Ateneo de Zamboanga University

College of Nursing
1st Semester S.Y. 2020-2021
NCM 106
NURSING PHARMACOLOGY
MODULE I

Fundamental Concept of Pharmacology

OVERVIEW

The purpose of this module is to provide an understanding of the basics of

pharmacology including pharmaceutics, pharmacokinetics, and pharmacodynamics.
Drug reactions in relation to side and adverse effects; hypersensitivity reactions; drug
tolerance, cumulative effects and drug toxicity; drug interactions; precautions and
contraindications, are also addressed to provide the nurse with a comprehensive
understanding of the knowledge needed for safe medication administration.

MODULE LEARNING OBJECTIVES: At the end of the session, the learners are
expected to:

1. Define common terms used in pharmacology.

2. Analyze the relevance of the four aspects of pharmacokinetics that include
absorption distribution metabolism and excretion.
3. Discuss the various routes of administration and related effect on the
pharmacokinetics of a drug.
4. Describe factors that can affect the pharmacokinetics of a drug.
5. Analyze the various chemical changes that take place in the body as a result of
the pharmacodynamics of the drug.
6. Discuss drug-drug and drug-food interactions and their relationship to the
development of adverse effects and toxicity.
7. Explore precipitating factors related to the occurrence of side and adverse
effects.
8. Analyze the etiology of hypersensitivity reactions, including anaphylaxis, and
actions taken to manage them.
9. Differentiate between drug tolerance, cumulative effects of drugs, and drug
toxicity.
10. Review precautions that should be taken when giving a medication and
contraindications that can make administering a drug dangerous or
detrimental to the patient.

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 11. Verbalize understanding of the general concepts/principles such as
pharmaceutics, pharmacokinetics, and pharmacodynamics and their
application in drug therapy and the nursing process.
12. Demonstrate an understanding of the various drug dosage forms as related to
drug therapy and the nursing process.
13. Discuss the relevance of the five aspects of pharmacokinetics (Liberation,
absorption, distribution, metabolism, excretion) to professional nursing
practice as related to drug therapy for a variety of patients and health care
settings.
14. Develop a nursing care plan that considers general pharmacologic principles,
specifically, pharmacokinetic principles, as they relate to the nursing process.

Key Words and Concepts: pharmacology, nursing process, pharmacokinetics,

pharmacodynamics, pharmaceutics,

Background

Curricula in nursing programs today have been tasked to incorporate concepts to

support safe medication administration. The joint commission as a part of their
national patient safety goals has identified two areas of interest regarding
medication administration. One area addresses medication error that occurs when
reading and interpreting new medication orders. A “Do Not Use” list of abbreviations
has been developed to prevent confusion that could lead to a medication
error. Appropriate medication labeling and use of anticoagulant medications have
also been targeted. The Institute for Safe Medication Practices (ISMP) has provided a
list of high alert medications that pose an enhanced risk of causing significant patient
harm if given inappropriately.

Special populations have also been targeted as high risk in relation to certain
medications and or how medications are administered. One special population is the
pregnant woman due to the potential for maternal or fetal adverse drug
reactions. Some drugs can be teratogenic and cause birth defects if given in the first
trimester. Historically these have been rated according to categories, but a new
system is being developed that allows for more specificity based on research that
supports evidence-based prescribing.

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DEFINITION OF TERMS:

1. ABSORPTION is the movement of the drug from the site of administration to

various tissues in the body.
2. ADVERSE EFFECTS are the unintended and unexpected effects of a drug that
can be severe and even be life-threatening in nature at a therapeutic dose.
3. AGONIST is a drug that stimulates the activity of one or more receptors in the
body.
4. ALLERGIC REACTION is an immunologic based hypersensitivity response that
results from administration of a drug to a person who is sensitive to that drug.
5. ANTAGONIST is a drug that inhibits the activity of one or more receptors in the
body.
6. BIOTRANSFORMATION is the biochemical reaction that primarily occurs in the
liver and produces a metabolite which is either an active or inactive form of the
original drug.
7. BLOOD BRAIN BARRIER is the barrier system that exists in certain parts of the
body that selectively restricts the passage of chemicals between the
bloodstream and the brain.
8. DURATION OF ACTION is the length of time a drug is in the blood in sufficient
amounts to elicit a response.
9. CONTRAINDICATION is a disease state or patient characteristic that renders a
drug inappropriate to be used due to the potential for adverse effects.
10. CUMULATIVE EFFECTS occur when the body is unable to metabolize and
excrete a drug before the next dose therapeutic if given.
11. DISTRIBUTION is the movement of the drug by the circulatory system to its
intended site of action.
12. DRUG’S GENERIC NAME is a term referring to the chemical makeup of a drug
rather than to the advertised brand name under which the drug is sold.
13. DRUG’S BRAND NAME is a term referring to the advertised brand name under
which the drug is sold.
14. DRUG-DRUG INTERACTION occurs when two drugs are given that can radically
change the action of one or both drugs in the body by reducing absorption or
increasing risk for toxicity
15. DRUG-FOOD INTERACTION occurs when a drug is given with a food that can
radically change the action of the drug by reducing absorption or increasing risk
for toxicity.
16. EXCRETION is the elimination of a drug or its metabolites through various parts
of the body.
17. FIRST PASS EFFECT is the effect that the liver has on medication as it passes
through the liver for the first time deactivating a certain amount of medication

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18. HALF-LIFE is the time it takes for a drug that enters the body to decrease in
amount by half.
19. HYPERSENSITIVITY REACTIONS occur secondary to administration of a drug
that a patient’s body sees as a foreign substance precipitating a mild to
moderate release of histamine.
20. METABOLISM is the change that occurs in a drug making it a more or less potent
form of the drug.
21. METABOLITE is a chemical form of a drug that remains after biotransformation
that may or may not have a pharmacologic effect.
22. ONSET OF ACTION is the time it takes for a drug to exert its therapeutic effect.
23. PEAK LEVEL of a drug is the point in time when a drug is at its highest level in
the body.
24. PHARMACEUTICS are the various pharmaceutical properties a drug possesses
based on its form and chemical composition.
25. PHARMACODYNAMICS are the biochemical changes that occur in the body
because of taking a drug.
26. PHARMACOKINETICS refers to how drugs travel through the body where they
undergo the biochemical processes of absorption, distribution, metabolism,
and excretion.
27. PHARMACOLOGY is the study of drugs and their effect on the human body
28. PRECAUTIONS are actions that should be taken when providers prescribe drugs
that have a potential to cause adverse effects in certain populations or in
combination with other drugs or certain foods.
29. SIDE EFFECTS are the unintended effects of a drug that commonly occur in
patients and are mild in nature at a therapeutic dose.
30. SYNERGISTIC EFFECT occurs when two drugs are given with similar actions
creating a summative response greater than what would be seen when the
drugs were given alone.
31. THERAPEUTIC EFFECT is the desired effect of a drug.
32. TOLERANCE the decrease in response to a drug after prolonged use.
33. TROUGH LEVEL of the drug is the point in time when the drug is at its lowest
level in the body.

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I.PHARMACOLOGY

• Pharmacology is the study of drugs and their effect on the human body. Drugs
can have a positive effect on the body which is called the therapeutic effect,
they can have non-therapeutic effects on the body called side effects, or they
can have negative effects on the body which are called adverse effects.
• When administering drugs one must also watch for contraindications that
would make a drug dangerous to give to a patient, precautions that should be
taken when administering a drug, and interactions, either drug-drug or drug-
food, that can increase or decrease the efficacy of the drug.
• Drugs are also called medications when given for therapeutic purposes. When
administering a drug to a patient the term medication is more commonly used
because it is being given to elicit a specific therapeutic response or to treat a
health alteration.
• Drugs are also known by two different names: their brand name and their
generic name. A drug’s brand name is a term referring to the advertised brand
name under which the drug is sold and a drug’s generic name is a term referring
to the chemical makeup of a drug rather than the advertised brand name under
which the drug is sold. An example of a drug’s generic and brand name is
PARACETAMOL whose brand name is BIOGESIC. Patient’s may be more familiar
with their medication’s brand names but health care providers should use the
generic form to prevent confusion because brand names can vary widely.
• Some drugs given for pain have addictive properties and can be abused by
patients. Of major concern is the improper use of opioid drugs by patients that
has led to an opioid crisis in our society. Approximately 20% of people who
require pain relief for acute pain such as post-operative pain or have chronic
pain related to a health issue such as low back pain are prescribed opioids.
• Opioids are narcotics and as such have addictive properties. These drugs are
safe if taken over a short period of time however, if taken for extended periods
of time or in higher than prescribed amounts a patient becomes at risk for
developing an addiction. It is critical that nurses give these medications as
prescribed and educate patients on their proper use and alternative non-
opioid drugs that can be taken when pain is subsiding.

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 A. PHARMACEUTICS

• Pharmaceutics are the various pharmaceutical properties a drug possesses

based on its form and chemical composition.
• The ability of a drug to dissolve in a patient’s body is largely dependent on its
form. For example, a drug taken orally in liquid form is going to be absorbed by
the body more quickly than a drug in pill form.
• Pills with an “enteric” coating delay dissolution of the pill until it reaches the
intestinal tract. This ensures that the acidic pH of the stomach does not break
down the chemical composition of a drug rendering it ineffective.
• Enteric-coated pills should never be crushed because their action may be lost
before leaving the stomach.

The table below illustrates the absorption rate of various forms of oral medication
based on their form.

Drug Form Rate of Absorption

Liquids, elixirs, and syrups Fastest
Suspensions solutions |
Powders |
Capsules |
Tablets |
Coated Tablets |
Enteric-coated Tablets Slowest

Drugs can be given in three dosage forms: enterally, parentally, and topically.
• Enteral forms are given via the intestinal tract either orally, sublingually (under
the tongue), buccally (between the gums and cheek), or rectally.
• Drugs that require quick absorption may be given sublingually or buccally
because the rich supply of blood vessels in the mouth and the ease of transport
through the mucous membranes supports immediate absorption by the body.
• Parenteral forms are given outside the gastrointestinal tract. They are given
intradermally, intramuscularly, subcutaneously, or intravenously. These forms
allow for immediate absorption by the body bypassing the gastrointestinal
track and the need for dissolution.

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 • Topical forms are given via aerosol, cream, foam, gel, suppository, and through
patches. These drugs may act directly on the skin or may be absorbed through
the skin for a systemic response.

Drugs may be chemically formulated to be released over a specific period.

• Extended-release forms release the drug in the patient’s gastrointestinal track
over an extended period. In contrast immediate-release dosage forms release
the drug upon contact with the gastrointestinal track.
• Nurses must be cognizant in noting when a drug has one of the following
abbreviations as a part of its name. Extended drugs will be administered less
often due to their slow release over time.

SR Slow release
SA Sustained action
CR Controlled releases
XL Extended release
XT Extended time

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B. PHARMACOKINETICS
• Pharmacokinetics refers to how drugs travel through the body where they
undergo a variety of biochemical processes that result in absorption,
distribution, metabolism, and excretion.

1. Absorption is the transmission of drugs from the location of administration,

including the gastrointestinal tract, muscle, skin, mucous membranes, and
subcutaneous tissue into the bloodstream. There are various factors that
influence the distribution of medication given through these various routes.

• Oral drugs must pass through a layer of epithelial cells that line the
gastrointestinal tract. The absorption pattern of drugs taken orally varies
due to solubility and stability of the medication, the pH of the
gastrointestinal tract and its motility, the presence of food in the stomach
or intestines, drugs given at the same time, and the form of the medication
in regard to whether a medication is a liquid, capsule, tablet, enteric-coated,
or time-released.
• Sublingual and buccal drugs which are placed under the tongue (sublingual)
or between the gums and the cheek (buccal) are absorbed before
swallowing. This prevents the gastric pH from inactivating the medication.
It also enhances the rate of absorption due to its passage through highly
vascular membranes.
• Rectal and vaginal drugs are easily absorbed and can precipitate both local
and systemic effects. However, the presence of stool in the rectum or
infectious discharge in the vagina limits tissue contact with the medication.
• Inhalation of medication through the mouth or nose is rapidly absorbed
through capillary networks in either the nose or alveoli in the lungs.
• Intradermal and topical drugs allow slow, gradual absorption of medication.
The effects of this type of medication is usually local but systemic effects
can occur as well.
• Subcutaneous and intramuscular drugs may be absorbed quickly or slowly.
Water-soluble drugs are absorbed rapidly while non water-soluble drugs
have a slower absorption rate. In general, drugs given intramuscularly are
absorbed quickly due to the vascularity of muscles however, patients with
poor peripheral perfusion may experience delayed absorption.
• Intravenous drugs are absorbed the most quickly and completely of any of
the other routes. Intravenous medication given directly into the
bloodstream reaches tissues in its original chemical form.

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2. Distribution is the transportation of drugs to sites of action by bodily fluids.
The organs that are exposed to the drug first are the heart, liver, kidneys, and
brain due to their vascularity and extensive supply of blood. Many drugs may
be hepatotoxic (can cause liver injury) or nephrotoxic (can cause kidney injury)
because drugs pass through these organs in a higher concentration increasing
their potential to cause damage to these organs. There are various factors that
influence the distribution of drugs.

a. Circulation is one factor that can either enhance or inhibit perfusion of

drugs throughout the body. Health alterations such as cardiac disease or
peripheral vascular disease can delay medication distribution. Dehydration
and overhydration can also affect the ability of a drug to perfuse in its
intended manner and for the expected amount of time through the body.

b. Permeability of cell membranes is another factor that affects perfusion of

medication through tissues and membranes. Drugs must pass through
several types of cell membranes before they reach their target tissue. Oral
drugs must pass through cell membranes in the gastrointestinal tract and
capillaries to enter the circulation; then leave the circulation to bind with
receptors on the target cells; then return to the circulation and pass through
the liver where a certain amount of the drug is metabolized by liver
enzymes; and then re-enter the circulation to be excreted by the
body. Certain areas of the body have cell membranes that decrease the
amount of drug that can pass through. This is true for the brain (also known
and the blood-brain barrier) and placenta.
c. Plasma protein binding sites also affect the distribution of drugs within the
bloodstream. Drugs that bind to proteins (drug-protein complex) will be
affected by how much of the medication is given and its transport to target
tissues. The drug-protein complex is usually too large to pass through the
capillaries into tissues so only unbound or “free” amounts of the drug is
pharmacologically active and can exert a therapeutic effect. Clients who
are malnourished or have a negative nitrogen balance are at higher risk of
toxicity due to the increased amounts of free drug. These patients require
lower dosages of certain drugs to prevent toxicity.

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3. Metabolism is the biotransformation that changes drugs into less active or
inactive forms through the action of enzymes. The new or altered form of the
drug is called a metabolite. Metabolism occurs primarily in the liver but also
takes place in the kidney, lungs, intestines, and blood. Once a drug enters the
body and passes through these organs, in particular the liver and kidneys, the
body begins to eliminate it by metabolizing it. An interesting note is that most
drugs are lipid soluble, but the kidneys can only excrete water soluble
substances. Therefore, it is necessary for the liver to convert lipid soluble drugs
to water soluble drugs as they pass through the liver and are metabolized.

a. Age is a factor that can affect the metabolism of a drug. Infants have a
limited “medication – metabolizing capacity”. Metabolism by the liver also
tends to decline with age requiring a decrease in dose when older adults are
given drugs to avoid inadvertently causing toxicity.

b. Increase in “medication metabolizing enzymes” can cause a drug to be

metabolized sooner. This increase may be a result of administering certain
drugs over an extended period. This may require an increase in dosage to
maintain a therapeutic level. An increase in “medication metabolizing
enzymes” can also cause an increase in the metabolism of other drugs being
given concurrently.

c. First pass effect results from the liver inactivating a certain amount of a
drug after it leaves the gastrointestinal tract and passes through the liver
for the first time. Drugs that are inactivated by the liver need to be given by
a route that does not pass the gastrointestinal tract.

d. Similar metabolic pathways can alter the metabolism of two drugs given at
the same time. The rate of metabolism can decrease for one or both drugs
leading to toxicity.

e. Nutritional status of clients affects the availability of a drug and number of

metabolizing enzymes available. Clients who are malnourished may have a
fewer number of enzymes increasing the risk of toxicity.

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 4. Excretion is the elimination of drugs from the body, primarily through the
kidneys. Kidney dysfunction can lead to an increase in the duration and
intensity of a medication’s response; as a result, the BUN and creatinine levels
of at-risk patients must be closely monitored. Elimination also takes place
through the liver, lungs, intestines, skin, and exocrine glands so sufficient
function of these organs is also necessary for effective excretion.

Renal excretion is supported by glomerular filtration, active tubular

reabsorption, and active tubular secretion.
• The free or unbound water-soluble form of a drug or metabolite enters
the kidney through passive glomerular filtration.
• The vasculature that surrounds the nephron may also transport
via tubular secretion molecules of the drug into the nephron.
• Active reabsorption may draw some of the drug back into circulation and
redistribute it throughout the body.
• Biliary excretion supports excretion of a drug through the
gastrointestinal in the form of feces.

HALF LIFE
• The half-life of a drug is the time it takes after a drug enters the body to
decrease in amount by half.
• This decrease reflects how quickly and efficiently a drug is metabolized and
then excreted.
• Drugs are excreted from the body when approximately five half-lives have
occurred.
• Drugs with a short half-life may need to administer several times a day as
compared to drugs with a long half-life which may only need to be
administered once a day.

o Since most drugs are metabolized in the liver and are excreted by the
kidneys; a decrease in functioning in either of these organs increases the
half-life of a drug.
o Subsequently, patients with liver or kidney dysfunction may experience
toxic effects of drugs much more easily if the dosage or frequency of
administration is not decreased.
o The nurse should also monitor labs that reflect liver function including
alanine transaminase (ALT), aspartate transaminase, (AST), alkaline
phosphatase (ALP) and kidney function including blood urea nitrogen (BUN)
and creatinine. The provider should be notified should an increase in any of
the values occur.

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ONSET, PEAK, TROUGH, AND DURATION
• Onset of action is the time it takes for a drug to exert its therapeutic
effect. Onset of action is influenced by the route of administration and patency
of patient’s gastrointestinal tract and circulatory system.
• Peak level of a drug is the point in time when a drug is at its highest level in the
body.
• Duration of action is the length of time a drug is in the blood in sufficient
amounts to elicit a response. Duration of action is influenced by the rate of
excretion from the body.
• Trough level of a drug is the point in time when a drug is at its lowest, non-
therapeutic level in the body.

PEAK AND TROUGH LEVELS

• The peak and trough level of a drug is very important regarding maintaining a
therapeutic level of a drug in a patient’s body. If the peak level of a drug is too
high the patient runs a risk of toxicity.
• If the peak level of a drug is too low the patient runs the risk of receiving a non-
therapeutic amount of the drug negating its intended effect.
• Determination of the amount of drug in the body during the time when it
should be peaking is done by taking a sample of blood and having a laboratory
measure the amount of drug in the blood at that point in time.
• It is the nurse’s responsibility to monitor the peak and trough level of a drug to
ensure the patient is receiving a therapeutic and not a toxic amount of the drug.
• For example, an antibiotic medication such as gentamycin needs to be
maintained at a therapeutic level to effectively treat the infection for which it
is being given. However, it is also highly nephrotoxic and requires diligent
monitoring of the peak level of the drug as well lab values that monitor kidney
function to ensure the antibiotic is not being given at a higher than therapeutic
level for the client.

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 C. PHARMACODYNAMICS

• Pharmacodynamics are the biochemical changes that occur in the body

because of taking a drug.
• After a drug has been introduced into the body it enters the circulation and
meets the cells of almost all the organs and tissues in the body.
• The cells that are the target site for a drug are impacted in one of three ways:
alteration in cellular function, alteration in cellular environment, and action of
enzymes in the body.

C.1 ALTERATION IN CELLULAR FUNCTION

▪ When a drug meets a cell, it can modify its function by either enhancing or
blocking the way in which the cell functions.
▪ The joining or binding of a drug with a cell is called the drug – receptor
interaction. Drugs bind with receptors on a cell through the formation of
chemical bonds between the receptor and the active site on the drug
molecule.
▪ Drugs given to enhance a physiologic response are called
agonists. Agonists are drugs that bind with a receptor and enhance the typical
response. Morphine is an example of an agonist because it binds with
receptors that produce the desirable effect of analgesia.
▪ Antagonists are drugs that bind with receptors and either block or lessen the
typical response. An example is a histamine-2 (H2) blocker such as ranitidine
which blocks the histamine induced gastric acid secretion from the parietal cell
of the gastric mucosa.

C.2 CHANGES IN CELLULAR ENVIRONMENT

▪ Changes in the cellular environment occur when a drug changes the structure
of a cell. Changes may be made in the cell wall or one of a cell’s critical processes
such as replication.
▪ For example, penicillin-type antibiotics inhibit cell wall synthesis of certain
types of bacteria resulting in the destruction and death of the bacteria.
▪ Sulfa-type antibiotics inhibit the replication of certain types of bacteria by
preventing folic acid from helping to make DNA and RNA.

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C.3 CHANGES IN ENZYMATIC ACTION
▪ Through a process called selective interaction a drug may change a target
molecule’s typical response by inhibiting or enhancing the action of an enzyme
that affects the target molecule.
▪ ACE inhibitors such as lisinopril block the “angiotensin converting enzyme”
which is needed to create the hormone angiotensin II. Blocking this hormone
relaxes blood vessels making it a good drug to treat hypertension.

C.4 DRUG INTERACTIONS

▪ Drug-drug and drug-food interactions can dramatically change the action of a
drug in the body.
▪ Precautions should be taken to limit or restrict certain types of food or
concurrent administration of certain types of drugs rather than restricting the
drug itself.
1. Drug-drug interactions occur when one drug changes the way another drug
affects the body. When the combined effect of two drugs you give together is
the same as each drug you give alone in similar doses an additive effect
occurs. An example would be a patient who ingests two drugs that are central
nervous system depressants, such as alcohol and opioids. Their effects add to
each other putting the patient at risk for significant and possibly fatal central
nervous system depression.
▪ Synergistic effects occur when the effect of one drug is greater if you give
it with another drug. An example would be giving aspirin to a patient who
is taking a blood thinner such as warfarin which would increase the patients
risk of bleeding and hemorrhage.
▪ Antagonistic effects occur when the effect of one drug is decreased or
blocked if you give it with another drug. An example would be giving
ciprofloxacin with an antacid which reduces the absorption of ciprofloxacin
decreasing its efficacy to treat infection.

2. Drug-food interactions occur when a drug is given with a food that can
radically change the action of the drug by reducing absorption or increasing
risk for toxicity. An example would be eating fruit or drinking fruit juice an
hour or two before or after taking fexofenadine. The juice can inhibit the
absorption of fexofenadine decreasing or inhibiting its ability to block the
release of allergy-related histamine.

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C.5 THERAPEUTIC, SIDE, AND ADVERSE DRUG EFFECTS

• Therapeutic effects are the desired effects of a drug being

given. Side and adverse effects of a drug are the undesirable effects that occur
in response to a drug being given.

• Side effects are the unintended effects of a drug that commonly occur in
patients and are mild in nature. Side effects occur as a result of a drug's effects
on the body. For example, side effects of diphenhydramine include dry mouth
and drowsiness. Nurses often help patients cope with common and often
uncomfortable side effects of prescribed drugs. A nurse caring for a patient
who is receiving diphenhydramine and reports having a dry mouth should
ensure water or ice chips are available, offer sugar-free hard candy, and use a
saliva substitute as needed. These patients should also be instructed to avoid
driving a car or using heavy machinery when experiencing drowsiness.

• Adverse effects are the unintended and unexpected effects of a drug that are
more severe and can even be life-threatening at a therapeutic dose. Adverse
effects are also side effects of a drug but are more severe in nature. For
example, adverse effects of diphenhydramine in some older adults include
confusion, incoordination, and dizziness. Another example is the risk of
serotonin syndrome when taking sertraline, a drug prescribed for major
depressive disorder, obsessive compulsive disorder, panic disorder,
posttraumatic stress disorder, social anxiety disorder, and premenstrual
dysphoric disorder. Serotonin syndrome results from concurrent
administration of a selective serotonin reuptake inhibitor (SSRI) or a
monoamine oxidase (MAO) inhibitor or any other drug that potentiates
serotonin neurotransmission. Serotonin syndrome is characterized by
hypertensive crisis, hyperpyrexia, muscle rigidity, seizure, and extreme
agitation that can progress to delirium and coma. Nurses must recognize when
a patient is receiving a drug that has life-threatening side effects and monitor
the patient very closely for the first sign of these adverse effects.

C.6 HYPERSENSITIVITY REACTIONS

▪ Hypersensitivity reactions occur secondary to administration of a drug that a
patient’s body sees as a foreign substance.
▪ An allergy to a drug usually occurs after more than one dose of a drug has been
given. It occurs secondary to the release of histamine which can cause
generalized inflammation and swelling of tissues (hives), increased mucous

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 production, and in severe cases constriction of the bronchioles. Mild to
moderate cases of hypersensitivity reactions can be treated with an
antihistamine such as diphenhydramine.

1. Anaphylactic shock is an exaggerated response of the body's immune system

to a drug which precipitates a massive release of histamine and other chemical
mediators into the body. Symptoms of anaphylactic shock can occur almost
immediately after exposure and include:
▪ Swelling of the eyes face mouth and throat
▪ Difficulty breathing
▪ Wheezing
▪ Rapid heart rate
▪ Extremely low blood pressure
▪ Cardiac arrest
o A patient in anaphylactic shock must be immediately brought to a
medical facility where he or she can receive cardiopulmonary
support along with rescue drugs.
o Treatment of anaphylactic shock focuses on reestablishment of
an airway and oxygen therapy, administration of epinephrine to
raise the patient's blood pressure and dilate respiratory bronchi,
and administration of diphenhydramine to block the additional
release of histamine.

▪ It is very important for nurses to ask patients if they have any allergies to
drugs. Even minor reactions to a drug are notable.
▪ If a patient admits to having an allergy to a drug, ask them what type of reaction
they had then note this information on the chart.
▪ The patient’s wristband should list all known allergies and be placed on a
patient immediately after admission.
▪ When administering medication be sure to check both the chart and patient’s
wrist band for allergies. When checking new orders review the patient’s chart
for allergies and bring to the provider’s attention any drug that could
precipitate a reaction.
▪ Some drugs can display a cross-sensitivity to another drugs. Patients who
report an allergy to penicillin may have a cross-sensitivity to cephalosporin
drugs.
▪ If the patient has not received a cephalosporin on a prior occasion monitor the
patient very closely during the first few doses for signs of an allergic reaction.

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C.7 DRUG TOLERANCE, CUMULATIVE EFFECTS, AND DRUG TOXICITY
▪ Drug tolerance, cumulative effects, and drug toxicity are other undesirable
effects related to safe medication administration that the nurse must monitor
for when caring for a patient receiving drug therapy.

1. Drug tolerance is a body’s decrease in response to a drug it receives over a

period. For the drug to continue to exert a therapeutic effect the dosage must
be increased. Tolerance is not synonymous with addiction. A patient can
develop tolerance to a drug and not be addicted. However, if the patient
continues to take the drug in increasing doses over a longer than recommended
period addiction can occur. Narcotic analgesics and antianxiety drugs are at
high risk for development of tolerance and subsequent addiction. Nurses must
monitor patients for the development of tolerance if one of these medications
has been given over an extended period or if the prescribed amount of
medication is no longer giving the patient relief.

2. Cumulative effects occur when the body is unable to metabolize and excrete a
drug before the next dose is given. If the next dose is given while some of the
drug from the previous dose is still in the patient’s body the drug begins to
accumulate in the body. The gradual increase in the amount of the drug in the
patient’s body increases the risk of adverse reactions and toxicity. The
development of cumulative effects is a common occurrence in older adults who
have a decreased cardiac and kidney function and in patients of any age who
have liver or kidney disease. The nurse should ensure the proper dose of
medication is given to these at risk patients and monitor for adverse effects
that could indicate too much of the drug is being given in relation to the body’s
ability to excrete it.

3. Drug toxicity occurs when a drug is given in amounts greater than what the
body can excrete. Drug toxicity may occur when a patient receives drugs in
greater than recommended dosages. It can also occur when impaired excretion
of the drug, secondary to impaired liver or kidney function, allows it to build up
in the body over a period. Eventually a toxic level is reached causing the patient
to experience severe and possibly fatal adverse effects. Drugs that have a
small margin of safety can quickly build up to a toxic level in the body. Patients
on drugs with a small margin of need to have their serum drug level regularly
drawn and be closely monitored for signs and symptoms of toxicity. The
effects of drug toxicity may be irreversible and life-threatening. For example,
vancomycin, given in toxic amounts may cause permanent damage to cranial

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 nerve VIII resulting in decreased hearing or deafness. Acetaminophen given in
amounts great than 4,000 milligrams per day may cause temporary damage to
the liver or permanent damage that results in liver failure. Nurses must make
certain when giving a patient acetaminophen that a review of all the drugs has
been done to determine if the patient is receiving additional acetaminophen in
any other drugs. Many drugs for pain are combination drugs that contain an
opioid and acetaminophen. Vicodin is an example of a combination drug which
contains 5 milligrams of hydrocodone and 300 milligrams of acetaminophen.

C.8 PRECAUTIONS AND CONTRAINDICATIONS

▪ Certain drugs should be given after careful consideration regarding
precautions or avoided completely because they are contraindicated in certain
populations.
1. Take precautions when providers prescribe drugs that have a potential to
cause adverse effects in certain populations or in combination with other drugs
or certain foods. Patients with certain diseases, are of a certain age, are
pregnant or lactating are some of these special populations. These drugs are
typically used only when necessary and when the benefits outweigh the
risks. For example, use of meperidine in older adults is discouraged because
decreased renal function can lead to accumulation of normeperidine, a
neurotoxic metabolite of meperidine.
2. Be cognizant of contraindications if a disease state or patient characteristic
renders a drug inappropriate for use due to the potential for adverse effects.
There are some drugs that providers should not prescribe because they have
the potential to cause serious or life-threatening adverse effects with certain
populations or in combination with other drugs and certain foods. Providers
should not consider the use of drugs in these situations except under
extremely unusual circumstances. For example, children under eight years of
age should not be given tetracyclines because they can permanently stain
developing teeth. Simvastatin should not be taken with grapefruit juice
because it can significantly increase blood levels of simvastatin. Increased
blood levels of simvastatin increase the risk of liver damage and breakdown of
skeletal muscle tissue. A high intake of dark green vegetables, beef liver, and
soybean-containing foods should be avoided in patients taking
warfarin. These foods interfere with the anticoagulant property of warfarin
because they contain high amounts of vitamin K which can decrease the effects
of warfarin.

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 3. Women who are pregnant or could become pregnant should avoid the use of
several types of drugs. Prior to 2015 the FDA supported a five-category
labeling system of prescription drugs that indicated their risk of fetal injury
when used by a pregnant mother during pregnancy. This manner of labeling
prescription medications has been replaced because the categories often led to
prescribing errors based on false conclusions made related to the categories. A
new registry system documents known or potential maternal or fetal adverse
reactions and pregnancy outcomes for individual drugs. This registry provides
information that supports evidence-based decisions regarding prescribing
appropriate and safe medications.

NURSING IMPLICATIONS
▪ Nurses must be knowledgeable of all drugs they are administering to their
patients. It is important to understand the pharmacokinetics and
pharmacodynamics of a drug to safely administer the drug while monitoring
for side and adverse effects, signs of an allergic response, and toxicity.
▪ Patient characteristics such as age, health alterations, and impairment of liver
or kidney function, must also be considered regarding increased risk for side
and adverse effects.
▪ The process of monitoring peak and trough level of drugs that are critical to be
maintained at a therapeutic level is also very important knowledge for nurses
caring for patients.
▪ All drugs that are prescribed by a provider should be reviewed in relation to
other drugs that are being given to prevent drug – drug interactions. If a
potential interaction is discovered or two similar drugs are prescribed
increasing the risk for toxicity the provider should be notified and concerns
brought to that individual’s attention so a substitution can be made, or a drug
discontinued.
▪ Foods that could precipitate a drug – food interaction must also be restricted
from a patient’s diet and patient education provided if the medication would
continue to be taken outside of the acute care setting.
▪ In summary, nurses are responsible for a deep understanding of the drugs they
are giving to administer drugs in a safe and evidence-based manner.

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KEYPOINTS

▪ The following definitions related to drug therapy are important to remember:

pharmacology-the study or science of drugs; pharmacokinetics-the study of
drug distribution among various body compartments after a drug has entered
the body, including the phases of absorption, distribution, metabolism and
excretion; pharmaceutics- the science of dosage form design.
▪ The nurses’ role in drug therapy and the nursing process is more than just
memorization of the names of drugs, their uses, and associated interventions.
It involves a thorough comprehension of all aspects of pharmaceutics,
pharmacokinetics, and pharmacodynamics and the sound application of this
knowledge to a variety of clinical situations.

SUMMARY

▪ A thorough understanding of the pharmacologic principles of

pharmacokinetics, pharmacodynamics, pharmacotherapeutics, and toxicology
is essential in drug therapy and to safe, quality nursing practice. Application of
pharmacologic principles enables the nurse to provide safe and effective drug
therapy while always acting on behalf of the patient and respecting the
patient’s rights.

REFERENCES:

1. Wintgerton Edmunds, M. (2016) Introduction to Clinical Pharmacology. St.

Louis, MO: Elsevier.
2. Frandsen, G. & Smith Pennington, S. (2018) Abram’s Clinical Drug
Therapy: Rationales for Nursing Practice. Philadelphia, PA: Wolters Kluwer
3. Lilley, L.L., Rainforth Collins, S. & Snyder, J.S. (2017) Pharmacology and the
Nursing Process. St. Louis, MO: Elsevier.

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LEARNING ACTIVITIES

A. REVIEW QUESTIONS:
1. An elderly woman took a prescription medicine to help her to sleep; however,
she felt restless all night and did not sleep at all. The nurse recognizes that
this woman has experienced which type of reaction or effect?
a. Allergic reaction
b. Idiosyncratic reaction
c. Mutagenic effect
d. Synergistic effect

2. While caring for a patient with cirrhosis or hepatitis, the nurse knows that
abnormalities in which phase of pharmacokinetics may occur?
a. Absorption
b. Distribution
c. Metabolism
d. Excretion

3. A patient has just received a prescription for an enteric-coated stool softener.

When teaching the patient, the nurses should include which statement?
a. Take the tablet with 2 to 3 ounces of orange juice.
b. Avoid taking all other medications with any enteric-coated tablet.
c. Crush the tablet before swallowing if you have problems with swallowing.
d. Be sure to swallow the tablet whole without chewing it.

4. The nurse is reviewing the various forms of topical medications. Which of

these are considered topical drugs? (select all that apply)
a. Rectal ointment for hemorrhoids
b. Eyedrops for inflammation
c. Sublingual tablet for chest pain
d. Inhaled medication for asthma
e. Intradermal injection for tb testing

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B. CRITICAL THINKING QUESTIONS:
1. Mr. Lim is admitted to the trauma unit with multisystem injuries from an
automobile accident. He arrived at the unit with multiple abnormal findings,
including shock from blood loss, decreased cardiac output, and urinary output
less than 30mL/hr. which route of administration would you expect to be the
best choice for this patient? Explain your answer.

2. You are administering medications to a patient who had an enteral tube

inserted 2 days earlier for continuous feedings. As you review the medication
list, you note that one drug is an enteric-coated tablet ordered to be given
twice a day. What is the best action regarding giving this drug to this patient?

C. Explain the following graphic based on what you learned from Prescription to
Patient Health - mapping the medicine to the patient. Use separate sheet of
paper.

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