs may impact many other types of cells and tissues, thus increasing the risk for unintended side effects and/or adverse effects. For example, in Chapter 4 selective and nonselective beta-blockers will be discussed. Selective beta-1 blockers search out specific receptors on the heart to create their effect, whereas nonselective beta-blockers may affect receptors in the lungs in addition to those in the heart, causing potential respiratory side effects like a cough.

A  side effect  occurs when the drug produces effects other than the intended effect. A side effect, although often unintended, is generally anticipated by the provider and is a known potential consequence of the medication therapy. Examples of common side effects are nausea, vomiting, diarrhea, and drowsiness. In some situations, however, side effects may have a beneficial impact. For example, a side effect of hydrocodone is drowsiness. A client who is having difficulty sleeping due to pain and takes hydrocodone at bedtime may find the drowsiness beneficial in helping them fall asleep.

Conversely, unanticipated effects can occur from medications that are harmful to the client. These harmful occurrences are known as  adverse effects . Adverse effects are relatively unpredictable, severe, and are reason to discontinue the medication.[ 1 ] For example, an adverse effect of ciprofloxacin is tendon rupture. Adverse effects should be reported to the pharmacy and tracked as a client safety concern according to agency policy.

1.12. LEARNING ACTIVITIES

You have been introduced to many concepts related to pharmacokinetics and pharmacodynamics in this chapter. These basic concepts are important to understand as we examine various medication classes.

“Medication Absorption Quiz” by E. Christman for Open RN is licensed under   CC BY 4.0

“Pharmacokinetics Flashcards” by E. Christman for Open RN is licensed under   CC BY 4.0

Light Bulb Moment

Test your knowledge and application. Use the information in the text above, as well as the  DailyMed  resource, to read more about the medications included in the client scenarios. Additional pharmacokinetics information can be found under the “Clinical Pharmacology” section of each drug in DailyMed.

2. You are working in a nursing home caring for an 86-year-old stroke client who complains of left knee pain secondary to arthritis. The client has right-sided weakness and difficulty swallowing with no gag reflex. You review the client’s medication administration record (MAR) and note the provider has prescribed acetaminophen 325 mg either per oral or per rectal route. Which route would you choose and why?

3. Mr. Johnson is a 92-year-old male admitted to the medical-surgical unit for severe pneumonia, and the provider prescribed gentamicin antibiotic therapy. Upon review of the order, you notice the initial dose is ordered at less than the standard recommended dose. What is the rationale behind the decreased starting gentamicin dose for this client?

4. Sara is a nurse working on the medical-surgical floor. She is reviewing her client’s chart and notes her client has a 0600 vancomycin infusion; however, the trough level is not available. The nurse phones the lab, and they state they will not be available to draw the trough level for an hour. What actions should the nurse take?

5. Sam is a nurse working on the cardiology floor. He has an order to administer a dose of atenolol (a beta-blocker medication) to a client at 0800. What actions should the nurse take prior to administering the medication? What is the anticipated therapeutic effect of this medication?

6. Julia is a 56-year-old client admitted to the cardiology unit with new-onset atrial fibrillation. She has been prescribed amiodarone for her irregular heartbeat and is set to receive her first dose with her morning breakfast tray. When you arrive in the room, you notice that she has grapefruit juice on her breakfast meal tray. Is this a concern? Why? As the nurse, what is your next action?

7. A nurse is caring for a 55-year-old male who recently was admitted to the medical-surgical unit for a total knee replacement. He is prescribed hydrocodone/acetaminophen 5/325 mg (Norco) every six hours for moderate pain. The client complains of pain in the knee, rating it at a “6.” Review the “Clinical Pharmacology” section for this medication using the  DailyMed , and answer the following questions:

• When does the nurse anticipate the medication will peak in action?

• When does the nurse anticipate another dose will be needed due to the half-life of this drug?

Note: Answers to the Light Bulb Moment can be found in the “ Answer Key ” section at the end of the book.

Test your clinical judgment with this NCLEX Next Generation-style bowtie question:  Pain Medication. [ 1 ]

I. GLOSSARY

The first stage of pharmacokinetics where medications enter the body and travel from site of administration into the body’s circulation.

An unintended and potentially dangerous pharmacological effect that occurs when a medication is administered correctly.

The strength of binding between drug and receptor.

A drug that binds to a “receptor” and produces an effect.

A molecule that prevents the action of other molecules, often by competing for a cellular receptor; opposite of agonist.

The presence of a drug in the bloodstream after it is administered.

A nearly impenetrable barricade that is built from a tightly woven mesh of capillaries cemented together to protect the brain from potentially dangerous substances such as poisons or viruses.

The second stage of pharmacokinetics where medication is dispersed throughout the body via the bloodstream.

The dose of medication required to achieve the desired response to the medication.

The length of time that a medication is producing its desired therapeutic effect.

The maximum effect of which the drug is capable.

The final stage of pharmacokinetics where drug byproducts and metabolites are eliminated from the body.

The inactivation of orally or enterally administered drugs in the liver and intestines.

How a medication works at a cellular level within the body.

The third stage of pharmacokinetics that involves the breakdown of a drug so that it can be excreted by the body.

When a medication first begins to work and exerts a therapeutic effect.

When the maximum concentration of a drug is in the bloodstream.

The effects of drugs in the body and the mechanism of their action.

The study of how a person’s genetic makeup affects their response to medicines.

The study of how the body absorbs, distributes, metabolizes, and eliminates drugs.

The science dealing with actions of drugs on the body.

The science of the preparation of drugs.

The drug dose required to produce a specific intensity of effect.

The separation between the desired and undesired effects of a drug.

Effect of a drug, other than the desired effect, sometimes in an organ other than the target organ.

A quantitative measurement of the relative safety of a drug that compares the amount of drug that produces a therapeutic effect versus the amount of drug that produces a toxic effect. Medication with a large therapeutic index is safer than a medication with a small therapeutic index.

The dosing window in which the safest and most effective treatment will occur.

Licensed under a Creative Commons Attribution 4.0 International License. To view a copy of this license, visit https://creativecommons.org/licenses/by/4.0/ .

• Cite this Page Open Resources for Nursing (Open RN); Ernstmeyer K, Christman E, editors. Nursing Pharmacology [Internet]. 2nd edition. Eau Claire (WI): Chippewa Valley Technical College; 2023. Chapter 1 Pharmacokinetics & Pharmacodynamics.
• PDF version of this title (145M)

In this Page

• PHARMACOKINETICS & PHARMACODYNAMICS INTRODUCTION
• PHARMACOKINETICS
• DISTRIBUTION
• PHARMACODYNAMICS
• TYPES OF MEDICATIONS
• EFFICACY, DOSE-RESPONSE, ONSET, PEAK, AND DURATION
• THERAPEUTIC LEVELS
• EVALUATING EFFECTS
• LEARNING ACTIVITIES

Other titles in this collection

• Open RN OER Textbooks

Related Items in Bookshelf

• All Textbooks

Bulk Download

• Bulk download content from FTP

Related information

• PMC PubMed Central citations
• PubMed Links to PubMed

Recent Activity

• Chapter 1 Pharmacokinetics & Pharmacodynamics - Nursing Pharmacology Chapter 1 Pharmacokinetics & Pharmacodynamics - Nursing Pharmacology

Your browsing activity is empty.

Activity recording is turned off.

Turn recording back on

Connect with NLM

National Library of Medicine 8600 Rockville Pike Bethesda, MD 20894

Web Policies FOIA HHS Vulnerability Disclosure

Help Accessibility Careers

Pharmacology & Drug Study (Notes)

Comprehensive and detailed drug studies of the most commonly use drugs in clinical nursing. Make sure to study these drugs for your foundation in Pharmacology.

Pharmacology Study Guide for Nursing Students

In nursing school, pharmacology class is challenging for most students. Pharmacology focuses on how drugs work, their effects, and how the body utilizes drugs. Most nursing students find pharmacology very tough. When they are in clinicals, they have to administer medicines to patients under the careful supervision of their instructors.

Pharmacology is one of the most essential subjects in nursing school because nurses are the ones who dispense medicines to patients. Nurses are also the one who supervises how well the patient is tolerating certain medications.

Without understanding how drugs work, a nurse might dose her patient with too much or too little medication, causing harm to her patient. A nurse must spend a significant amount of time in nursing school learning about hundreds of drugs.  So let’s talk about Pharmacology Study Guide for Nursing Students to help make mastering pharmacology a little easier.

In this article, we are going to talk about:

• Common problems students have in Pharmacology in Nursing Program
• Strategic ways  and study plan on How to ace Pharmacology for Nurses

But before, let’s take a brief look at the pharmacology course.

Why is Pharmacology a Challenging Course for Nurses?

Nursing students should not give up.

• Nursing Exams Can Be Hard, but It's Worth It!

Pharmacology Notes for Nurses

Pharmacology is a challenging course for nursing students because it requires them to know how drugs work. During clinical, nurses need to have enough knowledge about medications to plan when giving specific doses to their patients. Nurses are required to be knowledgeable to prevent dangerous drug interactions.

If a nurse does her patient the wrong way or has an inappropriate timing in giving medications, then that nurse will have problems with their nursing license and can even lose it if mistakes are big enough. It is crucial to learn pharmacology well so that nurses won’t make any severe mistake of administering meds during clinical rotations.

Pharmacology’s Content

Pharmacology courses contain much content, but most nursing students have trouble with drug calculation and metabolism. Some of the classes covered during pharmacology are Pharmacodynamics, Pharmacodynamics, Pharmacokinetics, Drug Metabolism, Excretion Mechanisms & Non-Prescription Medications.

These are some subtopics discussed in the pharmacology course that requires knowledge from students. Depending on the school where you are studying, there might be a different set of content for pharmacology courses. However, all nursing students have to learn about these essential facts about medications if they want to become a nurse.

Nursing school can be challenging, but most students enjoy going to classes and learning about topics related to nursing. However, pharmacology is very hard because there is much information about medications that need to be taught for nursing students to understand the whole picture of what they need to learn during their clinical.

Nursing students must know when to give certain medications to patients not to cause harm in drug interactions. Also, nurses need to know about administering specific dosages without making severe mistakes in administering meds to prevent errors caused by poor nurse practices. Drug dosage calculation is very important.

What Are the Problems Nursing Students Have in Pharmacology?

When it comes to the student’s problem, every student may be facing different issues, but the following are some common problems that almost every nursing students have during their pharmacology course:

Developing a Study Method to Use

When it comes to studying pharmacology, the first thing first is to develop a study method that’s customized for you. Everyone has their own way of studying and it should be made according to your preferences. There are many ways on how students can study pharmacology like reading lecture notes, reviewing questions, attending lectures, studying textbooks, writing down summaries of what was learned during classes, etc.

Learning What Material Is Essential to Know and What Is Not

Many students wonder how to make things easier for them to study pharmacology. Nursing students need to know what material is necessary and what is not because it will save their time and energy in studying unnecessary and unimportant materials to be learned.

Try to Memorize Every Single Drug Name and Its Side Effects

When it comes to memorizing drug pre-fixes and names, their side effects, students need to know about every individual drug. Students need to prioritize learning drugs essential to learning compared to those unrelated to the nursing profession. Certain medications need only high school basic knowledge of taking care of patients to take the information.

When it comes to cramming, it is not a part of the study method when studying pharmacology. There are many things that students need to learn about which is essential for them to know. Still, it is not recommended that nursing students do cramming when taking pharmacology because it is dangerous since there are many medications with different sides effects if they are taken in high dosage.

Most students find it hard to study pharmacology because of the high dosage of information they need to learn. However, there are some tips on how nursing students can ace their pharmacology course without studying too much and spending too much time memorizing drug names.

Make Outlines

After reading your lecture notes or your book for pharmacology, make outlines according to the topics covered by the teacher/professor during lectures or class discussions. These outlines will allow you to know what subtopics/chapters were discussed, including new terms and acronyms learned during the debate, which is vital for you to remember so that you don’t forget them when taking exams.

Review Materials Before Taking the Test

Before taking your exam, review all of your materials, notes, medication cards , and outlines that you have made at home. This will help you refresh your mind with what was discussed in class which is essential when taking lecture exams. Also, some students like to make flashcards of drugs names and their side effects, which is also an excellent way to study pharmacology.

Utilize Your Resources

There is no need for nursing students to study everything on their own; they can always seek help from other sources – professors, classmates, or even friends – who have the same class with you so that you guys could share ideas and concepts about what was discussed during lecture, instead of going to school/classrooms and listening to unnecessary things again.

Don’t Be Too Hard on Yourself

Take pharmacology as a subject that is easy to learn, and it’s okay if you don’t know everything about medications and their side effect; it is super normal for students who are taking this type of course.

Nursing students should not be afraid to ask professors questions if they find something confusing – professors will always answer your question with a clear explanation – instead of giving up studying altogether.

It is better to research pharmacology after discussing things with your classmates or friends than to learn alone without knowing what you’re learning because you fear that you might get something wrong, leading to failing the course. You can find in-depth online tutorials on youtube about your subject.

Studying pharmacology is difficult for nursing students because they are afraid of getting things wrong. After all, it can reflect poorly on them even if they have the best intentions. However, being a bad student is never an option which makes studying pharmacology easier for everyone.

Nursing students need to practice self-discipline and determination when taking this type of subject so that their grades won’t go down because of poor study habits. As long as you know what you are studying, where to find information, or how to learn something new, everything will be okay; don’t ever forget that it is a lifelong process, and you will know things step by step.

Where to Find Pharmacology Study Guide for Nursing Students

• Nursing Cheatsheets from Nursing.com
• Free Pharmacology Study Guides from Nurseslabs
• Pharmacology Guides and Flashcards from Level Up RN
• Pharmacology Study Guide Bundle
• Pharmacology study guide to pass BSN pharmacology class

Nursing Exams Can Be Hard, but It’s Worth It!

Many nursing students find themselves overwhelmed with the amount of information that they need to memorize to ace their pharmacology examinations; this is the reason why some people would rather quit studying and give up on what they have learned.

However, suppose nursing students feel like giving up. In that case, they should not because there are many ways to study for an exam – all of them do not necessarily mean memorizing everything about medications and their side effect – which will guarantee them passing marks/grades at the end of the semester.

So we hope you liked this information, don’t forget to share this with your friends because they might be facing the same issue as you are. Our only purpose is to help students with their exams.

Also Check Out:

• How to Study Pharmacology
• 5 Tips to Master Pharmacology for Nurses
• 3 Pharmacology Tips to Help You Pass the NCLEX
• Nursing Math Questions

About The Author

Brittney wilson, bsn, rn, related posts.

The Doctor-Nurse Relationship: Nurses Teach Doctors More Than You Think

How to Prepare and Register for Pearson VUE NCLEX

25 Inspirational School Quotes That Will Motivate You In Nursing School

How To Make Money While In Nursing School (9+ Options!)

Leave a comment cancel reply.

Your email address will not be published. Required fields are marked *

Save my name, email, and website in this browser for the next time I comment.

This site uses Akismet to reduce spam. Learn how your comment data is processed .

Start typing and press enter to search

2.1 Drug Administration and the Nursing Process

Learning outcomes.

By the end of this section, you should be able to:

• 2.1.1 Define the steps in the nursing process and how they relate to drug administration.
• 2.1.2 Apply the steps of nursing clinical judgment to drug administration.
• 2.1.3 Examine the principles of drug administration.
• 2.1.4 Identify the “seven rights” of drug administration.
• 2.1.5 Explain the nurse’s role in client education in regard to drug administration.

This section will describe the importance of making sound decisions, developing problem-solving skills through clinical reasoning, and how the nursing process relates to drug administration. This section will also discuss the seven rights of medication administration and the clinical judgment required for safe administration. The nursing process is a client-centered process and focuses on outcomes through a partnership relationship with the client and other health care providers.

Nursing Process

The nursing process is a method of critical thinking consisting of five steps that occur continuously while the client is in the nurse’s care. (The client may be an individual, a family, a group, or a community.) It is purposeful and systematic in its progression, designed to achieve optimal client outcomes. It is a framework for the nurse to apply scientific reasoning to client care. The steps to the nursing process are linear but overlap each other in their progression:

• Assessment of the client
• Diagnosis of actual or potential problems
• Planning nursing interventions
• Implementation of nursing interventions
• Evaluation of outcomes of nursing interventions as they relate to achieving the client’s goals

The client (not the nurse) is at the center of the nursing process, which encompasses health, wellness, and illness in a holistic sense, incorporating all aspects of the client—physical, psychological, social, emotional, cultural, and spiritual. The nurse is uniquely positioned to assess the whole client, administer therapies (including medications), evaluate their effectiveness, and teach the client about how to maintain optimal wellness. The following discussion will focus on the nursing process as it relates to the administration of medications.

Assessment is the process of data collection using a systematic method for collecting information and recognizing various clues as they relate to the client’s status. Assessment should relate to both actual and potential health problems. All other steps in the nursing process are based on an accurate assessment. This information can be obtained from a physical assessment of the client, a health record review, or a health history from other providers, the client, or family members. Before administering any medications to a client, it is important to be thorough in assessing the client to prevent harm and deliver optimal care.

Present Illness and Chief Complaint

The nurse must understand why the client is under their care, the medical diagnosis, and the presenting and current symptoms that the client is experiencing. What is the aim of treatment? Medications can affect disease processes and symptoms, and the disease process may affect the medications. Disease processes such as liver or kidney failure can affect the way drugs are metabolized and excreted. At times, dosage adjustments may need to be made due to these problems. It is essential to know how the medications will work to improve symptoms (or how they could worsen them).

Current Medications, Substance Use, and Allergies

The nurse should assess the client’s medication regime. Start by reviewing a list of the client's current drugs. If possible, encourage the client or family member to bring the actual medications. This includes prescription drugs, over-the-counter (OTC) medications, herbal supplements, illicit drugs, alcohol, nicotine, and caffeine. The nurse should ask specific questions. Some clients do not consider OTC drugs or herbal supplements to be important, but they do have the potential to interact with prescription medications. For example, the OTC drug ibuprofen can interact with certain medications for high blood pressure, causing the antihypertensive drugs to be less effective. Assessment of illicit drugs and alcohol use is also important. Alcohol may interact with benzodiazepines or opioids, causing respiratory and central nervous system depression. A client who recently used a street drug such as heroin, cocaine, or ketamine may also be at risk for dysrhythmias or respiratory depression. Unfortunately, these drugs may be laced with fentanyl, causing a client to be at risk for severe respiratory depression.

No medication should be given without first asking the client about allergies and reactions to medications. If a client has been previously exposed to a drug and had a mild reaction, the reaction could be more severe when they are exposed again. Some clients may reveal a reaction that is not an allergy but, instead, the result of a side effect. An example of this is a client who reports that they have an allergic reaction to diphenhydramine (Benadryl) that causes them to be very drowsy. This is a common and expected effect of this drug rather than an allergy. Once the nurse obtains the information about both the allergy and the reaction(s), it is important to document this clearly in the client record for future providers.

Past Medical History

Similar to ascertaining a client’s present symptoms and medical diagnoses, the past medical history is also important because it may impact the client’s current condition and response to medications. For example, liver and kidney dysfunction may affect the way drugs are metabolized and excreted. Some drugs may be contraindicated in some chronic diseases such as diabetes, hypertension, heart failure, or chronic obstructive pulmonary disease. Is the client visually challenged, or do they lack manual dexterity? A visually impaired client with diabetes, for example, will have challenges in drawing up and administering insulin that another client with healthy vision will not. A client with Parkinson’s disease or one who has had a stroke may also have difficulty with these psychomotor skills.

Psychosocial Factors

The use of alcohol, tobacco, or street drugs may affect the body’s response to some medications, so obtaining a psychosocial assessment is helpful. It is also important for the nurse to know the support systems in place for the client. Are there family members or friends who are able to assist with the medications at home? Does the client have insurance? Is the client able to afford the medications? For some individuals, even paying $4 for a prescription is difficult. There are prescription drug programs that may be able to assist, and collaborating with the pharmacist or a social worker may help the client adhere to the medication regimen. A pharmacist may also be able to suggest alternative therapies that might be cheaper for the client.

Health Literacy and Education

Another important piece of this assessment is evaluating an individual’s health literacy and determining a client’s understanding of their disease process and the recommended treatment (including medications). Health literacy is a general term used to describe an individual’s ability to obtain, understand, and make appropriate decisions based on information to promote their health and wellness (Taylor et al., 2023). A client who is new to their disease process may require more explanation than someone who has managed a chronic disease for years. It is crucial for a client to know why a drug is important to their health and well-being so that they will adhere to a medication regimen. It is also vital that the client understands both the therapeutic effects and side effects of the drug. Once side effects are discussed, the nurse must explain which side effects are not harmful and when to notify the health care provider of problems. Assessing the client’s level of education is helpful in presenting the information in a way that will be most easily understood by the client and family.

Physical Findings and Laboratory Values

When administering medications, the nurse should complete a focused assessment as it relates to the medication to be given. For example, if giving a medication to lower blood pressure, blood pressure should be assessed before giving the drug. If that specific drug lowers blood pressure and heart rate, then both should be measured before giving the medication.

Laboratory values should also be assessed prior to giving medication. One diuretic may cause potassium to be excreted from the body, requiring the nurse to withhold the diuretic if the client is hypokalemic, but another may cause potassium to be conserved and should not be given to a client who is already hyperkalemic. Some drugs should not be given if liver enzymes are elevated; others should not be given if the kidney values of blood urea nitrogen (BUN) and creatine are elevated.

Weight and Age

A client’s weight should be obtained prior to administering some drugs, especially in the pediatric population . An accurate weight will assist the nurse in determining if the dosage is appropriate.

Children and older adults may require medication dosage adjustments due to issues such as kidney or liver function changes. A child may be unable to metabolize some medications well due to an immature hepatic system or to excrete drugs through an immature renal system; however, the older adult may have a decline in kidney and liver function due to age and chronic disease conditions. Medication delivery may also need to be altered in these age groups. For example, an infant or child may need a liquid dosage form because they may be unable to swallow tablets or capsules; older adults with Alzheimer’s disease or stroke may also be unable to swallow those medication forms.

Nursing Diagnosis and Problem List

In the diagnosis phase of the nursing process, the nurse uses the information from the assessment to identify and prioritize problems. Whereas the health care provider’s medical diagnosis focuses on disease process or pathophysiology, the nursing diagnosis focuses holistically on any physical, psychosocial, sociocultural, or spiritual changes or problems in the client’s health, wellness, or illness. Part of the assessment the nurse completes before drug administration is determining if the drug is appropriate for the client (right diagnosis or indication ) and identifying any potential problems that might arise if the drug is given (adverse effects). Will the proposed treatment be safe and effective? In the case of the client taking an antihypertensive drug, for example, what are the potential adverse effects of the drug? Will the drug lower the blood pressure to an unsafe level? What is the client’s ability to adhere to the medication regimen at home?

When considering these questions, it is important to analyze what is known about the client—the medical diagnosis; whether or not the client has taken the drug in the past; potential adverse reactions, contraindications, and allergies; comorbidities that might affect the response to the drug; potential drug–drug interactions; and current laboratory data. There are many potential nursing diagnoses or health problems related to drug administration. Consider utilizing the North American Nursing Diagnosis Association (NANDA) website for more information regarding nursing diagnoses and problems.

Once the nurse has completed the assessment and has identified the actual or potential nursing diagnoses or problems, they must develop the plan. This is done by formulating client goals that address the client’s problems (or nursing diagnoses) that have been identified. When possible, the client, family, and nurse should work together in the planning process to better understand the desired outcomes. Goals are written in such a way that it is clear what type of observable response should be seen (Callahan, 2023). Part of this process is prioritizing the information that was gathered in the assessment, integrating this into the nursing diagnosis, and then setting the goals with the client. Collaboration with the client and family also allows the nurse to become aware of unidentified problems that might prevent the outcome from being realized.

Consider the client with severe postoperative pain (problem) secondary to a recent right knee replacement (etiology of the problem) who has an order for an opioid agent. The goal is defined as the result that the nurse and client wish to see due to the nursing interventions (Callahan, 2023). A potential goal for the hospitalized client with postoperative knee pain could read, “The client will rate their knee pain as 4 or less on a 0 to 10 scale during this shift.” Remember to include the client in this process. Is a pain level of 4 or less acceptable to the client?

The planned interventions are developed specific to the goal and are explicit actions that relate to that goal. In the previous example, the interventions might read like this:

• Assess the pain level every hour using the pain scale of 0 to 10.
• Administer hydrocodone 5/325 mg 30 minutes prior to physical therapy and every 6 hours PRN as ordered. (PRN stands for pro re nata , a Latin term meaning “as the circumstances arise.” This medication is not a scheduled drug; it will be taken as needed.)
• Apply ice packs to the right knee for 20 minutes four to six times each day.
• Demonstrate the use of a walker to assist the client with ambulation.

It is important for goals and interventions to be client-centered and very specific. Be sure that the interventions are related to the individual goal and are realistic for the client.

Implementation of Nursing Interventions

The fourth phase of the nursing process is the implementation phase. During this phase, the interventions are performed in order to reach the client’s goal(s). At the heart of the implementation phase is the concern for client safety. No goal or intervention should be planned without consideration of the client’s safety in the nursing process. The nurse should assess for any potential complications during this process. Interventions or goals may need to be modified depending on the client’s circumstances. In the example of the client with postoperative pain following a right knee replacement, the nurse evaluates the client’s pain before a physical therapy visit. If it is not time for the pain medication to be given, it is possible that the physical therapy visit will need to be postponed.

Some potential interventions related to medication administration for this client might include:

• Assess safety prior to administering the medication (check vital signs and laboratory values). (See Appendix B: Common Abbreviations and Lab Values for typical lab values.)
• Verify the rights to medication administration (right client, right medication, right indication, right dosage range and rate of administration [if appropriate], right route, right time, and right documentation).
• Verify allergies and reactions.
• Assess for adverse effects of the medication (both before, if the drug was administered previously, and after).
• Teach the client about the medication, indications, expected effects, and potential side effects. The nurse should also explain the drug names (brand and generic), dose, route, and frequency.
• Document medication administration and any pertinent data related to that.

This phase of the nursing process assesses and evaluates the outcomes of the nursing goals and interventions. For example, has the client’s pain been controlled during this shift? Did the client rate the pain as 4 or less on the pain scale? Did the client have any adverse reactions to the medication? This ongoing process evaluates the client’s response to the drug—for the therapeutic effect, the development of adverse effects, and teaching needs—and anticipates discharge needs. Therapeutic effectiveness refers to whether the drug did what it was supposed to do. Did the pain medication relieve the pain? One intervention may assist the client in meeting the goal, but another intervention does not. In this case, the intervention may need to be modified. For example, in the case of the postoperative client who had a knee operation, if the client had developed a rash following the last dose of hydrocodone, the nurse must notify the provider to order an alternative drug to control the pain. Alternatively, if the client’s pain remained an 8 on a 0 to 10 scale even after hydrocodone, the nurse will notify the provider to order an alternative drug to meet the goal of a pain level of less than 4.

The evaluation phase of the nursing process is ongoing until the client outcomes are met or the client reaches an optimal state of well-being. The client’s goals and interventions may need to be modified according to the ever-changing status of the client.

Nursing Clinical Judgment

The National Council of State Boards of Nursing (NCSBN) has “developed the NCSBN Clinical Judgment Measurement Model (NCJMM) as a framework for the valid measurement of clinical judgment and decision making within the context of a standardized, high-stakes examination” (NCSBN, 2023, para. 1). Nursing students across the United States are now being tested using the Next Generation National Council Licensure Examination (NGN) model , which was first administered in April 2023. This exam helps to protect the public and measures the minimum competence of a new graduate in regard to safety. Why is this information presented in this text? The nurse must be able to problem-solve and critically think, and the clinical judgment model was developed as a way to test clinical judgment in nursing. Much of a nurse’s clinical judgment revolves around medications and whether a drug is safe to give or recognizing problems.

Clinical judgment is defined by the NCSBN as “the observed outcome of critical thinking and decision making. It is an iterative process that uses nursing knowledge to observe and assess presenting situations, identify a prioritized client concern, and generate the best possible evidence-based solutions in order to deliver safe client care” (NCSBN, 2018). An iterative process is one that builds, refines, and improves the process for the best possible outcome.

Safe, efficient care of the client and improved clinical outcomes rely on sound decision-making, clinical reasoning, and clinical nursing judgment. Errors in clinical decision-making often lead to poor outcomes (Nibbelink & Brewer, 2018). According to Sherrill (2020), there are two common errors that novice nurses make that cause them to undergo disciplinary action against their license—a failure to notice and a failure to act. Failure to notice refers to failure on the part of the nurse to see a change in the condition or status of the client. Once a change in the client is observed, it is the nurse’s duty to act in some way to prevent a negative outcome for the client.

The nurse must possess many skills to take care of the client: interpersonal, cognitive, technical, and ethical/legal knowledge (Taylor et al., 2023). The nurse needs to have the technical skill to administer an intravenous push (IVP) medication and subsequently document it in the electronic medical record (eMAR) as well as the ability to determine cognitively that the medication is safe to give. Interpersonal skills are necessary for the interaction between the nurse and the client during the administration of the medication or with the pharmacist and provider when discussing potential problems that might arise from an adverse drug event. Ethical and legal responsibilities are a part of the nurse’s workday each time they chart or encounter an ethical dilemma when deliberating over the risk versus the benefit of a drug. Often this can be seen in the nurse’s role of advocate for the client.

Critical thinking is an essential piece of the nurse’s clinical judgment and is absolutely crucial to the process of administering medications safely. The nurse must think through every decision and action before administering a drug. According to the NCJMM, the nurse must first recognize cues (Dickison et al., 2019). Where is the client located, and how do they present? For example, the client may have presented to a health care clinic in mild distress due to a cough and sinus congestion, or they may have presented to the emergency department with severe shortness of breath and chest pain. What is their history? The nurse should recognize the various signs and symptoms of a disease process and recognize abnormal vital signs and laboratory work, then hypothesize what may be occurring with the client. What is the most important thing for the nurse to assess? Analyzing the cues is important. What is the priority in this situation? How acute are the symptoms? Does immediate action need to occur? The nurse needs to have the underlying knowledge to recognize relationships between signs and symptoms and potential disease processes and likely treatments (including medications). However, the ability to recall nursing knowledge is only part of the nurse’s thinking; the nurse then needs to make the clinical judgments suitable to the situation (Silvestri et al., 2023). What interventions will be most helpful in this situation? Once the nurse intervenes, the question then becomes whether those actions and decisions helped the client.

The nursing process is an integral piece of nursing clinical judgment and embraces the critical thinking process. The nursing process was discussed earlier in this chapter in relation to medication administration. The nursing process can be integrated into the clinical judgment model.

Recognizing cues is the nurse’s skill of observing cues or signs and symptoms of a client’s problem (Dickison et al., 2019). This is accomplished through assessing (the first part of the nursing process). A nurse collects information from many different resources. An example of this might be the nurse who is caring for a client who experienced a myocardial infarction 3 days ago and is to administer metoprolol, a medication that decreases blood pressure and heart rate. The nurse recognizes that those parameters should be assessed prior to giving the drug. Other data will be collected that the nurse then needs to sort through and determine which information is expected and which is unexpected or concerning. The nurse should assess and recognize that the blood pressure of 84/60 mm Hg and the heart rate of 48 beats per minute with the symptoms of dizziness are abnormal.

Analyzing cues is the skill of organizing the information obtained and linking it to the situation (Dickison et al., 2019). Continuing with the previous example, the nurse interprets the data and recognizes that the blood pressure and heart rate are too low to give the metoprolol. A nursing diagnosis or problem list can be formed during this phase based on the assessment data. The nurse requires a knowledge of the pathophysiology of myocardial infarction and knowledge of the therapeutic and adverse effects of metoprolol. The clinical reasoning model uses critical thinking to understand that the nurse recognizes the problem and knows what to do in response to the findings.

The next phase of the process is to prioritize hypotheses (Dickison et al., 2019). This means the nurse will attempt to focus on the meaning of the information that has been obtained and prioritize the client’s problems (Silvestri et al., 2023). What is the priority problem for the client on metoprolol mentioned above? In this example, the client has three problems:

• Low blood pressure, which may be due to the myocardial infarction or a previous dose of metoprolol
• Low heart rate due to a previous dose of metoprolol
• Dizziness due to the abnormal blood pressure and heart rate

The next phase of the process is to generate solutions (Dickison et al., 2019). In this phase, the nurse wants to consider all possible actions that might be utilized to resolve the problem(s). Many times, this includes actions that will be implemented to achieve the desired outcome, but sometimes this will include withholding a medication or recognizing which actions should be avoided (Silvestri et al., 2023). In this instance, the nurse may predict complications of further lowering of the blood pressure and heart rate if the metoprolol is administered. The consequences of administering metoprolol to the client might mean a critical drop in the blood pressure or heart rate, potentially even causing shock.

Dickison et al. (2019) then state that the next phase of this model is taking action . In the example given, the actions the nurse takes during this phase are to withhold the medication, metoprolol, and notify the provider of the problem. This aligns with the implementation phase of the nursing process.

Evaluating outcomes is the last clinical judgment thinking skill in the clinical reasoning model and aligns with evaluating the interventions that the nurse implemented (Silvestri et al., 2023). The nurse must evaluate the outcome of whether the client meets the goal of improved blood pressure and heart rate when the metoprolol is withheld.

These processes are not linear; they are cyclical. The nurse will continue to assess, recognize, analyze, generate solutions, respond by taking action, and reflect on the outcomes. The nurse expects the outcome of the blood pressure and heart rate to return to baseline after holding the metoprolol; however, the nurse must continue to reassess the client to ensure that this occurs and act accordingly. If the blood pressure and/or heart rate do not increase, the nurse must then implement other interventions and evaluate whether they were successful.

This example of clinical judgment actually occurs before administering the drug. A similar process would occur even if the blood pressure and heart rate were normal. Then the process would occur again when the nurse assesses the client for adverse effects.

Principles of Safe Drug Administration

Safety is a fundamental element in the process of medication administration . It is important to demonstrate good clinical decision-making skills throughout the procedure. The focus of the nurse’s clinical judgment during medication administration begins with first knowing the client and assessing the relevant information according to the medications that need to be delivered. Medication reconciliation is performed to ensure that the medications that the provider has ordered are accurate and appropriate for the client. Medication reconciliation is the process of identifying and verifying the most accurate list of medications that a client is taking. This should include the drug name, dosage, frequency, and route for the client. This process should also determine why the client is taking the medication. It should include all over-the-counter medications, vitamins, and supplements. This list is then compared to the provider(s) list. This process should occur at any transition in care (admission, transfer to another unit, discharge, and clinic visit). The nurse should scrutinize the list for duplications, incorrect dosages, and omissions (Agency for Healthcare Research and Quality [AHRQ], 2019). Once a focused physical assessment and laboratory assessment have been completed, the client should be informed about the drugs that have been prescribed. If the nurse is unfamiliar with a drug, it is crucial that they learn about it before administering it. Many resources are available to the nurse for that purpose—drug guides, the pharmacist, drug insert labels, or drug apps on the phone or computer, to name a few.

When planning drug administration, the nurse needs to keep safety foremost in mind. Medication errors are common, preventable errors with far-reaching consequences for the client, the institution, and the nurse. The U.S. Food and Drug Administration (FDA) receives more than 100,000 reports of potential drug errors each year (not all errors are reported to the FDA) (FDA, 2019). Tariq et al. (2023) reported that the cost of caring for individuals who had been the victim of drug errors is over $40 billion each year. A meta-analysis by Panagioti (2019) reported that 1 out of 20 clients may be impacted by a preventable medical error and that as much as 12% of this preventable harm results in death or disability. Of these errors, medication-related errors accounted for the majority. Ethics, Legal Considerations, and Safety discusses medication safety in further depth and emphasizes additional strategies to prevent errors.

Medication safety means ensuring that the right dosage of the right drug is administered to the right client at the right time by the right route or the right reason, and it is documented correctly (the seven rights of medication administration ; see Figure 2.2 ). Nursing practice has expanded the original five rights of medication administration to seven. These rights have been identified as basic standards of care in medication administration in order to preserve client safety. Most institutions require nurses to review these rights at least three times before administering medications. An example of what can happen if all seven rights are not followed might look like this: the nurse has the right dose of the right drug via the right route at the right time for the right reason, but if the nurse walks into the wrong room and fails to identify the right client, a medication error (and potential harm) occurs.

The seven rights are:

• Right client (person): The Joint Commission recommends using at least two identifiers to ensure that the nurse administers drugs to the right client. Name, date of birth, and/or medical record number are standard client identification methods. Confirming two identifiers safeguards the client from harm. When possible, request that the client verbalize their name and date of birth while verifying this information by comparing it to the wrist ID band and the client’s chart.
• Barcode scanning: For institutions that use barcode scanning, each drug container (usually a unit dose package such as a blister pack, vial, or prefilled syringe) is labeled with a unique barcode. The information in the barcode allows for the comparison of the medication being administered with what the health care provider ordered for the client before administration. The nurse first signs into the computer or uses the barcode scanner, a handheld device, to scan the barcode on the clinician’s badge. The nurse then uses the scanner to scan the barcode on the client’s unique client identification wristband and the drug. The system then verifies the drug to be given with the order in the system. The clinician is given a warning if the information does not match. Strudwick et al. (2018) report in an integrative review that barcode technology significantly decreases medication errors when proper scanning is completed consistently before administration.
• Right dose: The nurse must validate the right dose and any drug calculations that were performed. They can ask another nurse to validate doses of high-alert (more dangerous) drugs, such as heparin or insulin. The nurse needs to know the usual safe dosage ranges and maximum doses to ensure safe administration and question doses that are outside the usual range or seem unsafe.
• Right time: Each institution has its own policy regarding acceptable time frames for medication administration. Most institutions allow a drug to be given within a time frame of 30–60 minutes before or after the scheduled dose. Drug schedules are important to keep drug concentrations steady. If a drug is given too early, this might result in a drug overdose; however, if it is given too late or omitted, then the client may be undertreated.
• Right route: The nurse must administer the drug via the correct route and verify that the route is safe for that particular client. They should never assume the route of administration—it must be confirmed with the provider if it was omitted from the order.
• Right indication for use (reason): The nurse confirms why the client has been ordered the medication; for example, beta-adrenergic blockers may be administered for angina, hypertension, myocardial infarction, dysrhythmias, or heart failure. Knowing why the medication has been ordered will assist the nurse in assessing the drug’s therapeutic effect. They should clarify orders that do not seem appropriate for the client.
• Right documentation: The nurse needs to ensure that documentation is completed after the drug has been administered. They should not document medication administration prior to giving the drug. If there was any variance in the drug administered, the nurse needs to ensure that the reason is documented. The nurse also should document if the client refuses the drug and why, as well as if a medication was withheld and the explanation for holding it.

Link to Learning

The seven rights of medication administration.

This video provides more information about the rights of medication administration in nursing. A BSN/RN explains the rights of medication administration and gives examples and anecdotes from their own experiences.

Nurses should encourage clients to participate in their care by questioning the nurse about the medications being delivered. Collaboration with other health care providers will also assist in keeping the client safe during medication administration. In the inpatient setting, the verified medications are withdrawn from the medication dispensing machine, the materials needed to administer the drugs are obtained, and all are taken to the client. The medication should remain in the original container until the nurse is at the bedside, ready to administer the medication. The nurse identifies the client, using two unique client identifiers, and the drug is reverified as the correct drug before giving to the client. The medication can be reverified by checking the drug label with the medication administration record or through the use of barcode scanning, where available, at the bedside prior to administering the medication. The nurse follows medication administration by planning on when to reevaluate the client for therapeutic response and adverse effects.

Client Education and Drug Administration

One important responsibility that a nurse has is client education . According to the American Nurses Association (2021), teaching and promoting health and wellness is expected of the nurse providing care to a client. Teaching is about using specific strategies to reinforce or change specific behaviors. Learning is the desired outcome that results from teaching. A change in behavior is the evidence of teaching and learning. The primary target for teaching in the health care setting is the client and family or caregiver. In order for the nurse to be an effective teacher, it is important to understand how individuals learn. There are three domains of learning: cognitive, psychomotor, and affective.

Cognitive Domain

The cognitive domain of learning is the thinking domain within the learning process. Concepts related to this domain include knowing, comprehending or understanding, applying, analyzing, evaluating, and synthesizing. Within this domain, an individual’s past experiences and perceptions are important to consider because they will impact the client’s ability to learn. The foundation for any learning experience is a person’s previous experience and knowledge. Teaching a client with diabetes about insulin, how it works, its therapeutic effects, dosing, and side effects is within the cognitive domain.

Psychomotor Domain

The psychomotor domain relates to doing or skill , specifically motor skills. Nurses will frequently teach clients various skills related to their disease process. The nurse who teaches the client about insulin and demonstrates how to inject themselves with a dose of insulin is teaching within the psychomotor domain. The client with diabetes learning within the psychomotor domain will need to learn the physical skill of drawing up the insulin and then injecting the insulin into their body.

Affective Domain

The affective domain refers to the feelings, emotions, and beliefs within the learning process. It also encompasses an individual’s interests and attitudes toward learning. The client with diabetes who is frightened about shots and is anxious about this process may have difficulty learning the skill of giving injections.

Ideally, the nurse will use each domain in the teaching plan for the client. In order to be an effective teacher, the nurse will try to develop a positive teacher–learner relationship by developing different approaches for different learning styles. For a learner who learns best by doing the skill, the nurse should encourage the client to practice the skill under their supervision rather than simply explaining what must be done. It is important to assess the client’s readiness for learning and adapt strategies that will help the process.

Factors that Influence Learning

According to Callahan (2023), many factors may facilitate learning in the client. The information needs to have relevance to the client. Someone who is actively involved in the learning process and is motivated to learn will usually master the content more readily. The nurse can approach the client and determine their readiness to learn. The client may wish to have a support person(s) with them to help them retain the information. The nurse should begin with a simple explanation and expand to more complex topics as time allows. Repetition is helpful in the learning process to reinforce the concepts. The nurse may make further arrangements to continue teaching or pass this on to a colleague as appropriate.

There are also many potential barriers to learning ; for example, a client who is extremely anxious or in a lot of pain may not have the ability to focus on the process. Other common barriers include:

• Educational level
• Developmental level
• Attitudes, values, and beliefs
• Unmet needs
• Emotions (fear, anger, depression)
• Physical health status (pain, anxiety, medication, fatigue, hunger)
• Self-concept
• Self-esteem
• Cultural considerations (the individual’s health beliefs and practices)
• Language barriers
• Lack of motivation
• Lack of readiness
• Psychomotor ability (e.g., the client with Parkinson’s disease or who has had a stroke may have the cognitive ability to understand how to give an injection but may be limited physically by muscle strength or coordination)

Developing a Teaching Plan

To develop a teaching plan , the nurse should assess the client’s learning needs. (The first part of the nursing process is to assess.) Determine their disease process, discover what the client already knows, and discuss the client’s support system. Consider the client’s characteristics. Are they motivated to learn? Are they ready to learn? What is their reading and comprehension level? What are their health and belief practices? What is their learning style? Do they learn best by visualizing material in colors, maps, and diagrams? Or do they learn best by listening (auditory learner) or by doing (kinesthetic learner)? Another characteristic to assess is the client’s health literacy and where they obtain information. According to the Agency for Healthcare Research and Quality (Bakerjian, 2023), health information should be written in plain, straightforward language and should not exceed a sixth-grade reading level. The information should use short sentences with pictures that illustrate instructions for the client. This should be adapted according to the educational level of the client. Teach the priority information first and then repeat as needed.

Part of the teaching process is to evaluate the learning. This is an ongoing process, and consideration of the evaluation tools is important. Direct observation of behaviors and asking the client to teach back information or demonstrate a skill back to the nurse are helpful ways to evaluate learning (Bakerjian, 2023). It is important to ask for feedback and clarify when information is unclear. In order to promote a helping-trust relationship, the nurse should instill faith and hope in the client while providing a supportive environment.

Teaching Resources

Discover the teaching materials at your institution. Most institutions have written materials, and some have various smart tablets or e-health portals for educational information. Information provided by institutions or health systems is considered reliable and accurate and can be very helpful to clients and their family members.

Many clients have smartphones and can access health learning applications with tutorials and quizzes that help the learning process. A great deal of information is available to the client through the internet, and the nurse can assist them in finding the appropriate websites to obtain reliable information on their disease process and treatment.

Trending Today

Determining a website’s reliability.

The National Institutes of Health (2022) provide these guidelines for determining the reliability of websites:

• Is there an author listed? If so, what are their qualifications?
• What is the website’s address? (Credible websites usually end in either .gov, .org, or .edu.)
• Who pays for the website?
• Is the website current? Are there references? Are there working links?
• What is the content? Is it biased? Is it opinion? Is it fact? Why was it written?
• Is it trying to sell a product?
• How is the website constructed? Can the information be easily found?

Many applications (apps) available on phones or smartwatches can assist the client and provider in monitoring the client’s health, including pulse rate and rhythm monitoring, blood pressure monitoring, and blood glucose monitoring. It is helpful to the client if the nurse has firsthand knowledge of the site or applications recommended. Using reliable, credible resources can help the client and family make more informed decisions and become an active participant in their care.

This book may not be used in the training of large language models or otherwise be ingested into large language models or generative AI offerings without OpenStax's permission.

Want to cite, share, or modify this book? This book uses the Creative Commons Attribution License and you must attribute OpenStax.

Access for free at https://openstax.org/books/pharmacology/pages/1-introduction

• Authors: Tina Barbour-Taylor, Leah Mueller (Sabato), Donna Paris, Dorie Weaver
• Publisher/website: OpenStax
• Book title: Pharmacology for Nurses
• Publication date: May 29, 2024
• Location: Houston, Texas
• Book URL: https://openstax.org/books/pharmacology/pages/1-introduction
• Section URL: https://openstax.org/books/pharmacology/pages/2-1-drug-administration-and-the-nursing-process

© May 15, 2024 OpenStax. Textbook content produced by OpenStax is licensed under a Creative Commons Attribution License . The OpenStax name, OpenStax logo, OpenStax book covers, OpenStax CNX name, and OpenStax CNX logo are not subject to the Creative Commons license and may not be reproduced without the prior and express written consent of Rice University.

Nursing Pharmacology

Oct 06, 2012

950 likes | 1.77k Views

Nursing Pharmacology. Antimicrobials NUR 127. Medications and Administration. Prototype approach to teaching pharmacology:

Share Presentation

• adverse effect
• common symptoms
• chemical structure
• antibiotic combination therapy
• monitor liver function tests
• immune system

Presentation Transcript

Nursing Pharmacology Antimicrobials NUR 127

Medications and Administration Prototype approach to teaching pharmacology: Uses a prototype (a drug that is representative of it’s class) to help students learn by grouping the medications. It is a method of learning and organizing large amounts of information.

Drugs for Bacterial Infections OBJECTIVES: Identify various types of pathogenic organisms Identify and describe pathogenicity and virulence of common bacterial pathogens Discuss the development of anti-infective drug resistance and identify the nurse/patient role in preventing development of resistant pathogens Discuss the development and common symptoms of superinfections caused by anti-infective therapy Identify prototype drugs within the anti-infective drug classes. Discuss mechanism of action, indication for use, contraindications, adverse effects and administration. Identify drugs within each class with specific features differing from the prototype.

Terminology • Pathogenicity—ability of an organism to cause disease in a human • Virulence—severity of disease that an organism is able to cause; a highly virulent pathogens causes disease when present in very small numbers • Acquired Resistance—when a microbe is no longer affected by an anti-infective • Nephrotoxicity—an adverse effect on the kidneys • Hepatotoxicity—an adverse effect on the liver • Ototoxicity—an adverse effect on hearing • Superinfection—condition caused when a microorganism grows rapidly as a result of having less competition in its environment

Terminology • Anti-infective aka antimicrobial—General term referring to drugs active against pathogens • Antibiotic aka antibacterial—Drugs active against bacteria • Bacteriocidal—kill bacteria • Bacteriostatic—slow the growth of bacteria • Chemoprophylaxis—prophylactic use of a medication

Characteristics of Anti-Infectives • Includes antibacterials, antivirals and antifungals • Antibacterials (antibiotics) refer to drugs which treat bacterial infections • Narrow spectrum • Broad spectrum • Bactericidal (kills) vs. Bacteriostatic (inhibits)

Common Human Pathogens • Viruses • Gram+: • enterococci, streptococci and staphylococci • Gram- organisms: • E.coli, Bacteroides, Klebsiella, Proteus, Pseudomonas • Opportunistic • Community-acquired vs. nosocomial

Common Bacterial Pathogens • Staphylococci—Common in wounds , URI’s and pneumonia (MRSA—resistant strain) • Streptococci—Common infection in URI’s, ear infections & pneumonia • Enterococci—Common infection in UTI’s & wounds (VRE—resistant strain) • Escherichia coli—UTI’s; GI infection most commonly related to contaminated ground beef • Klebsiella—Causes respiratory tract infections, UTI’s, bloodstream, burn wound infections • Pneumococci—Most common cause of pneumonia in children; otitis media • Proteus—Cause UTI’s and wound infections • Pseudomonas—Cause respiratory tract infections, UTI’s, wound & burn wound infections (high resistance to many antibiotics)

Disease Process • Pathogens generally cause disease by one of two basic mechanisms • Rapid growth • Production of toxins

Normal Bacterial Flora • Colonized areas include the skin, upper respiratory tract, colon and vagina • Skin Flora (eg, staphylococci, streptococci) • Upper Respiratory Tract (eg, staphylococci, streptococci, pneumococci, Haemophilus influenzae) • Colon (eg, escherichia coli, Klebsiella, Enterobacter, Proteus, Pseudomonas, Bacteroids, clostridia, lactobacilli, strep, staph) • Vaginal (eg, Candida, lactobacilli, Bacteroids)

Infectious Diseases • Presence of a pathogen plus clinical s/sx of infection • Patient with a compromised immune system may be prone to opportunistic infections caused by endogenous or environmental flora

Drug Classification Classified by their chemical structure or by their mechanism of action • Mechanism of action • Cell-wall synthesis inhibitors, protein synthesis inhibitors, RNA or DNA synthesis inhibitors, antimetabolites ( • Bacteriocidal vs. Bacteriostatic • Bactericidal drugs kill organisms • Bacteriostatic drugs inhibit growth of organisms • Classification by chemical class • Share similar mechanisms of action and side effects (aminoglycoside, fluoroquinolone, sulfonamide)

Antimicrobials • Used to prevent or treat infections caused by pathogenic microorganisms • Broad-spectrum drugs are effective against a wide variety of microorganisms • Narrow-spectrum drugs are effective against one or a restricted group of microorganisms

Guidelines for use • Collect specimens before beginning therapy • Avoid use of broad-spectrum drugs • Use with other interventions—universal precautions, hand hygeine, isolation techniques, preoperative skin and bowel cleansing • Multidrug therapy should be avoided except in specific circumstances

Anti-microbial Drug Administration • Dosage should be individualized • Dosages often determined by grams or milligrams per kilogram of body weight • Routes of administration • Most PO or IV • IM doses : deep and into a large muscle (Ventrogluteal preferred for adults) • Topical • Duration of therapy varies from single dose to years; most acute infections treated for 7 to 10 days

Anti-microbial Drug Reactions • Hypersensitivity reactions • Occur most often with the ____________ administration • S/Sx: Low grade fever, rash, hives and swelling • Anaphylactic reactions • More likely to occur with IV route • Most often occur within 5-30min of injection • S/Sx: ________________________________________ ______________________________________________

Common Adverse Effects • Phlebitis at IV sites; pain at IM sites • Nausea & Vomiting—Most Common Side Effect • Diarrhea (severe colitis possible with some antimicrobial therapy—s/sx blood stool, pus mucous) • Bone marrow suppression with thrombocytopenia (decreased plt)—most common with penicillins and cephalosporins • Nephrotoxicity—espaminoglycosides and sulfonamides • -

Common Adverse Effects • Neurotoxicity—IV penicillins or cephalosporins • Ototoxicity: S/Sx: Tinnitus , vertigo, hearing loss • Hepatoxicity • Monitor Liver Function Tests: ALT, AST, Bilirubin • S/Sx: Jaundice, dark urine, pale stools, abd pain, fever • Photosensitivity

Age-Related Considerations-Children • Penicillins and Cephalosporins generally safe • Fewer clinical trials on children • Erythromycin, Zithromax (azithromycin) and Biaxin (clarithromycin) considered safe

Antimicrobials and Children • Aminoglycosides can cause ototoxicity and nephrotoxicity. • Tetracyclines are contraindicated in children younger than 8 years old, effects on teeth • Cleocin (clindamycin) admin. requires liver and kidney monitoring in neonates and infants

Antimicrobials and Children • Fluoroquinolones contraindicated in children under 18 yo. May have effects on weight bearing joints. • Bactrim (trimethoprim-sulfamethoxazole) no longer 1st line due to resistance

Antimicrobials and Older Adults • Penicillins are generally safe, IV admin. can cause hyperkalemia • Cephalosporins are considered sage but can affect or worsen renal failure • Macrolides are generally safe • Aminoglycosides are contraindicated in severe renal impairment

Antimicrobials and Older Adults • Aminoglycosides can also cause ototoxicity • Cleocin (clindamycin)-diarrhea, colitis • Bactrim (trimethoprim-sulfamethoxazole) may be associated with impaired liver or kidney function • Tetracyclines (except doxycycline) and Macrodantin (nitrofurantoin) are contraindicated in impaired renal function

In General • With most oral antibiotics, liberal fluid intake is recommended • Always be aware of pregnancy category before administering medication

Lab ID of Pathogens • Culture and sensitivity • Serology-measures antibody levels • Polymerase Chain Reaction (PCR) detects the specific DNA for a specific organism

Antibiotic-Resistant Microorganisms Occurs when: • Clinical condition of host is impaired • Normal flora have been suppressed • interrupted or inadequate tx • Type of bacteria • Widespread use of broad spectrum abx • Environmental setting of host

Host Defense Weakened by • Breaks in skin and mucous membranes • Impaired blood supply • Neutropenia • Malnutrition • Poor personal hygiene • Suppression of normal flora • Diabetes, advanced age or immunosuppression

Mechanisms of Action • Inhibit cell wall synthesis • Alter membrane permeability (PCNs, Cephalosporins, Vancomycin_ • Inhibition of protein synthesis (EES, tetracyclines, clindamycin, aminoglycosides)

Mechanisms of Action cont. • Disruption of microbial cell membranes (anti-fungals) • Inhibition of organism reproduction by interfering w/nucleic acid synthesis (fluoroquinolones, HIV anti-retrovirals) • Inhibition of cell metabolism and growth (sulfonamides)

Administration • Labs to Monitor • Blood levels of the antibiotic • CBC (complete blood count) • WBC (white blood cell) count • WBC should return to normal if med is effective

Prophylactic Therapy • STD exposure • Recurrent UTIs • TB • Perioperative infections in high risk patients or high risk surgeries

Antibiotic Combination Therapy • Used when infection is caused by multiple microorganisms • Nosocomial infections • Serious infections in which a combination is synergistic (aminoglycoside and antipseudomonal PCN)

Antibiotic Combination Therapy cont. • Likely emergence of drug resistant organisms • In those who are immunosuppressed

Antibiotics Affecting the Bacterial Cell Wall • Monobactam Antibiotics • Penicillins • Penicillin (P) • Cephalosporins • Cefotaxime (P) • Vancomycins • vancomycin • Carbapenems • meropenem

Beta Lactams • Contain a beta-lactam ring that is part of their chemical structure • An intact beta-lactam ring is essential for antibacterial activity • Include: Penicillins, Cephalosporins, Carbapenems • Cross-sensitivity

Penicillins • Prototype is Penicillin G • Most serious complication is hypersensitivity. Can cause seizures and nephropathy. • Contraindicated in patients with known allergy to PCN, cephalosporins, or imipenem.

Indications for Penicillins

Examples of Penicillins • Penicillins G and V (parenteral); dicloxacillin (antistaph); • Ampicillins—Principen, Amoxil • Antipseudomonals—Geocillin (carbenicillin), Ticar (ticaracillin), Pipracil (piperacillin) • Combinations for beta lactamase—Unasyn (ampicillin/sulbactam), Zosyn (piperacillin/taxobactam)

Cephalosporins • Also derived from a mold • Broad spectrum with activity against both gram positive and gram negative bacteria • Cefotamine (P)- 3rd generation

Cephalosporins • Indications-surgical prophy, tx infections of the respiratory tract, skin, bone and joints, urinary tract, brain and spinal cord and in septicemia

Cephalosporins • Contraindicated in anaphylaxis to a penicillin • May develop a delayed reaction or cross-sensitivity • A/E: • Hypersensitivity • Anaphylaxis • GI: n/v/d • Pain at injection site

Examples • Oral—Keflex (cephalexin); Ceclor (cefaclor), Lorabid (lorcarbef); Omnicef (cefdinir) • Parenteral—Ancef (kefzol); Mefoxin (cefoxitin); Claforan (cefotaxime), Fortaz (ceftazidime), Rocephin (ceftriaxone); Maxipime (cefepime)

Carbapenems • Broad spectrum, bactericidal, beta-lactam anti-microbials. Inhibit synthesis of cell walls. • All are parenteral • Indicated for organisms resistant to other drugs • Examples: Merrem (meropenem) and Primaxin (imipenem-cilastatin)

Monobactam Antibiotics • Azactam (aztreonam) is active against gram-negative bacteria and to many resistant strains • Stable in presence of beta lactamase • Preserves normal gram positive and anaerobic flora

FYI • Penicillins may be given with Probenecid or aminoglycosides for serious infections • PCN can cause nephropathies • Ticaracillin has been linked to hypernatremia • PCN G can cause hyperkalemia • Caution w/Augmentin in hepatic impairment • Need to adjust dosages of all beta lactams in the presence of renal impairment whether PCN, cephalosporins, carbapenems and monobactams

Antibiotics affecting Protein Synthesis • Aminoglycosides • Gentamicin (P) • Tetracyclines • Tetracycline (P) • Macrolide Antibiotics • Erythromycin (P)

Aminoglycosides • Bactericidal agents to treat gram negative organisms such as: Proteus, Klebsiella, Enterobacter, Serratia, Escherichia coli, and Pseudomonas • Narrow specturm • Accumulate in kidneys and ears • Gentamycin (P)

• More by User

Pharmacology

Pharmacology. Drugs that Affect the Gastrointestinal System. Topics. Peptic Ulcer Disease Constipation Diarrhea Emesis Digestion. Peptic Ulcer Disease. Factors that Increase Acidity. Factors that Protect Against Acidity. Factors Increasing H. pylori NSAIDs Acidic agents Pepsin

1.18k views • 28 slides

Pharmacokinetics

670 views • 26 slides

GM6677 Principles of Pharmacology for Nursing Inflammation, Analgesics Opioids

Inflammation. Inflammation manifests itself by rednessswellingheat painalteration of functionWe will examine how inflammation causes these signs and symptoms. Inflammation. The inflammatory response involves three key processes

678 views • 32 slides

Overview . The aim of drug therapy is to prevent, cure, or control various disease states. To achieve this goal, adequate drug doses must be delivered to the target tissues so that therapeutic yet nontoxic levels are obtained.. PRINCIPLES OF PHARMACOLOGY . Pharmacology definition: The scien

1.02k views • 12 slides

Pharmacology in Nursing Men s Health Drugs

Androgens. TestosteroneResponsible for normal development and maintenance of the primary and secondary male sex characteristicsDevelopment of bone and muscle tissueInhibition of protein catabolism (metabolic breakdown)Retention of various electrolytes. Androgens (cont'd). Several synthetic der

426 views • 24 slides

Nursing 3703 Pharmacology Digestive System Drugs

Nursing 3703 Pharmacology Digestive System Drugs. By Linda Self APN, MSN, CCRN. Effects of Drugs on the Digestive System. Digestive system and drug therapy have a reciprocal relationship

1.17k views • 68 slides

Pharmacology. Drugs That Affect The: Nervous System. Topics. Analgesics and antagonists Anesthetics Anti-anxiety and sedative-hypnotics Anti-seizure / anti-convulsants CNS stimulators Psychotherapeutics ANS/PNS/SNS agents. But first. A colorful review of neurophysiology!.

1.42k views • 83 slides

Introduction to Pharmacology in Nursing

Introduction to Pharmacology in Nursing. Donna Penn RN MSN CNE . Nurses need to have knowledge about the actions and effects of medications To safely and accurately administer medications nurses need to have an understanding of pharmacologic principles. Pharmacologic Principles.

2.81k views • 171 slides

Pharmacology. Gimme ‘da DRUGS, man!. Case.

561 views • 32 slides

Pharmacology . Medical Careers Eden Area ROP. What is Pharmacology?. Pharmacology is the study of drugs and their actions, uses, properties and origins. Drug: Any substance that causes a change to the body’s function and/or structure. . Drug Sources. Plant:

986 views • 21 slides

Pharmacology.

778 views • 16 slides

Pharmacology. Introduction & Pharmacokinetic Principles Sean Burfeind, ATC, LAT, OTC. Objectives. Define drug; differentiate between names Explain difference between generic name & drug Explain drug classification FDA role in development and recall Apply drug concepts

1.21k views • 67 slides

Introduction to Clinical Pharmacology Chapter 04- The Nursing Process

Introduction to Clinical Pharmacology Chapter 04- The Nursing Process . The Five Phases of the Nursing Process: Assessment. *Assessment: Collecting objective and subjective data Objective data: Facts obtained by means of a physical assessment, physical examination Subjective data:

524 views • 18 slides

Pharmacology in Nursing Men’s Health Drugs

Pharmacology in Nursing Men’s Health Drugs. Androgens. Testosterone Responsible for normal development and maintenance of the primary and secondary male sex characteristics Development of bone and muscle tissue Inhibition of protein catabolism (metabolic breakdown)

607 views • 24 slides

Focus on Nursing Pharmacology

Focus on Nursing Pharmacology. AMY M. KARCH, RN, MS. Chapter One ( Introduction to Drugs). Pharmacology : is the study of the biological effects of chemicals. Drugs: are chemicals that are introduced into the body to cause some sort of change.

1.56k views • 15 slides

Nursing Pharmacology. NURS200 Lansing Community College. Drugs Acting On the Autonomic Nervous System (ANS). UNIT III. Nervous System Organization. How do Drugs Affect Synaptic Transmission?. Transmitter synthesis Increase transmitter synthesis Decrease transmitter synthesis

1.41k views • 33 slides

Pharmacology In Nursing GI Medications

Pharmacology In Nursing GI Medications. Drugs To Tx Peptic Ulcer Disease. Antacids Helicobacter Pylori Agents Histamine-2 Receptor Antagonists Proton Pump Inhibitors Prostaglandins Sucralfate. Antacids: General. Neutralize acid

988 views • 40 slides

Pharmacology in Nursing Women’s Health Drugs

Pharmacology in Nursing Women’s Health Drugs. Female Reproductive Functions. Female sex steroid hormones Estrogens Progestins Pituitary gonadotropin hormones Follicle stimulating hormone (FSH) Luteinizing hormone (LH) Development of primary and secondary sex characteristics

656 views • 61 slides

Pharmacology for Nursing

Pharmacology for Nursing. Munir Gharaibeh, MD, PhD, MHPE Department of Pharmacology School of Medicine The University of Jordan [email protected] June 2019. Pharmacology.

475 views • 33 slides

Pharmacology in Nursing Adrenal Drugs

Pharmacology in Nursing Adrenal Drugs. Adrenal Gland. Adrenal cortex Adrenal medulla Each portion has different functions and secretes different hormones Feedback process of hormone regulation. Adrenal Gland (cont’d). Adrenal medulla secretes catecholamines: Epinephrine Norepinephrine

305 views • 29 slides

Pharmacology. Dr. J. Domenech. Learning Outcomes. Review the cognitive competencies from the Pharmacology Domain. Competencies in Athletic Training.

1.15k views • 90 slides

• Antidepressants

Antidepressants are used to alter the concentration of neurotransmitters in the brain that is responsible for the depressed affect (feelings in response to the environment, whether positive and pleasant or negative and unpleasant).

These drugs counteract the effects of neurotransmitter deficiencies in three ways:

• Inhibit the effects of monoamine oxidase (MAO) resulting to increased norepinephrine and serotonin or 5-hydroxytryptamine (5-HT) in the synaptic cleft;
• Block the reuptake function of the synaptic cleft resulting to increased neurotransmitter levels in the synaptic cleft; and
• Regulate receptor sites and breakdown of neurotransmitters resulting in accumulation of neurotransmitter in the synaptic cleft.

Antidepressants are classified into three groups: tricyclic antidepressants (TCAs), monoamine oxidase inhibitors (MAOIs), and selective serotonin reuptake inhibitors (SSRIs).

Table of Contents

Antidepressants: generic and brand names, manifestation spotlight: depression, therapeutic action, indications, pharmacokinetics, contraindications and cautions, adverse effects, interactions, nursing assessment, nursing diagnoses, implementation with rationale, recommended resources, references and sources.

Here is a table of commonly encountered diuretic agents, their generic names, and brand names:

• amitriptyline
• amoxapine (Asendin)
• clomipramine (Anafranil)
• doxepin (Sinequan)
• imipramine (Tofranil)
• despiramine (Norpramin)
• nortriptyline (Aventyl)
• protriptyline (Vivactil)
• tetracyclic (Maprotiline)
• isocarboxazid (Marplan)
• phenelzine (Nardil)
• tranylcypromine (Parnate)
• citalopram (Celexa)
• escitalopram (Lexapro)
• fluoxetine (Prozac)
• fluvoxamine (Luvox)
• paroxetine (Paxil)
• sertraline (Zoloft)

Depression is an affective disorder characterized by a persistent and intense feeling of sadness much more severe and longer lasting than the suspected precipitating event. There may be no external causes.

• Individuals with depression have little energy, disturbed sleep patterns, loss of appetite, and absence of motivation to perform activities of daily living . They describe overwhelming feelings of sadness, despair, hopelessness , and disorganization.
• It can interfere with a person’s life, his family, job, and social relationships. It can lead to multiple physical problems that further depression and increase risk of suicide .
• Researches about drugs that can effectively relieve depression lead to the formulation of biogenic amine theory which states that depression results from a deficiency of biogenic amines (NE, dopamine , and 5-HT) in key areas of the brain that regulate arousal, alertness, attention, moods, appetite, and sensory processing.

Tricyclic Antidepressants (TCAs)

• Has three sub-class namely: amines, secondary amines, and tetracyclics
• Primarily reduce the uptake of 5HT and NE into nerves
• The choice of TCA depends on individual response and tolerance to the drug.
• By inhibiting presynaptic reuptake of NE and 5-HT, there will be an accumulation of these neurotransmitters in the synaptic cleft which will increase the stimulation of the postsynaptic receptors.
• Primarily indicated for the relief of symptoms of depression, particularly anxiety and sleep disturbances.
• Some TCAs are indicated for enuresis in children older than 6 years.
• Researches on its possible indications for treatment of chronic and intractable pain are currently conducted.
• TCAs also act as anticholinergic.
• Clomipramine is approved for use in treatment of obsessive-compulsive disorders (OCDs).
• Indication for treatment of depression in children is a challenge because children respond unpredictably.
• Studies have not shown that antidepressants in children are effective.
• On the other hand, it is linked to increased suicidal ideation and behavior in depressed children.
• Only clomipramine, imipramine, nortriptyline, and trimipramine have established pediatric doses for children older than 6 years.
• Adults must be educated that effects of drug therapy may not be seen for 4 weeks. Also, cause of depression must be ruled out before therapy begins.
• Use cautiously for pregnant and lactating women because of potential adverse effects to fetus and baby.

Older adults

• Older adults are more susceptible to the adverse effects of the drugs and from CNS effects (e.g. increased sedation, dizziness, etc.)
• Doses of these drugs need to be reduced and careful monitoring for drug toxicity is a must, especially for those who have hepatic and renal impairment.

• Allergy to TCAs . Prevent severe hypersensitivity reactions.
• Myocardial infarction . Can reoccur because of the cardiac effects of the drug
• Myelography within previous 24 hours or in the next 48 hours . Prevent possible drug-drug interaction with dyes
• Concurrent use of MAOIs . Potential for serious adverse effects or toxic reactions
• Pregnancy, lactation . Potential adverse effects to the fetus and the baby
• Preexisting cardiovascular disorders . Drug has cardiac stimulatory effect
• Angle -closure glaucoma, urinary retention , prostate hypertrophy, GI or GU surgery . Exacerbated by the anticholinergic effects of the drug
• History of seizures . Seizure threshold is decreased because of stimulation of receptor sites
• Hepatorenal diseases. Interfere with drug metabolism and excretion which increase the risk of drug toxicity
• CV: orthostatic hypotension , hypertension , arrhythmias, palpitations, myocardial infarction , angina , stroke
• GI: dry mouth , constipation , nausea , vomiting , anorexia , increased salivation, cramps, diarrhea
• GU: urinary retention and hesitancy, loss of libido, changes in sexual functioning
• Miscellaneous: alopecia, weight gain or loss, flushing, chills, nasal congestion
• Abrupt cessation causes withdrawal syndrome characterized by nausea, headache, vertigo, malaise, and nightmares.
• Cimetidine, fluoxetine, ranitidine: increased therapeutic and adverse effects of TCAs
• Oral anticoagulants : higher serum levels of anticoagulants and increased risk of bleeding
• Sympathomimetics or clonidine : increased risk for hypertension and arrhythmia
• MAOIs: increased risk for severe hyperpyretic crisis with severe convulsions, hypertensive episodes, and death

Nursing Considerations

Here are important nursing considerations when administering this drug:

These are the important things the nurse should include in conducting assessment , history taking, and examination:

• Assess for the mentioned cautions and contraindications (e.g. drug allergies, hepatorenal diseases, psychosis, glaucoma, etc.) to prevent any untoward complications.
• Assess for history of seizure disorders , psychiatric problems, suicidal thoughts and myelography within the past 24 hours or in the next 48 hours to avoid potentially serious adverse reactions.
• Perform a thorough physical assessment to establish baseline data before drug therapy begins, to determine the effectiveness of therapy, and to evaluate for the occurrence of any adverse effects associated with drug therapy.
• Monitor results of electrocardiogram and laboratory tests (e.g. renal and liver function tests) to monitor the effectiveness of the therapy and provide prompt treatment to developing complications.

Here are some of the nursing diagnoses that can be formulated in the use of this drug for therapy:

• Acute pain related to anticholinergic effects, headache, and CNS effects
• Decreased cardiac output related to cardiovascular effects
• Disturbed thought processes and sensory perception related to CNS effects
• Risk for injury related to CNS effects

These are vital nursing interventions done in patients who are taking TCAs:

• Limit drug access if patient is suicidal to decrease the risk of overdose to cause harm.
• Administer a major portion of dose at bedtime as ordered if drowsiness and anticholinergic effect are severe to decrease the risk of patient injury.
• Provide comfort measures (e.g. voiding before dosing, taking food with drug, etc.) to help patient tolerate drug effects.
• Provide safety measures (e.g. adequate lighting, raised side rails , etc.) to prevent injuries.
• Educate client on drug therapy to promote compliance .

Here are aspects of care that should be evaluated to determine effectiveness of drug therapy:

• Monitor patient response to therapy (e.g. alleviation of signs and symptoms of depression).
• Monitor for adverse effects (e.g. hypotension , suicidal thoughts, cardiac arrhythmias, etc).
• Evaluate patient understanding on drug therapy by asking the patient to name the drug, its indication, and adverse effects to watch for.
• Monitor patient compliance to drug therapy.

Monoamine Oxidase Inhibitors (MAOIs)

• Monoamine oxidase (MAO) is an enzyme found in nerves and other tissues. MAOIs exert their effect in relieving depression by inhibiting this enzyme to break down the biogenic amines NE, dopamine, and 5-HT.
• Now used rarely because of their strict and specific dietary regimen to prevent toxicity. However, there are patients who respond only to MAOIs and so these remain to be available.
•  By blocking the breakdown of the biogenic amines, these drugs pave way for the accumulation of NE, dopamine, and 5-HT in the neuronal storage vesicles to cause increased stimulation of the postsynaptic receptors. This increased stimulation is thought to be the reason for the relief of depression.
• MAOIs are generally indicated for patients who do not respond to other safer antidepressants.
• Avoided in children if at all possible because of the potential for drug-food interactions and serious adverse effects.
• Adults must be educated that effects of drug therapy may not be seen for 4 weeks.
• Also, the cause of depression must be ruled out before therapy begins.
• Older adults more susceptible to the adverse effects of the drugs and from CNS effects (e.g. increased sedation, dizziness, etc.)

• Allergy to MAOIs . Prevent severe hypersensitivity reactions.
• Pheochromocytoma . Sudden increase in NE can lead to severe hypertension and CV emergencies
• CV diseases ( hypertension , coronary artery disease, angina , congestive heart failure ) . Exacerbated by increased NE levels
• History of headaches .
• Abnormal CNS vessels or defects . Potential increase in blood pressure and vasoconstriction associated with higher NE levels can precipitate a stroke
• CNS: dizziness, excitement, nervousness, mania, hyperreflexia, tremors, confusion , insomnia , agitation, blurred vision
• CV: orthostatic hypotension, arrhythmias, palpitations, angina , potentially fatal hypertensive crisis (occipital headache, palpitations, neck stiffness, nausea, vomiting , sweating , dilated pupils, photophobia, tachycardia, chest pain )
• GI: liver toxicity, nausea, vomiting , diarrhea or constipation, anorexia, weight gain, dry mouth, abdominal pain
• GU: urinary retention , dysuria , incontinence , changes in sexual function
• TCAs: hypertensive crisis, coma, severe convulsions
• SSRIs: potentially life-threatening serotonin syndrome (a period of 6 weeks should  elapse after stopping an SSRI before beginning therapy with MAOI)
• Sympathomimetics: increased sympathomimetic effects
• Insulin , oral antidiabetic agents: additive hypoglycemic effects
• Phentolamine is the treatment for hypertensive crisis.
• Assess for the mentioned cautions and contraindications (e.g. drug allergies, hepatorenal diseases, cardiac dysfunction, etc.) to prevent any untoward complications.
• Acute pain related to sympathomimetic effects, headache, and CNS effects

These are vital nursing interventions done in patients who are taking MAOIs:

• Limit drug access if the patient is suicidal to decrease the risk of overdose to cause harm.
• Monitor patient for 2-4 weeks to ascertain onset of full therapeutic effect.
• Monitor blood pressure carefully to determine the possible need for dose adjustment.
• Secure phentolamine at the bedside as a treatment in case of hypertensive crisis.
• Educate client on a low tyramine-containing diet . Provide a list of potential drug-food interactions that can cause severe toxicity to decrease the risk of a serious drug-food interaction.
• Provide comfort measures (e.g. voiding before dosing, taking food with the drug, etc.) to help patient tolerate drug effects.
• Provide safety measures (e.g. adequate lighting, raised side rails, etc.) to prevent injuries.
• Monitor for adverse effects (e.g. hypotension, hypertensive crisis, cardiac arrhythmias, etc).

Selective Serotonin Reuptake Inhibitors (SSRIs)

• SSRIs is the newest group of antidepressants available in the market.
• Only has blocking effect on the reuptake of 5-HT and has little to no effect on NE.
• Have lesser adverse effects compared to TCAs and MAOIs. This makes them a better choice for many patients.
•  Blocks the reuptake of 5-HT and therefore increases its level in the synaptic cleft.
• Realization of full therapeutic effect is up to 4 weeks.
• Indicated for treatment of depression, OCDs, panic attacks, bulimia , premenstrual dysphoric disorder (PMDD), social phobias, and social anxiety disorders .
• Can cause serious adverse effects on children.
• Only fluvoxamine and sertraline have established pediatric dosage guidelines for treatment of OCDs.
• Fluoxetine is widely used to treat depression in adolescents.
• Must be educated that effects of drug therapy may not be seen for 4 weeks. Also, the cause of depression must be ruled out before therapy begins.
• More susceptible to the adverse effects of the drugs and from CNS effects (e.g. increased sedation, dizziness, etc.)

• Allergy to SSRIs . Prevent severe hypersensitivity reactions.
• Severely depressed, suicidal patients. Risk of increased suicidality
• CNS: headache, drowsiness, dizziness, insomnia , anxiety , tremor, agitation, seizures
• Respiratory: cough , dyspnea , upper respiratory infections, pharyngitis
• GI: nausea, vomiting , diarrhea , dry mouth, anorexia, constipation, changes in taste
• GU: painful menstruation , cystitis , sexual dysfunction , urgency, impotence
• Miscellaneous: sweating , rash, fever , pruritus
• MAOIs: increased risk of serotonin syndrome
• TCAs: increased therapeutic and adverse effects of SSRIs

These are the important things the nurse should include in conducting assessment, history taking, and examination:

• Assess for the mentioned cautions and contraindications (e.g. drug allergies, hepatorenal diseases, severe depression, and suicidality, etc.) to prevent any untoward complications.
• Perform a thorough physical assessment to establish baseline data before drug therapy begins, to determine the effectiveness of therapy, and to evaluate for occurrence of any adverse effects associated with drug therapy.
• Acute pain related to GI, GU, and CNS effects

These are vital nursing interventions done in patients who are taking SSRIs:

• Arrange for lower dose in elderly patients and in those with renal or hepatic impairment because of the potential for severe adverse effects.
• Monitor patient for 4 weeks to ascertain onset of full therapeutic effect.
• Establish suicide precautions for severely depressed patients to decrease the risk of overdose to cause harm.
• Administer drug once a day in the morning to achieve optimal therapeutic effects.
• Suggest that the patient use barrier contraceptives to prevent pregnancy while taking this drug because serious fetal abnormalities can occur.
• Provide comfort measures (e.g. taking food with the drug) to help patient tolerate drug effects.
• Educate client on drug therapy to promote compliance.
• Monitor for adverse effects (e.g. sedation, dizziness, respiratory dysfunctions, GU problems, etc).
• Evaluate patient understanding on drug therapy by asking patient to name the drug, its indication, and adverse effects to watch for.

Our recommended nursing pharmacology resources and books:

Disclosure:  Included below are affiliate links from Amazon at no additional cost from you. We may earn a small commission from your purchase which will help support us. Thank you! For more information, check out our  privacy policy .

Pharm Phlash! Pharmacology Flash Cards #1 BEST SELLER! Test-yourself review cards put critical clinical information for nearly 400 of the top generic medications at your fingertips. And, you can count on them for accuracy, because each card is based on content from Davis’s Drug Guide for Nurses. Increase your test scores in pharmacology class.

Focus on Pharmacology (8th Edition) Focus on Nursing Pharmacology makes challenging concepts more approachable. Engaging learning features cultivate your clinical application, critical thinking and patient education capabilities. This updated 8th edition builds on your knowledge of physiology, chemistry and nursing fundamentals to help you conceptualize need-to-know information about each group of drugs.

Pharmacology Made Incredibly Easy (Incredibly Easy! Series®) Nursing pharmacology guide offers step-by-step guidance so you can grasp the fundamentals in enjoyable Incredibly Easy style. This is the perfect supplement to class materials, offering solid preparation for NCLEX® as well as a handy refresher for experienced nurses. Colorfully illustrated chapters offer clear, concise descriptions of crucial nursing pharmacology concepts and procedures.

Lehne’s Pharmacology for Nursing Care (11th Edition) The Eleventh Edition of Lehne’s Pharmacology for Nursing Care provides a thorough understanding of key drugs and their implications for nursing care. This text, written by renowned nursing educators, helps you comprehend and apply pharmacology principles. A clear and engaging writing style simplifies complex concepts, making even the most challenging pharmacology content enjoyable. We recommend this book if you want a comprehensive nursing pharmacology guide.

Nursing Drug Handbook Nursing2023 Drug Handbook delivers evidence-based, nursing-focused drug monographs for nearly 3700 generic, brand-name, and combination drugs. With a tabbed, alphabetical organization and a “New Drugs” section, NDH2023 makes it easy to check drug facts on the spot.

Pharmacology and the Nursing Process The 10th edition of Pharmacology and the Nursing Process offers practical, user-friendly pharmacology information. The photo atlas contains over 100 unique illustrations and photographs depicting drug administration techniques. Updated drug content reflects the most recent FDA drug approvals, withdrawals, and therapeutic uses.

Mosby’s Pharmacology Memory NoteCards: Visual, Mnemonic, and Memory Aids for Nurses The 6th edition of Mosby’s Pharmacology Memory NoteCards: Visual, Mnemonic, & Memory Aids for Nurses incorporates illustrations and humor to make studying easier and more enjoyable. This unique pharmacology review can be utilized as a spiral-bound notebook or as individual flashcards, making it ideal for mobile study.

Here are other nursing pharmacology study guides:

• Nursing Pharmacology – Study Guide for Nurses Our collection of topics related to nursing pharmacology
• Pharmacology Nursing Mnemonics & Tips These nursing mnemonics aim to simplify the concepts of pharmacology through the use of a simple, concise guide.
• Generic Drug Name Stems Cheat Sheet Learn about these generic drug name stems to help you make sense of drugs easier!
• Common Drugs and Their Antidotes A guide to drug antidotes that nurses should be familiar about.
• IV Fluids and Solutions Guide & Cheat Sheet Get to know the different types of intravenous solutions or IV fluids in this guide and cheat sheet.
• Drug Dosage Calculations NCLEX Practice Questions (100+ Items) Care to take the challenge? This quiz aims to help students and registered nurses alike grasp and master the concepts of medication calculation.

We have a pill for that…

Drug Guides NEW!

Individual drug guides and nursing considerations for the most common medications used in nursing pharmacology:

• Acetaminophen (Tylenol)
• Atorvastatin (Lipitor)
• Enoxaparin (Lovenox)
• Furosemide (Lasix)
• Hydromorphone (Dilaudid)

Gastrointestinal System Drugs

• Histamine-2 Antagonists
• Proton Pump Inhibitors

Respiratory System Drugs

• Antihistamines
• Bronchodilators and Antiasthmatics
• Decongestants
• Expectorants and Mucolytics
• Inhaled Steroids
• Lung Surfactants

Endocrine System Drugs

• Adrenocortical Agents
• Antidiabetic Agents
• Glucose-Elevating Agents
• Hypothalamic Agents
• Parathyroid Agents: Bisphosphonates, Calcitonins
• Pituitary Drugs
• Sulfonylureas
• Thyroid Agents

Autonomic Nervous System Drugs

• Adrenergic Agonists (Sympathomimetics)
• Adrenergic Antagonists (Sympatholytics)
• Anticholinergics (Parasympatholytics)
• Cholinergic Agonists (Parasympathomimetics)

Immune System Drugs

• Antiarthritic Drugs
• Immunostimulants
• Immunosuppressants
• Nonsteroidal Anti-Inflammatory Drugs
• Salicylates

Chemotherapeutic Agents

• Anthelmintics
• Anti-Infective Drugs
• Antibiotics
• Antifungals
• Antineoplastic Agents
• Antiprotozoal Drugs
• Antiviral Drugs

Reproductive System Drugs

• Male Reproductive System Drugs
• Female Reproductive System Drugs

Nervous System Drugs

• Antiparkinsonism Drugs
• Antiseizure Drugs
• Anxiolytics and Hypnotic Drugs
• General and Local Anesthetics
• Muscle Relaxants
• Narcotics, Narcotic Agonists, and Antimigraine Agents
• Neuromuscular Junction Blocking Agents
• Psychotherapeutic Drugs

Cardiovascular System Drugs

• Antianginal Drugs
• Antiarrhythmic Drugs
• Antihyperlipidemic Drugs
• Antihypertensive Drugs
• Cardiotonic-Inotropic Drugs
• Drugs Affecting Coagulation

References and sources for this pharmacology guide for Antidepressants :

• Karch, A. M., & Karch. (2011).  Focus on nursing pharmacology . Wolters Kluwer Health/Lippincott Williams & Wilkins. [ Link ]
• Katzung, B. G. (2017).  Basic and clinical pharmacology . McGraw-Hill Education.
• Lehne, R. A., Moore, L. A., Crosby, L. J., & Hamilton, D. B. (2004). Pharmacology for nursing care.
• Smeltzer, S. C., & Bare, B. G. (1992).  Brunner & Suddarth’s textbook of medical- surgical nursing . Philadelphia: JB Lippincott.

Leave a Comment Cancel reply

You are using an outdated browser. Please upgrade your browser to improve your experience.

• Drug Shortages
• Current Drug Shortages
• -1 ? window.location.search.substring(1) : '')"> Add To Favorites

Methylphenidate Extended Release Oral Presentations

Products affected - description.

• Aptensio XR extended release capsule, Rhodes, 10 mg, 90 count, NDC 42858-0401-45
• Aptensio XR extended release capsule, Rhodes, 15 mg, 90 count, NDC 42858-0402-45
• Aptensio XR extended release capsule, Rhodes, 20 mg, 90 count, NDC 42858-0403-45
• Aptensio XR extended release capsule, Rhodes, 30 mg, 90 count, NDC 42858-0404-45
• Aptensio XR extended release capsule, Rhodes, 60 mg, 90 count, NDC 42858-0407-45
• Methylphenidate CD extended release capsule, Amneal, 30 mg, 100 count, NDC 00115-1738-01
• Methylphenidate CD extended release capsule, Lannett, 30 mg, 100 count, NDC 00527-4581-37
• Methylphenidate CD extended release capsule, Teva, 10 mg, 100 count, NDC 00093-5295-01
• Methylphenidate CD extended release capsule, Teva, 20 mg, 100 count, NDC 00093-5296-01
• Methylphenidate CD extended release capsule, Teva, 30 mg, 100 count, NDC 00093-5297-01
• Methylphenidate CD extended release capsule, Teva, 40 mg, 100 count, NDC 00093-5298-01 - discontinued
• Methylphenidate CD extended release capsule, Teva, 60 mg, 100 count, NDC 00093-5293-01 - discontinued
• Methylphenidate CD extended release capsule, Teva, 50 mg 100 count, NDC 00093-5292-01 - discontinued
• Methylphenidate LA extended release capsule, Teva, 20 mg, 100 count, NDC 00093-5346-01
• Methylphenidate LA extended release capsule, Teva, 30 mg, 100 count, NDC 00093-5347-01
• Methylphenidate LA extended release capsule, Teva, 40 mg, 100 count, NDC 00093-5348-01
• Methylphenidate XR extended release capsule, Rhodes, 10 mg, 90 count, NDC 42858-0075-45
• Methylphenidate XR extended release capsule, Rhodes, 15 mg, 90 count, NDC 42858-0076-45
• Methylphenidate XR extended release capsule, Rhodes, 20 mg, 90 count, NDC 42858-0077-45
• Methylphenidate XR extended release capsule, Rhodes, 30 mg, 90 count, NDC 42858-0078-45
• Methylphenidate XR extended release capsule, Rhodes, 40 mg, 90 count, NDC 42858-0079-45
• Methylphenidate XR extended release capsule, Rhodes, 60 mg, 90 count, NDC 42858-0081-45
• Methylphenidate XR extended release capsule, Teva, 10 mg, 90 count, NDC 00591-3854-19
• Methylphenidate XR extended release capsule, Teva, 15 mg, 90 count, NDC 00591-3862-19
• Methylphenidate XR extended release capsule, Teva, 20 mg, 90 count, NDC 00591-3869-19
• Methylphenidate XR extended release capsule, Teva, 30 mg, 90 count, NDC 00591-3873-19
• Methylphenidate XR extended release capsule, Teva, 40 mg, 90 count, NDC 00591-3891-19
• Methylphenidate XR extended release capsule, Teva, 60 mg, 90 count, NDC 00591-3902-19
• Methylphenidate Hydrochloride extended release tablet, Camber, 18 mg, 100 count, NDC 31722-0952-01
• Methylphenidate Hydrochloride extended release tablet, Camber, 27 mg, 100 count, NDC 31722-0953-01
• Methylphenidate Hydrochloride extended release tablet, Camber, 36 mg, 100 count, NDC 31722-0954-01
• Methylphenidate Hydrochloride extended release tablet, Camber, 54 mg, 100 count, NDC 31722-0955-01
• Methylphenidate Hydrochloride extended release tablet, Lannett, 54 mg, 100 count, NDC 62175-0313-37
• Methylphenidate Hydrochloride extended release tablet, Sun Pharma, 18 mg, 100 count, NDC 57664-0606-88 - discontinued
• Methylphenidate Hydrochloride extended release tablet, Sun Pharma, 27 mg, 100 count, NDC 57664-0607-88 - discontinued
• Methylphenidate Hydrochloride extended release tablet, Sun Pharma, 36 mg, 100 count, NDC 57664-0608-88 - discontinued
• Methylphenidate Hydrochloride extended release tablet, Sun Pharma, 54 mg, 100 count, NDC 57664-0609-88 - discontinued
• Methylphenidate Hydrochloride extended release tablet, Teva, 18 mg, 100 count, NDC 62037-0725-01
• Methylphenidate Hydrochloride extended release tablet, Teva, 27 mg, 100 count, NDC 62037-0734-01
• Methylphenidate Hydrochloride extended release tablet, Teva, 36 mg, 100 count, NDC 62037-0726-01
• Methylphenidate Hydrochloride extended release tablet, Teva, 54 mg, 100 count, NDC 62037-0727-01
• Methylphenidate Hydrochloride extended release tablet, XLCare, 18 mg, 100 count, NDC 72865-0133-01
• Methylphenidate Hydrochloride extended release tablet, XLCare, 27 mg, 100 count, NDC 72865-0134-01
• Methylphenidate Hydrochloride extended release tablet, XLCare, 36 mg, 100 count, NDC 72865-0135-01
• Methylphenidate Hydrochloride extended release tablet, XLCare, 54 mg, 100 count, NDC 72865-0136-01

Reason for the Shortage

• Acella was not available to provide information.
• Adlon discontinued Adhansia XR in July 2022.
• Amneal discontinued the extended release tablets in March 2023. The company has the extended-release (CD) capsules available.
• Aytu BioPharma has Cotempla XR-ODT extended-release oral disintegrating tablets available. Cotempla is dose equivalent to methylphenidate hydrochloride extended-release (CD) capsules.
• Camber discontinued methylphenidate extended-release tablets.
• Ironhorse has Jornay PM available.
• Janssen has Concerta extended-release tablets available.
• KVK-Tech was not available to provide information
• Lannett has methylphenidate tablets on shortage due to increased demand and shortage of active ingredient. Lannett is shipping most presentations to forecast.
• Mallinckrodt has all presentations available.
• Patriot discontinued methylphenidate extended-release tablets (authorized generic) in January 2023.
• Rhodes has Aptensio XR capsules available.
• Sandoz has methylphenidate (LA) capsules and Ritalin LA capsules available.
• Sun Pharma discontinued methylphenidate extended-release tablets.
• Teva states the reason for the delay is manufacturing delay. Teva has the extended-release (LA) capsules temporarily unavailable. Teva discontinued the 40 mg, 50 mg, and 60 mg extended-release (CD) capsules in December 2023.
• Trigen has methylphenidate extended-release tablets available.
• Tris Pharma has Quillichew ER chewable tablets and Quillivant XR liquid available.
• Vertical has Relexxii tablets available.
• XLCare has methylphenidate extended-release tablets on shortage because the company is awaiting DEA allocation for active ingredient.

Available Products

• Aptensio XR extended release capsule, Rhodes, 40 mg, 90 count, NDC 42858-0405-45
• Aptensio XR extended release capsule, Rhodes, 50 mg, 90 count, NDC 42858-0406-45
• Concerta extended release tablet, Janssen, 18 mg, 100 count, NDC 50458-0585-01
• Concerta extended release tablet, Janssen, 27 mg, 100 count, NDC 50458-0588-01
• Concerta extended release tablet, Janssen, 36 mg, 100 count, NDC 50458-0586-01
• Concerta extended release tablet, Janssen, 54 mg, 100 count, NDC 50458-0587-01
• Cotempla XR-ODT oral disintegrating tablet, Aytu BioPharma, 17.3 mg, unit-dose blister pack, 30 count, NDC 70165-0200-30
• Cotempla XR-ODT oral disintegrating tablet, Aytu BioPharma, 25.9 mg, unit-dose blister pack, 30 count, NDC 70165-0300-30
• Cotempla XR-ODT oral disintegrating tablet, Aytu BioPharma, 8.6 mg, unit-dose blister pack, 30 count, NDC 70165-0100-30
• Jornay PM extended release capsule, Ironhorse, 100 mg, 100 count, NDC 71376-0205-03
• Jornay PM extended release capsule, Ironhorse, 20 mg, 100 count, NDC 71376-0201-03
• Jornay PM extended release capsule, Ironhorse, 40 mg, 100 count, NDC 71376-0202-03
• Jornay PM extended release capsule, Ironhorse, 60 mg, 100 count, NDC 71376-0203-03
• Jornay PM extended release capsule, Ironhorse, 80 mg, 100 count, NDC 71376-0204-03
• Methylphenidate CD extended release capsule, Amneal, 10 mg, 100 count, NDC 00115-1736-01
• Methylphenidate CD extended release capsule, Amneal, 20 mg, 100 count, NDC 00115-1737-01
• Methylphenidate CD extended release capsule, Amneal, 40 mg, 100 count, NDC 00115-1739-01
• Methylphenidate CD extended release capsule, Amneal, 50 mg, 100 count, NDC 00115-1740-01
• Methylphenidate CD extended release capsule, Amneal, 60 mg, 100 count, NDC 00115-1741-01
• Methylphenidate CD extended release capsule, Lannett, 10 mg, 100 count, NDC 00527-4579-37
• Methylphenidate CD extended release capsule, Lannett, 20 mg, 100 count, NDC 00527-4580-37
• Methylphenidate CD extended release capsule, Lannett, 40 mg, 100 count, NDC 00527-4582-37
• Methylphenidate CD extended release capsule, Lannett, 50 mg, 100 count, NDC 00527-4583-37
• Methylphenidate CD extended release capsule, Lannett, 60 mg, 100 count, NDC 00527-4584-37
• Methylphenidate LA extended release capsule, Mayne Pharma, 10 mg, 100 count, NDC 51862-0609-01
• Methylphenidate LA extended release capsule, Mayne Pharma, 20 mg, 100 count, NDC 51862-0610-01
• Methylphenidate LA extended release capsule, Mayne Pharma, 30 mg, 100 count, NDC 51862-0611-01
• Methylphenidate LA extended release capsule, Mayne Pharma, 40 mg, 100 count, NDC 51862-0612-01
• Methylphenidate LA extended release capsule, Mayne Pharma, 60 mg, 30 count, NDC 51862-0614-01
• Methylphenidate LA extended release capsule, Sandoz, 10 mg, 100 count, NDC 00781-2361-01
• Methylphenidate LA extended release capsule, Sandoz, 20 mg, 100 count, NDC 00781-2362-01
• Methylphenidate LA extended release capsule, Sandoz, 30 mg, 100 count, NDC 00781-2363-01
• Methylphenidate LA extended release capsule, Sandoz, 40 mg, 100 count, NDC 00781-2364-01
• Methylphenidate XR extended release capsule, Rhodes, 50 mg, 90 count, NDC 42858-0080-45
• Methylphenidate XR extended release capsule, Teva, 50 mg, 90 count, NDC 00591-3895-19
• QuilliChew ER extended-release chewable tablet, Tris Pharma, 20 mg, bottle, 100 count, NDC 24478-0074-01
• QuilliChew ER extended-release chewable tablet, Tris Pharma, 30 mg, bottle, 100 count, NDC 24478-0075-01
• QuilliChew ER extended-release chewable tablet, Tris Pharma, 40 mg, bottle, 100 count, NDC 24478-0076-01
• Quillivant XR extended-release oral powder for suspension, Tris Pharma, 5 mg/mL, 120 mL bottle, NDC 24478-0322-04
• Quillivant XR extended-release oral powder for suspension, Tris Pharma, 5 mg/mL, 150 mL bottle, NDC 24478-0323-05
• Quillivant XR extended-release oral powder for suspension, Tris Pharma, 5 mg/mL, 180 mL bottle, NDC 24478-0324-06
• Quillivant XR extended-release oral powder for suspension, Tris Pharma, 5 mg/mL, 60 mL bottle, NDC 24478-0321-02
• Relexxii extended release tablet, Vertical, 18 mg, 100 count, NDC 68025-0095-10
• Relexxii extended release tablet, Vertical, 27 mg, 100 count, NDC 68025-0096-10
• Relexxii extended release tablet, Vertical, 36 mg, 100 count, NDC 68025-0097-10
• Relexxii extended release tablet, Vertical, 45 mg, 30 count, NDC 68025-0088-30
• Relexxii extended release tablet, Vertical, 54 mg, 100 count, NDC 68025-0098-10
• Relexxii extended release tablet, Vertical, 63 mg, 30 count, NDC 68025-0089-30
• Relexxii extended release tablet, Vertical, 72 mg, 30 count, NDC 68025-0084-30
• Ritalin LA extended release capsule, Sandoz, 10 mg, 100 count, NDC 00078-0424-05
• Ritalin LA extended release capsule, Sandoz, 20 mg, 100 count, NDC 00078-0370-05
• Ritalin LA extended release capsule, Sandoz, 30 mg, 100 count, NDC 00078-0371-05
• Ritalin LA extended release capsule, Sandoz, 40 mg, 100 count, NDC 00078-0372-05
• Methylphenidate Hydrochloride extended release tablet, Lannett, 18 mg, 100 count, NDC 62175-0310-37
• Methylphenidate Hydrochloride extended release tablet, Lannett, 27 mg, 100 count, NDC 62175-0311-37
• Methylphenidate Hydrochloride extended release tablet, Lannett, 36 mg, 100 count, NDC 62175-0312-37
• Methylphenidate Hydrochloride extended release tablet, Mallinckrodt, 27 mg, 100 count, NDC 00406-0127-01
• Methylphenidate Hydrochloride extended release tablet, Mallinckrodt, 36 mg, 100 count, NDC 00406-0136-01
• Methylphenidate Hydrochloride extended release tablet, Mallinckrodt, 54 mg, 100 count, NDC 00406-0154-01
• Methylphenidate Hydrochloride extended release tablet, Trigen, 18 mg, 100 count, NDC 13811-0706-10
• Methylphenidate Hydrochloride extended release tablet, Trigen, 27 mg, 100 count, NDC 13811-0707-10
• Methylphenidate Hydrochloride extended release tablet, Trigen, 36 mg, 100 count, NDC 13811-0708-10
• Methylphenidate Hydrochloride extended release tablet, Trigen, 45 mg, 30 count, NDC 13811-0711-30
• Methylphenidate Hydrochloride extended release tablet, Trigen, 54 mg, 100 count, NDC 13811-0709-10
• Methylphenidate Hydrochloride extended release tablet, Trigen, 63 mg, 30 count, NDC 13811-0700-30
• Methylphenidate Hydrochloride extended release tablet, Trigen, 72 mg, 30 count, NDC 13811-0710-30

Estimated Resupply Dates

• Camber has methylphenidate 18 mg, 27 mg, 36 mg, and 54 mg XR capsules on allocation.
• Lannett has methylphenidate 54 mg extended-release tablets on back order and the company cannot estimate a release date. The 30 mg extended-release (CD) capsules are on intermittent back order and the company is releasing supplies as they become available.
• Rhodes has Aptensio XR 10 mg and 20 mg, capsules on back order and the company cannot estimate a release date. Aptensio XR 15 mg, 30 mg, and 60 mg capsules are available but with short dating (June 2025 for the 15 mg and 30 mg capsules and April 2025 for the 60 mg capsules). Generic methylphenidate 10 mg, 15 mg, 20 mg, 30 mg, 40 mg, and 60 mg extended-release capsules on back order and the company cannot estimate a release date.
• Teva has methylphenidate 18 mg, 27 mg, 36 mg, and 54 mg extended-release tablets on intermittent back order and the company is releasing supplies as they become available. Teva has 10 mg, 20 mg, and 30 mg extended-release (CD) capsules on back order and the company cannot estimate a release date. The 10 mg, 15 mg, 20 mg, 30 mg, 40 mg, and 60 mg extended-release (XR) capsules are on intermittent back order and the company is releasing supplies as they become available.
• XLCare has methylphenidate extended-release tablets on back order and the company cannot estimate a release date.

Implications for Patient Care

• Lannett and Mallinckrodt extended-release tablets have a therapeutic equivalence rating of BX in FDA's Orange Book. The available data on these generic drug products are insufficient for FDA to determine therapeutic equivalence with Concerta
• The CDC has issued a health advisory regarding potential disrupted access to care in patients taking prescription stimulant medications and possible increased risks for injury and overdose. The health advisory can be found at https://emergency.cdc.gov/han/2024/han00510.asp

Updated September 8, 2024 by Elyse MacDonald, PharmD, MS, BCPS. Created December 20, 2022 by Leslie Jensen, PharmD, Drug Information Specialist. © 2024, Drug Information Service, University of Utah, Salt Lake City, UT.

Drug Shortage Bulletins are copyrighted by the Drug Information Service of the University of Utah and provided by ASHP as its exclusive authorized distributor. ASHP and the University of Utah make no representations or warranties, express or implied, including, but not limited to, any implied warranty of merchantability and/or fitness for a particular purpose, with respect to such information, and specifically disclaim all such warranties. Users of this information are advised that decisions regarding the use of drugs and drug therapies are complex medical decisions and that in using this information, each user must exercise his or her own independent professional judgment. Neither ASHP nor the University of Utah assumes any liability for persons administering or receiving drugs or other medical care in reliance upon this information, or otherwise in connection with this Bulletin. Neither ASHP nor the University of Utah endorses or recommends the use of any particular drug. Any application of this information for any purpose shall be limited to personal, non-commercial use.

« Back to Drug Shortage Product Bulletins

• Midyear Clinical Meeting 2022
• Match Day Resources
• continuing education
• drug shortages
• policy positions and guidelines
• for presenters
• get involved in a meeting