PHARMACOLOGY
 Etymologically, it is the science of drugs.
 Pharmacology is derived from Greek words:
Pharmacon = Drug
Logos = Discourse in / study
 It is the study of how chemical agents affect living
processes.
 It studies the effects of drugs and how they exert
their effects to the body.
 Pharmacology is the branch of biology concerned
with the study of drug action.
 It deals with interaction of exogenously
administered drugs with living systems.
PHARMACOTHERAPEUTICS
 Otherwise known as clinical pharmacology, the
branch of pharmacology that uses drugs to treat,
prevent, and diagnose disease.
 Addresses two key concerns: the drug’s effects on
the body and the body’s response to the drug.
PHARMACOGNOSY
• branch of pharmacology dealing with natural drugs &
their constituents.
• deals with the sources, procurement & chemistry of
natural products.
PHARMATHERAPEUTICS
 treatment of diseases with medicines.
TOXICOLOGY
 study of poisons
CHEMOTHERAPY
 The use of chemicals for the treatment of any
disease.
 May also be synonymous to cancer treatment.
PHARMACY
 The science of identification, compounding and
dispensing of drugs.
 It also includes collection, isolation, purification,
synthesis and standardization of medical
substances.
PHARMACOLOGY HISTORY
MATERIA MEDICA Latin (medical material)
• Body of collected knowledge about the therapeutic
properties of any substance used for healing.
• Derived from work of ancient Greek physician
DIOSCORIDES in 1st century AD
 The term material medica was used from the
Roman Empire until the 20th century but now has
been replaced in medical education contexts by the
term PHARMACOLOGY.
 1st extensive PHARMACOPEIA commentary on 600
plants along with therapeutically useful animal and
mineral products.
 De Materia Medica included about a thousand
natural product drugs (mostly plant-based), 4,740
medicinal usages for drugs, and 360 medical
properties (antiseptic, anti-inflammatory etc.)
ANCIENT EGYPT
 The EBERS PAPYRUS is an Egyptian Medical
Papyrus of herbal knowledge.
 A scroll, some 60 feet long and a foot wide,
contains 700 magical formula and folk
medicines.
 The EBERS PAPYRUS is meant to cure afflictions
ranging from crocodile bite to toe nail pain and
to get rid of the pest such as flies, rats, and
scorpions.
 The EBERS PAPYRUS also includes an accurate
description of the circulatory system, noting the
existence of blood vessels throughout the body
and the hearths function as center of the blood
supply.
 The EBERS PAPYRUS is an ancient recipe book
dated to
 approximately 1552 BC. It contains a mixture of
magic and medicine with invocations to banish
disease and a catalogue of useful plants,
minerals, magic amulets and spells.
 The most famous Egyptian physician was
IMHOTEP who lived in Memphis around 2500
B.C.
ANCIENT INDIA – AYURVEDIC MEDICINE
 In India, the Ayurveda is traditional medicine that
emphasizes plant-based treatments, hygiene, and
balance in the body’s state of being.
 Indian materia medica included knowledge of
plants, where they grow in all season, methods for
storage and shelf life of harvested materials. It also
included directions for making juice from
vegetables, dried powders from herb, cold infusions
and extracts.
ANCIENT CHINA MEDICINE
 Compendium of Materia Medica (also known by
the romanizations Bencao Gangmu or Pen-tsao
Kang-mu) is a Chinese herbology volume
written by Li Shizhen during the Ming dynasty;
its first draft was completed in 1578.
 It is a work epitomizing the materia medica
known at the time.
The Compendium of Materia
 Medica is regarded as the most complete and
comprehensive medical book ever written in
the history of traditional Chinese medicine.
 It lists all the plants, animals, minerals, and
other items that were believed to have
medicinal properties.
 The text consists of 1,892 entries, each entry
with its own name called a gang. The mu in the
title refers to the synonyms of each name.
 HIPPOCRATES – Father of Medicine
 He founded a school of medicine that focused
on treating the causes of disease rather than its
symptoms.
 Disease was dictated by natural laws and
therefore could be treated through close
observation of symptoms.
DRUG
According to WHO, “Any substance or product which is
used or intended to be used to modify or explore
physiological systems or pathological states for the
benefit of the recipient”.
DRUG NOMENCLATURE
Every DRUG has three (3) of Names
1. Chemical Name
2. Non-proprietary Name (Generic Name)
3. Proprietary Name ( Trade/Brand Name)
It is a chemical substance used in the treatment, cure,
prevention or diagnosis of disease or used to otherwise
enhance physical or mental wellbeing.
1. Chemical Name – These are given according to the
chemical constitution of drug.
2. Non-proprietary Name– (Official name) It is
assigned by the United States Adopted name
(USAN) council. It is uniform all over the world.
 Generic Name – Typically derived from
chemical name. Usually shorter.
 Proprietary Name– It is given by the
pharmaceutical manufacturer.
3. Trade/Brand Name – Name registered by the
manufacturer; only be used by the single
manufacturer; The first letter of the name is
Capitalized,
CHARACTERISTICS OF IDEAL DRUG
1. It should be biocompatible and biodegradable.
2. No side effects.
3. Shows the selectivity in its action.
WISHLIST FOR A PERFECT DRUG
1. Reversible
2. Predictable
3. NO adverse effects
4. NO interaction
5. Cheap and simple
GOALS OF PHARMACOLOGY
1. Maximum benefit for the patient.
2. Minimum harm to the patient.
NURSING RESPONSIBILITIES IN DRUG THERAPY
1. Administering drugs.
2. Assessing drug effects.
3. Intervening to make the drug regimen more
tolerable.
4. Providing patient teaching about drugs and the
drug regimen.
 5. Monitoring the overall patient care plan to
prevent medication errors.
SOURCES OF DRUGS
PLANT SOURCES
 Is the oldest source of drugs.
 Almost all parts of the plants are used i.e. leaves,
stem, bark, fruits and roots.
 Ex: Morphine, Digoxin, Quinine, Reserpine etc.
ALKALOIDS
 Diverse group of bitter tasting, organic, basic
 substances found in plants with examples such
as
 caffeine, morphine and atropine.
o Digitalis purpurea are the source of
Digitoxin and Digoxin, which are cardiac
glycosides.
o Leaves of Eucalyptus give oil of
Eucalyptus, which is important
component of cough syrup.
 Tobacco leaves give nicotine.
o Poppy papaver somniferum gives
morphine (opoid)
ANIMAL SOURCES
 Drugs obtained from animals sources are whole
animals, glandular products (thyroid organ), insulin,
heparin, liver extract, polypeptide venoms, non-
peptide toxins and
 Urine of pregnant women
 Gives hCG used for the treatment of infertility.
 Thyroid of sheep is a source of thyroxine, used in
hypothyroidism
 Cod liver is used as a source of vitamin A and D.
INORGANIC COMPUNDS REFER TO NB
SYNTHETIC SOURCES
Drugs that are produced upon alteration of chemical
compositions of exisiting plants and animals when
proven to have therapeutic activity.
Advantage:
1. Quality can be controlled.
2. Process is easier and cheaper.
3. More potent and safer
4. Large scale production.
MINERAL SOURCES and EARTH SOURCES REFER TO NB
DRUG EVALUATION PHASES
A study to test a drug, a procedure, or another medical
treatment in animals. The aim of a preclinical study is to
collect data in support of the safety of the new
treatment.
Preclinical studies
 are required before clinical trials in humans can
 be started In this stage, chemicals that may have
therapeutic value are tested on laboratory animals
for two main purposes:
o To determine whether they have the
presumed effects in living tissue.
o To evaluate any adverse effects.
At the end of the preclinical trials, some chemicals are
discarded for the following reasons:
1. The chemical lacks therapeutic activity when
used with living animals.
2. The chemical is too toxic to living animals to be
worth the risk of developing into a drug.
3. The chemical is highly teratogenic (causing
adverse effects to the fetus).
4. The safety margins are so small that the
chemical would not be useful in the clinical
setting.
NOTE:
Some chemicals, however, are found to have
therapeutic effects and reasonable safety margins.
This means that the chemicals are therapeutic at doses
that are reasonably different from doses that cause
toxic effects.
 PHASE 1 STUDIES
 Uses human volunteers to test the drugs.
 More tightly controlled than preclinical trials
and are performed by specially trained clinical
investigators.
 The volunteers are fully informed of possible
risks and may be paid for their participation.
 Usually, the volunteers are healthy, young men.
 Women are not good candidates because the
chemicals may exert unknown and harmful
effects on a woman’s ova.
Many chemicals are dropped from the process for the
following reasons:
1. They lack therapeutic effect in humans.
2. They cause unacceptable adverse effects.
3. They are highly teratogenic.
4. They are too toxic.
NOTE:
Some chemicals move to the next stage of testing
For example, the antihypertensive drug minoxidil
malignant hypertension, but it caused unusual hair growth on
Now, its hair-growing effect has been channeled for
h preparations such as Rogaine.
PHASE 2 STUDIES
 Allows clinical investigators to try out the drug
in patients who have the disease that the drug
is designed to treat to evaluate the drug’s
effects.
 Usually, phase II studies are performed at
various sites across the country—in hospitals,
clinics, and doctors’ offices—and are monitored
by representatives of the pharmaceutical
company studying the drug.
Drug may be removed from further investigation for the
following reasons:
1. It is less effective than anticipated.
2. It is too toxic when used with patients.
3. It produces unacceptable adverse effects.
4. It has a low benefit-to-risk ratio, meaning that
the therapeutic benefit it provides does not
outweigh the risk of potential adverse effects
that it causes.
5. It is no more effective than other drugs already
on the market.
PHASE 3 STUDIES
 Involves use of the drug in a vast clinical market.
 Prescribers are informed of all the known reactions
to the drug and precautions required for its safe
use.
 Prescribers observe patients very closely,
monitoring them for any adverse effects.
 Prescribers ask patients to keep journals and record
any symptoms they experience.
 Prescribers then evaluate the reported effects to
determine whether they are caused by the disease
or by the drug.
 A drug that produces unacceptable adverse effects
is usually removed from further study by the drug
company.
 In some cases, the FDA may have to request that a
drug be removed from the market.
FDA APPROVAL
 Drugs that finish phase III studies are evaluated
by the Food and Drug Administration, which
relies on committees of experts familiar with
the specialty area in which the drugs will be
used before marketing in the public.
 An approved drug will be given generic name,
brand name, and chemical name.
PHASE 4 STUDIES
 Stage of continual evaluation.
 Prescribers are obligated to report to the FDA any
untoward or unexpected adverse effects associated
with drugs.
 Some drugs cause unexpected effects that are not seen
until wide distribution occurs.
 Sometimes, those effects are therapeutic.
o For example, patients taking the antiparkinsonism
drug amantadine (Symmetrel) were found to have
fewer cases of influenza than other patients, leading
to the discovery that amantadine is an effective
antiviral agent.
 In other instances, the unexpected effects are
dangerous.
 The diet drug dexfenfluramine (Redux) may develop
serious heart problems.
 NSAID Rofecoxib (Vioxx) show an increase in
cardiovascular mortality.
SUMMARY
To be approved for marketing, a drug must pass
through animal testing, testing on healthy humans,
selected testing on people with the disease being
treated, and then broad testing on people with the
disease being treated.
DRUG CLASSIFICATIONS
ORPHAN DRUGS
 Drugs that have been discovered but are not
financially viable and therefore have not been
“adopted” by any drug company.
 It may be useful in treating a rare disease, or
they may have potentially dangerous adverse
effects.
 These are often abandoned after preclinical
trials or phase I studies.
OVER-THE-COUNTER DRUG
 Products that are available without prescription
for self-treatment of a variety of complaints.
 OTC drugs have been found to be safe when
taken as directed, nurses should consider
several problems related to OTC drug use:
1. Taking these drugs could mask the signs and
symptoms of underlying disease, making diagnosis
difficult.
2. Taking these drugs with prescription medications
could result in drug interactions and interfere with drug
therapy.
3. It could result in serious overdoses.
GENERIC DRUGS
These are drugs no longer protected by patent and can
be produced by companies other than the one that
developed it.
OTHER WAYS TO CLASSIFY DRUGS
BODY SYSTEM CLASSIFICATION
 It answer the question, “Which system of the body
is the drug for?” Examples include drugs intended
for the cardiovascular system, respiratory,
genitourinary, gastrointestinal etc.
THERAPEUTIC USE/ CLINICAL INDICATION
 It answer the question, “What disease or illness is
being treated”
 Examples include drugs intended for diabetes,
hypertension, kidney problems etc.
PHYSIOLOGICAL/ CHEMICAL ACTION
 It answer the question, “What does the drug do
in the body”
 Examples include drugs to reduce cholesterol,
lower down blood pressure, relieve pain, etc.
 PRESCRIPTION / NONPRESCRIPTION
 It answer the question, “Does the medication
require a prescription or can be availed OTC?”
o Examples include prescription drugs
such as for hypertension, anti-cancer
drugs or nonprescriptions drugs such as
some pain relievers, supplements, etc.
ILLEGAL DRUGS
It answer the question, “Is the drug use for non
therapeutic reasons?”
Examples include some controlled substances such as
cannabis.
DRUG FORMS/ PREPARATIONS
1. SOLID FORMS
 The entire dose is contained in the preparation
minimizing measuring errors.
 Difficult to swallow, slower onset and may be
degraded by acidic content of the stomach.
TABLET / CAPLET
The active ingredient is combined with another
substance and pressed into a round or oval solid shape.
Soluble or dispersible tablets can safely be dissolved in
water.
Buccal or Sublingual Tablets
These are held in the cheek (buccal) or underneath the
tongue (sublingual) so the mouth lining absorbs the
active ingredient.
FORMS OF TABLET
A.) Chewable Tablets – designed to be chewed and
contain a base that is flavored or colored.
Covenient for patients who have difficulty swallowing
tablets.
B.) Oral Disintegrating Tablets (ODT) - designed to
dissolve in the mouth without water; useful for pedia
and eriatric clients who have difficulty swallowing and
for those who are experiencing nausea and vomitting.
Can not be “cheeked” by patients who are not
compliant with the drug regimen.
C.) Enteric- Coated Tablets – with coating to mask the
unpleasant flavor or odor, and to protect the drug from
the stomach contents.
The coat prevents dissolution in the stomach and are
meant to dissolve in the intestines
Protects as well the stomach lining with the effects of
the drug (i.e. KCl and ASA)
D.) Film- Coated Tablets – are coated with a thin outer
layer of water soluble material that dissolves rapidly in
the stomach.
The coat is designed to cover the unpleasant taste or
smell and protect sensitive drugs from deterioration
due to air and light (i.e. Erythromycin).
E.) Sugar- Coated Tablets - are coated with outside
layer of sugar that protects the medication and
improves the taste and the appearance of the
medication.
CAPSULES
 The active part of the medicine is contained inside a
plastic shell (transparent, semi-transparent, or
opaque) that dissolves slowly in the stomach.
 It contains liquid, powder, granule, or crushed
tablet and are formulated with delayed-release
characteristics to allow for less-frequent dosing and
or side effects.
FORMS OF CAPSULES
A.) Spanules - capsules that are filled with granules that
dissolves at different rates, in effect causing sustained
release of the active ingredient.
B.) Sprinkle Capsule - similar to spanules but unique in
that it is designed to be pulled apart and the contents
are sprinkled into foods.
DOSAGE FORMULATIONS TO DESIGNED TO ALTER
RATE OF RELEASE
1. Immediate- Release Formulation
The medication is released within a short period of time
after the drug is taken.
2. Delayed- Release Formulation
The release of the medication is extended or delayed
until it has passed through the stomach.
3. Controlled- Release Formulation
 It regulate the rate of release of the active
ingredient.
 They are designed to vary the dissolution rate or
release of the active drug.
 Also referred to as long-acting and timed-released
formulations.
4. Sustained- Release Formulation
It allows the frequency of the dosing to be reduced
compared to that of immediate- release dosage forms.
5. Extended- Release Formulation
 The active ingredient is released at a constant rate
for a prolonged period so that the frequency of
dosing is less than the immediate-release dosage
form.
 Usually for once daily dosing and the medication is
available over an extended period of time.
 Compared to immediate-release preparations,
advantages of extended-release dosage forms
include the following:
o Constant drug level following long-term
administration
o Reduction of side effects
o Reduction in administration frequency
o Increased patient compliance
LOZENGES / TROCHES / PASTILLES
Identified as flat, hard, oval, or discoid disks containing
a medicinal agent in a suitable flavoured base which is
held in the mouth to dissolve slowly.
POWDERS
 Consists of fine mineral dusts such as talc and are
applied by dusting.
 This is used to absorb moisture from the skin
thereby altering conditions favorable to the growth
of microorganisms.
 It can be used internally and should be dissolved in
water prior to ingestion.
GRANULES
 Larger than powders and are wetted, allowed to
dry, and ground into coarse, irregularly shaped
pieces.
 More stable than powders and are more suitable in
solutions because they will less likely to float in
liquids.
2. SEMI SOLID FORMS
 They come in tubs, bottles or tubes depending on
the type of medicine.
 The active part of the medicine is mixed with
another substance, making it easy to apply to the
skin.
 These are creams, lotions or ointments applied
directly onto the skin (topical application).
 Maybe placed in nasal, vaginal, rectal, and anorectal
cavities.
 The dosage are too thick not to be considered a
liquid form and not solid enough to be considered
solid form.
EMULSIONS
 A type of semi-solid dosage form wherein a mixture
is unblendable.
 One substance is dispersed in the other.
 An Oil-in-Water (O/W) emulsion contains small
amount of oil dispersed in water.
 A Water-in-Oil (W/O) emulsion contains small
amount of water dispersed in oil.
EMULSIFYING AGENT
 A chemical that is used to bind substances that
normally do not mix.
 It has water-loving and oil-loving properties that
keep oil and water together.
OINTMENTS
 Applied externally to the skin or mucous
membranes or can be formulated and sterilized for
use in the eyes.
 It is an example of water-in-oil emulsion.
 It contain medication in a glycol or oil base and can
effectively cover the skin.
 Generally greasier and can leave oily residue at the
site of application.
CREAMS
 It contains suspension or solutions of drug
intended for external use.
 An example of oil-in-water emulsion and can
easily be massaged into the skin without leaving
oily residue.
 It can be formulated for vaginal or rectal use.
Examples include hydrocortisone cream, benzoyl
peroxide cream, and betamethasone valerate cream.
LOTIONS
 An oil-in-water emulsion that is thinner than a
cream because it contains more water.
 It can penetrate in the skin and can cover large
areas without leaving an oily residue.
o Examples are calamine lotion and
hydrocortisone lotion.
GELS
 Contain solid medication like a suspension in a
thick liquid that can be used internally or
externally.
 Particles are ultrafine and form semisolid.
 Can penetrate the skin without leaving residue.
o Examples are aluminum hydroxide gel
and benzocaine gel.
PASTES
 It contains more solid material and less liquid base Aqueous solution that contains oil or other volatile
than a solid. substance. They usually have pleasant smell.
 They are like ointments, but stiffer, less greasy, and
B.) Elixir
applied more thickly.
 An example is zinc oxide. It is a clear, sweet solution that contains dissolved
medication in a base of water and ethanol
SUPPOSITORIES
(hydroalcoholic).
 The active part of the medicine is combined with
C.) Syrup
another substance and pressed into a “bullet
shape” so it can be inserted in the anal, rectal, Sugar-based solution that may masked the taste of the
vaginal or urethral area and melts in a cavity, drug.
releasing the medication.
D.) Extract
 It can be for local action and vehicle for systemic
drugs. It is a powder or liquid derived from animal or plant
 Suppositories must not be swallowed. sources in which all or most of the solvent has been
 Used for children with difficulty taking oral evaporated.
medications.
E.) Tincture
Rectal suppositories by- pass stomach and helpful to
An alcoholic or hydroalcoholic solution that contains
patients with nausea and vomitting.
plant extract.
Used to treat inflammatory bowel disease or pain.
F.) Spirit
Vaginal suppositories are for yeast infections and
It is an alcoholic or hydroalcoholic solution that contains
vaginal athropy.
volatile, aromatic ingredients.
 Examples are miconazole (vaginal) and bisacodyl
G.) Irrigating Solution
(rectal) suppositories.
A solution that is used for cleansing an area of the body.
3.) LIQUID FORMS
DISPERSIONS
The active part of the medicine is combined with a
liquid to make it easier to take or better absorbed. The medication is not dissolved in a liquid but is
“dispersed” throughout.
It is also called a “mixture”, “solution” or “syrup”.
SUSPENSION
DROPS
- a mixture of undissolved, fine, solid particles
 These are often used where the active part of the
throughout the solid, liquid, or gas.
medicine works best if it reaches the affected area
directly. AQUEOUS SUSPENSION- a mixture of medication in
 They tend to be used for eye, ear or nose. which solids are dispersed in a water medium.
SOLUTIONS NOTE: Suspension needs to be shaken before use and
must have shake well” auxillary label.
A homogenous mixture of solute and solvent where it is
in aqueous (water-based), alcoholic or hydroalcoholic INJECTABLE SUSPENSION
form.
allows insoluble drugs to be administered using a
syringe.

Often used for depot therapy- the drug is released over

a long period of time.
A.) Aromatic Solution
Subcutaneous or SC injections are given just under the
surface of the skin.
Intramuscular or IM injections are given into a muscle.
Intrathecal injections are given into the fluid around
the spinal cord.
Intravenous or IV injections are given into a vein.
ENEMAS
 Deliver medications rectally, a way that by-passes
the stomach.
 Water-based medication used to evacuate intestinal
contents as a preparation for surgeries and
examinations of the intestines.
4. INHALATION FORMS
The active part of the medicine is released under
pressure directly into the lungs via the nose or mouth.
AEROSOLS
It is a spray that contains very fine liquid or solid
particles in a gas propellant that is packaged under
pressure.
It has a rapid onset of action
SPRAYS
 It consists of a container that has a valve assembly
unit that contains various bases, such as alcohol or
water, in pump-type dispenser.
 When activated, it emits fine liquid, solid or gaseous
material.
5. TRANSDERMAL FORMS
Patch or Disk
 Designed to hold medication to be released in the
skin and absorbed into the blood stream.
 It contains backing, drug reservoir, control
membrane and adhesive layer.
 Drugs are absorbed slowly, easily applied, and
minimized stomach upset.
o Examples are nitroglycerine, fentanyl,
scopolamine, and nicotine for their systemic
effects.
Note: Gels are also in transdermal forms which are
slowly absorbed in the skin.
IMPLANTS
Placing a drug form or a device in the desired site by
insertion in a body tissue or cavity by surgical or
appropriate insertion techniques.
SOURCES OF DRUG INFORMATION
PACKAGE INSERTS
 It contains all of the chemical and study information
that led to the drug’s approval.
 It is difficult to understand and are almost always in
very small print, making them difficult to read.
REFERENCE BOOKS
 The Physician’s Desk Reference (PDR) is a
compilation of the package insert information from
drugs along with some drug advertising.
 Information is not refereed and is not the best
source of information about a drug.
 This information is heavily cross-referenced.
 The book may be difficult to use.
The Drug Facts and Comparisons
 It provides a wide range of drug information,
including comparisons of drug costs, patient
information sections, and preparation and
administration guidelines.
 This book is organized by drug class and can be
more user-friendly than the PDR.
 However, it is cumbersome and very expensive.
The AMA Drug Evaluations
 It contains detailed monographs in an unbiased
format and includes many new drugs and drugs
still in the research stage.
The Lippincot's Nursing Drug Guide
 It has drug monographs organized
alphabetically and includes nursing implications
and patient teaching points.
JOURNALS
 The Medical Letter is a monthly review of new
drugs, drug classes, and specific treatment
protocols.

The American Journal of Nursing HIGH or WIDE therapeutic index

offers information on new drugs, drug errors, and = safer drugs

nursing implications.
GRADED DOSE RESPONSE RELATIONSHIP
ONLINE SOURCES
DOSE - RESPONSE CURVE

An illustration that evaluates and compares efficacy and

The American Hospital Formulary Service Dug potency of related drugs.
Information
DRUG POTENCY AND EFFICACY
OTHER SOURCES
DRUG POTENCY
 Drug Interaction Facts
It refers to the concentration or amount of drug needed
 Handbook of Nonprescription Drugs
to achieve a therapeutic effect.
 Natural Medications Comprehensive
 Database The lesser the amount of drug needed to achieve a
therapeutic effect, the more potent the drug is.

DRUG EFFICACY
PHARMACODYNAMICS
The level as to which a drug reaches a therapeutic
The study of the interactions between the chemical
effect. The higher the effect, the more efficacious the
components of living systems and the foreign chemicals,
drug is.
including drugs, that enter those systems.
CALCULATING PERCENT ADHERENCE
“how the drug affects the body”.
PERCENT ADHERENCE

The extent to which a persons behavior when taking

THERAPEUTIC INDEX AND DRUG SAFETY THERAPEUTIC
INDEX
Also known as therapeutic window or ratio.
medication, following a diet or executing lifestyle
changes, corresponds with agreed recommendations
from health care provider.

It is the comparison between the amount of drug that Non-adherent behaviors include missing doses, taking
causes harm (toxicity) and the amount of drug providing drug holidays, taking extra doses when not feeling well,
therapeutic effect. changing the timing of doses or inconsistently not taking
medications.
Mathematically expressed as:
REASONS FOR NON ADHERENCE
TD50 / ED50
 Complex instructions
Where:  Asymptomatic diseases
ED = median effective dose, a dose where 50% effect is  Side effects of medications
reached.  Cognitive impairment
 Poor insight to illness
TD = toxic dose, a dose where 50% experience toxicity is  Cost of medication
reached.  Poor nurse-patient relationship
INTERPRETATIONS  Inadequate discharge planning
 Lack of follow up
LOW therapeutic index  Lack of belief in the regimen
=not safe drugs

= needs monitoring
GENERAL FORMULACELLULAR RECEPTOR SITES AND
DRUG ACTION
1. Drugs usually work in one of four ways:
2. To replace or act as substitutes for missing
chemicals.
3. To increase or stimulate certain cellular
activities.
4. To depress or slow cellular activities.
5. To interfere with the functioning of foreign
cells, such as invading microorganisms or
neoplasms.
RECEPTOR SITES
 Areas on the cell membrane where drugs or
chemical react to cause an effect within the cell.
 Nearby enzymes break down the reacting chemicals
and open the receptor site for further stimulation.
 The interaction between the chemical and the
receptor site affects enzyme systems within the cell.
 The activated enzyme systems then produce certain
effects, such as increased or decreased cellular
activity, changes in cell membrane permeability, or
alterations in cellular metabolism.
AGONIST
 These are drugs that interact directly with receptor
sites to cause the same activity that natural
chemicals would cause at that site.
 For example, insulin reacts with specific insulin-
receptor sites to change cell membrane
permeability, thus promoting the movement of
glucose into the cell.
ANTAGONIST
 These are drugs act to prevent the breakdown of
natural chemicals that are stimulating the receptor
site.
 EXAMPLE Monoamine oxidase (MAO) inhibitors
block the breakdown of norepinephrine by the
enzyme MAO.
 Normally, MAO breaks down norepinephrine.
 The blocking action of MAO inhibitors allows
norepinephrine to stay on the receptor site,
stimulating the cell longer and leading to prolonged
norepinephrine effects.
Those effects can be therapeutic (e.g., relieving
depression) or adverse (e.g., increasing heart rate and
blood pressure).
COMPETITIVE ANTAGONIST
 Drugs react with receptor sites to block normal
stimulation, producing no effect.
 EXAMPLE: Curare occupies receptor sites for
acetylcholine, which is necessary for muscle
contraction and movement.
 Curare prevents muscle stimulation, causing
paralysis.
NON COMPETITIVE ANTAGONST
 Drugs that react with specific receptor sites on a cell
and by reacting there, prevent the reaction of
another chemical with a different receptor site on
that cell.
DRUG- ENZYME INTERACTION
 Drugs can interfere with the enzyme systems that
act as catalysts for various chemical reactions.
Enzyme systems work in a cascade fashion, with one
enzyme activating another until a cellular reaction
eventually occurs.
If a single step in one of the many enzyme systems is
blocked, normal cell function is disrupted.
EXAMPLE: Acetazolamide (Diamox) is a diuretic that
blocks the enzyme carbonic anhydrase, which
subsequently causes alterations in the hydrogen ion and
water exchange system in the kidney, as well as in the
eyes.
SELECTIVE TOXICITY
The ability of a drug to attack only those systems found
in foreign cells.
Penicillin, an antibiotic affects an enzyme system unique
to bacteria, causing bacterial cell death without
disrupting normal human cell functioning.
TYPES OF INTERACTIONS
1. Drug–Drug / Drug–Alternative Therapy Interactions
2. Drug–Food Interactions
3. Drug–Laboratory Test Interactions
INTERACTIONS
When two or more drugs or substances are taken
together, there is a possibility that an interaction can
occur, causing unanticipated effects in the body.
Drug–Drug / Drug–Alternative Therapy Interactions
If there is very little difference between a therapeutic
dose and a toxic dose of the drug (margin of safety),
interference with the drug’s pharmacokinetics or
pharmacodynamics can produce serious problems.
Drug–drug interactions can occur in the following
situations:
1. At the site of absorption: One drug prevents or
accelerates absorption of the other drug.
o For example, the antibiotic tetracycline is not
absorbed from the GI tract if calcium or
calcium products (milk) are present in the
stomach.
2. During distribution: One drug competes for the
protein-binding site of another drug, so the second drug
cannot be transported to the reactive tissue.
o For example, aspirin competes with the drug
methotrexate (Rheumatrex) for protein-
binding sites.
o Because aspirin is more competitive for the
sites, the methotrexate is bumped off, resulting
in increased release of methotrexate and
increased toxicity to the tissues.:
3. During biotransformation: One drug stimulates or
blocks the metabolism of the other drug.
o For example: Warfarin (Coumadin), an oral
anticoagulant, is biotransformed more quickly if it is
taken at the same time as barbiturates, rifampin, or
many other drugs.
o Because the warfarin is biotransformed to an
inactive state more quickly, higher doses will be
needed to achieve the desired effect.
o Patients who use St. John’s wort may experience
altered effectiveness of several drugs that are
affected by that herb’s effects on the liver.
o Digoxin, theophylline, oral contraceptives,
anticancer drugs, drugs used to treat HIV, and
antidepressants are all reported to have serious
interactions with St. John’s wort.
4. During excretion: One drug competes for excretion
with the other drug, leading to accumulation and toxic
effects of one of the drugs.
o For example, Digoxin (Lanoxin) and quinidine are
both excreted from the same sites in the kidney.
o If they are given together, the quinidine is more
competitive for these sites and is excreted, resulting
in increased serum levels of digoxin, which cannot
be excreted.
5. At the site of action: One drug may be an antagonist
of the other drug or may cause effects that oppose
those of the other drug, leading to no therapeutic
effect.
Example, when an antihypertensive drug is taken with
an antiallergy drug that also increases blood pressure.
The effects on blood pressure are negated, and there is
a loss of the antihypertensive effectiveness of the drug.
o Example: If a patient is taking antidiabetic
medication and also takes the herb ginseng,
which lowers blood glucose levels, he or she
may experience episodes of hypoglycemia
and loss of blood glucose control.
NURSE'S RESPONSIBILITY
1. Whenever two or more drugs are being given
together, first consult a drug guide for a listing of
clinically significant drug–drug interactions.
2. Sometimes problems can be avoided by staggering
the administration of the drugs or adjusting their
doses.
DRUG - FOOD INTERACTIONS
It occurs when the drug and the food are in direct
contact in the stomach. Some foods increase acid
production, speeding the breakdown of the drug
molecule and preventing absorption and distribution of
the drug.
EXAMPLES
1. Antibiotic tetracycline cannot be taken with iron
products. Tetracycline binds with calcium and should
not be taken with foods or other drugs containing
calcium.
2. Grapefruit juice has found to affect liver enzyme
systems for up to 48 hours after it has been ingested.
This can result in increased or decreased serum levels of
certain drugs.
NURSE'S RESPONSIBILITY
 Food selection for ingestion with the drug should be
something that is known not to interact with it.
 Drug monographs usually list important drug–food
interactions and give guidelines for avoiding
problems and optimizing the drug’s therapeutic
effects.
DRUG - LAB TEST INTERACTIONS
 It is caused by the drug being given and not
necessarily by a change in the body’s responses or
actions.
 If one test result is altered and does not fit in with
the clinical picture or other test results, consider the
possibility of this interaction.
EXAMPLE:
Dalteparin (Fragmin), a low-molecular_x0002_weight
heparin used to prevent deep vein thrombosis after
abdominal surgery, may cause increased levels of the
liver enzymes aspartate aminotransferase and alanine
aminotransferase with no injury to liver cells or
hepatitis.
OPTIMAL THERAPEUTIC EFFECT
 History taking and physical assessment should be
added in the plan of care so that problems can be
handled promptly.
 If a drug just does not do what it is expected to do,
further examine the factors that are known to
influence drug effects.
 Drug regimen can be modified to deal with that
influence.
 Rarely it is necessary to completely stop drug
regimen because of adverse or intolerable effects.
PHARMACOKINETICS
 How the body acts on the drug including
absorption, distribution, biotransformation, and
excretion.
 In clinical practice, it include the onset of drug
action, drug half-life, timing of the peak effect,
duration of drug effects, metabolism or
biotransformation of the drug, and the site of
excretion.
CRITICAL CONCENTRATION
 The amount of a drug that is needed to cause a
therapeutic effect (recommended dose).
 Too much of a drug will produce toxic (poisonous)
effects.
 Too little will not produce the desired therapeutic
effects.
LOADING DOSE
Some drugs may take a prolonged period to reach a
critical concentration.
If their effects are needed quickly, a loading dose is
recommended.
A higher dose than that usually used for treatment to
reach the critical concentration.
The critical concentration then is maintained by using
the recommended dosing schedule.
EXAMPLE
 Digoxin (Lanoxin) - a drug used to increase the
strength of heart contractions.
 Xanthine bronchodilators (e.g., aminophylline,
theophylline) used to treat asthma attacks are
often started with a loading dose.
DYNAMIC EQUILIBRIUM
The actual concentration that a drug reaches in the
body results from a dynamic equilibrium involving
several processes:
1. Absorption from the site of entry
2. Distribution to the active site
3. Biotransformation (metabolism) in the liver
4. Excretion from the body
These processes are key elements in determining the
amount of drug (dose) and the frequency of dose
repetition (scheduling) required to achieve the critical
concentration for the desired length of time.
When administering a drug, the nurse needs to consider
the phases of pharmacokinetics so that the drug
regimen can be made as effective as possible.
PHASES OF PHARMACOKINETICS
1.) LIBERATION
The process in which a pharmaceutical substance is
released from the formulation it is delivered in.
The release of the drug from it's dosage form.
This must occur before the drug can be absorbed into
the body.
2.) ABSORPTION
immediate onset and are fully absorbed at
administration because they directly enter the blood
stream.
These drugs are more likely to cause toxic effects
because the margin for error in dose is much smaller.
INTRAMUSCULAR ROUTE - absorbed directly into the
capillaries in the muscle and sent into circulation.
This takes time because the drug must be picked up by
the capillary and taken into the veins.

It refers to what happens to a drug from the time it is Men have more vascular muscles than women do. As a
introduced to the body until it reaches the circulating result, drugs administered to men via the IM route
fluids and tissues. reach a peak level faster than they do in women.

Site of absorption: GI tract either orally or rectally,
mucous membranes, skin, lungs, muscles or
subcutaneous tissues.
GENERAL CLASSIFICATION OF ROUTES
ENTERAL- drugs administered directly in the
gastrointestinal tract.
PARENTERAL- drugs administered that by-pass the
gastrointestinal tract.
PERCUTANEOUS- drugs administered through the skin
or mucous membrane.
SUBCUTANEOUS ROUTE - deposit the drug just under
the skin, where it is slowly absorbed into circulation.
Timing of absorption varies with subcutaneous
injection, depending on the fat content of the injection
site and the state of local circulation.
TOPICAL ROUTE - suitable on intact skin and others that
contain a medication are used for the treatment of
broken skin or a wound.
TRANSDERMAL- absorbed from the surface of the skin.
OPTHALMIC ROUTE - medications are administered and
absorbed in the eyes.

OTIC ROUTE- absorbed from the ears.

ROUTES OF ADMINISTRATION
INHALATION ROUTE- absorbed in the lungs via the
ORAL ROUTE - slow absortion, most frequently used, nose.
less expensive, safest, and patients can easily continue
their drug regimen at home when they are taking ROUTES OF ADMINISTRATION
medications.
1. NGT BOLUS ROUTE
 It subjects the drug to a number of barriers aimed 2. INTRAVAGINAL ROUTE
at destroying ingested foreign chemicals. 3. INTRAVENOUS PIGGY BACK
 When food is present, stomach acidity is higher and 4. RECTAL ROUTE
the stomach empties more slowly, thus exposing 5. BUCCAL AND SUBLINGUAL ROUTES
the drug to the acidic environment for a longer 6. ROUTES OF ADMINISTRATION
period. 7. INTRATHECAL
 Certain foods that increase stomach acidity, such as 8. INTRACARDIAL
milk products, alcohol, and protein, also speed the 9. INTRA-ARTICULAR
breakdown of many drugs. 10. NASAL
 Oral drugs ideally are to be given 1 hour before or 2 11. INTRADERMAL
hours after a meal. 12. ABSORPTION PROCESSES

INTRAVENOUS ROUTE - reach their full strength at the

time of injection, avoiding initial breakdown, have an
PASSIVE DIFFUSION- movement of drug from higher to
lower concentration and does not require energy.
Occurs quickly to smaller molecules, soluble in water &
lipids, has no electrical charge that could repel it from
the cell membrane.
ABSORPTION PROCESSES
ACTIVE TRANPOST - that uses energy to actively move a
molecule across a cell membrane.
The molecule may be large, or it may be moving against
a concentration gradient.
It is a very important process in drug excretion in the
kidney.
FILTRATION - involves movement through pores in the
cell membrane, either down a concentration gradient or
as a result of the pull of plasma proteins (when pushed
by hydrostatic, blood, or osmotic pressure).
It is another process the body commonly uses in drug
excretion.
3. DISTRIBUTION
It involves the movement of a drug to the body’s
tissues.
Factors that can affect distribution include the drug’s
lipid solubility and ionization and the perfusion of the
reactive tissue.
EXAMPLE # 1
 Tissue perfusion is a factor in treating a patient with
diabetes who has a lower-leg infection and needs
antibiotics to destroy the bacteria in the area.
 In this case, systemic drugs may not be effective
because part of the disease process involves
changes in the vasculature and decreased blood
flow to some areas, particularly the lower limbs.
 If there is no adequate blood flow to the area, little
antibiotic can be delivered to the tissues, and little
antibiotic effect will be seen.
EXAMPLE # 2
Patients in a cold environment may have constricted
blood vessels (vasoconstriction) in the extremities,
which would prevent blood flow to those areas.
The circulating blood would be unable to deliver drugs
to those areas, and the patient would receive little
therapeutic effect from drugs intended to react with
those tissues.
DISTRIBUTION PROCESSES
PROTEIN BINDING
 Some drugs are tightly bound and are released very
slowly.
 These drugs have a very long duration of action
because they are not free to be broken down or
excreted and are released very slowly into the
reactive tissue.
 Some drugs are loosely bound; they tend to act
quickly and to be excreted quickly.
 Some drugs compete with each other for protein
binding sites, altering effectiveness or causing
toxicity when the two drugs are given together.
BLOOD- BRAIN BARRIER
 It is a protective system of cellular activity that
keeps foreign invaders, poisons and similar
materials away from the CNS.
 Drugs that are highly lipid soluble are more likely to
pass through the blood–brain barrier and reach the
CNS.
 Almost all antibiotics are not lipid soluble and
cannot cross the blood–brain barrier. Effective
antibiotic treatment can occur only when the
infection is severe enough to alter the blood–brain
barrier and allow antibiotics to cross.
 Although many drugs can cause adverse CNS
effects, these are often the result of indirect drug
effects and not the actual reaction of the drug with
CNS tissue.
 For example, alterations in glucose levels and
electrolyte changes can interfere with nerve
functioning and produce CNS effects such as
dizziness, confusion, or changes in thinking ability.
PLACENTA & BREAST MILK
Many drugs readily pass through the placenta and affect
the developing fetus in pregnant women.
It is best not to administer any drugs to pregnant
women.
Drugs should be given only when the benefit clearly
outweighs any risk.
4.) METABOLISM/ BIOTRANSFORMATION
The liver is the most important site of this process
wherein drugs are changed into new, less active
chemicals.
Everything that is absorbed from the GI tract first enters
the liver to be “treated.”
The liver detoxifies many chemicals and uses others to
produce needed enzymes and structures.
FIRST- PASS EFFECT
The phenomenon in which drugs given orally are carried
directly to the liver after absorption, where they may be
largely inactivated by liver enzymes before they can
enter the general circulation.
Oral drugs frequently are given in higher doses than
drugs given by other routes because of this early
breakdown.
HEPATIC ENZYME SYSTEM
Phase I biotransformation- involves oxidation-
reduction, or hydrolysis of the drug via the cytochrome
P450 system of enzymes.
Phase II biotransformation- usually involves a
conjugation reaction that makes the drug more polar
and more readily excreted by the kidneys.
 Increased activity in an enzyme system speeds the
metabolism of the drug.
 This explains why some drugs cannot be taken
together effectively.
 The presence of one drug speeds the metabolism of
others, preventing them from reaching their
therapeutic levels.
 Some drugs inhibit an enzyme system, making it less
effective.
 As a consequence, any drug that is metabolized by
that system will not be broken down for excretion,
and the blood levels of that drug will increase, often
to toxic levels.
 These actions also explain why liver disease is often
a contraindication or a reason to use caution when
administering certain drugs. If the liver is not
functioning effectively, the drug will not be
metabolized as it should be, and toxic levels could
develop rather quickly.
5.) EXCRETION
It is the removal of a drug from the body.
The kidneys, skin, saliva, lungs, bile and feces are some
of the routes used to excrete drugs.
Drugs that have been made water soluble in the liver
are often readily excreted from the kidney by
glomerular filtration—the passage of water and water-
soluble components from the plasma into the renal
tubule.
Kidney dysfunction and urine acidity are factors to
consider in drug toxicity due to inability to excrete
poisonous substances.
NURSING RESPOSIBILITY
Dose adjustment needs to be considered if a patient has
problems with either the liver or the kidneys.
Assessment should be done before starting drug
therapy.
DRUG HALF- LIFE
 The time it takes for the amount of drug in the body
to decrease to one half of the peak level it
previously achieved.
 This information is important in determining the
appropriate timing for a drug dose or determining
the duration of a drug’s effect on the body.
 The half-life that is indicated in any drug monograph
is the half-life for a healthy person.
 Using this information, one can estimate the half-
life of a drug for a patient with kidney or liver
dysfunction allowing the prescriber to make
changes in the dosing schedule.
Factors Affecting Responses to Drug
NOTE:
The nurse must be aware that the human factor has a
tremendous influence on what actually happens to a
drug when it enters the body.
No two people react in exactly the same way to any
given drug.
WEIGHT
People who are much heavier mayr equire larger doses
to get a therapeutic effect from a drug because they
have increased tissues to perfuse and increased
receptor sites in some reactive tissue.
Toxic effects may occur at the recommended dose if the
person is very small.
AGE
Older adults undergo many physical changes that are a
part of the aging process.
Their bodies may respond very differently in all aspects
of pharmacokinetics—less effective absorption,
distribution, perfusion, altered biotransformation or
metabolism and less effective excretion.
Children metabolize many drugs differently than adults
do, and they have immature systems for handling drugs.
Many drugs come with recommended pediatric doses,
and others can be converted to pediatric doses.
GENDER
When giving IM injections, for it is important to
remember that men have more vascular muscles, so the
effects of the drug will be seen sooner in men than in
women.
Women have more fat cells than men do, so drugs that
deposit in fat may be slowly released and cause effects
for a prolonged period.
EXAMPLE, gas anesthetics have an affinity for
depositing in fat and can cause drowsiness and sedation
sometimes weeks after surgery.
PHYSIOLOGIC FACTORS
 Physiological differences such as diurnal rhythm of
the nervous and endocrine systems, acid–base
balance, hydration, and electrolyte balance can
affect the way that a drug works on the body and
the way that the body handles the drug.
 If a drug does not produce the desired effect, one
should review the patient’s acid–base and
electrolyte profiles and the timing of the drug.
PATHOLOGIC FACTORS
 The disease that the drug is intended to treat can
change the functioning of the chemical reactions
within the body and thus change the response to
the drug.
 Body conditions can change the basic
pharmacokinetics of a drug.
EXAMPLES:
o GI disorders can affect the absorption of
many oral drugs.
o Vascular diseases and low blood pressure
alter the distribution of a drug, preventing it
from being delivered to the reactive tissue,
thus rendering the drug nontherapeutic.
o Liver or kidney diseases affect the way that
a drug is biotransformed and excreted and
can lead to toxic reactions when the usual
dose is given.
GENETICS
Some people lack certain enzyme systems necessary for
metabolizing a drug, whereas others have overactive
enzyme systems that cause drugs to be broken down
more quickly.
Others have differing metabolisms or slightly different
enzymatic makeups that alter their chemical reactions
and the effects of a given drug.
PHARMACOERGONOMICS
It is an area of study that explores the unique
differences in response to drugs that each individual
possesses based on genetic makeup.
Predictable differences in the pharmacokinetics and
pharmacodynamic effects of drugs can be anticipated
with people of particular cultural backgrounds.
IMMUNOLOGIC FACTORS
 People can develop an allergy to a drug.
 After exposure to its proteins, a person can
develop antibodies to a drug.
 With future exposure to the same drug, that
person may experience a full-blown allergic
reaction.
PSYCHOLOGICAL FACTORS Cross-tolerance—or resistance to drugs within the same
class may also occur in some situations.
 The patient’s attitude about a drug have an effect
on how that drug works. CUMULATION
 A drug is more likely to be effective if the patient
If a drug is taken in successive doses at intervals that are
thinks it will work than if the patient believes it will
shorter than recommended, or if the body is unable to
not work.
eliminate a drug properly, the drug can accumulate in
 This is called the PLACEBO EFFECT.
the body, leading to toxic levels and adverse effects.
 The patient’s personality also influences compliance
This can be avoided by following the drug regimen
with the drug regimen.
precisely.
 Some people willingly follow a prescribed regimen.
 Others do not trust the medical system. INTERACTIONS
ENVIRONMENTAL FACTORS When two or more drugs or substances are taken
together, there is a possibility that an interaction can
Some drug effects are enhanced by a quiet, cool, non-
occur, causing unanticipated effects in the body.
stimulating environment.
DRUG STANDARDS
Other drug effects may be influenced by temperature.
LEGAL REGULATIONS OF DRUGS
EXAMPLE # 1: Sedating drugs are given to help a patient
relax or to decrease tension. Reducing external stimuli
to decrease tension and stimulation help the drug be
more effective. Pure Food and Drug Act of 1906

EXAMPLE # 2: Antihypertensives that work well during
cold, winter months may become too effective in
warmer environments, when natural vasodilation may
lead to a release of heat thattends to lower the blood
pressure.
The law that prevented the marketing of adulterated
drugs; required labeling to eliminate false or misleading
claims.

TOLERANCE Federal Food, Drug and Cosmetic Act of 1938

Tolerance may arise because of increased
biotransformation of the drug, increased resistance to
its effects, or other pharmacokinetic factors.
When tolerance occurs, the drug no longer causes the
same reaction.
Therefore, increasingly larger doses are needed to
achieve a therapeutic effect.
EXAMPLE:
Morphine is an opiate used for pain relief.
The longer morphine is taken, the more tolerant the
body becomes to the drug, so that larger and larger
doses are needed to relieve pain.
It should be given in smaller doses or in combination
with other drugs that may also relieve pain.
Mandated tests for drug toxicity and provided means
for recall of drugs; established procedures for
introducing new drugs; gave FDA the power of
enforcement.
Durham- Humphrey Amendment of 1951
Tightened control of certain drugs; specifi ed
drugs to be labeled “may not be distributed
without a prescription”.
Kefauver- Harris Act of 1962
Tightened control over the quality of drugs; gave
FDA regulatory power over the procedure of drug
investigations; stated that efficacy as well as
safety of drugs had to be established.
Controlled Substances Act of 1970
Defined drug abuse and classified drugs as to
their potential for abuse; provided strict
controls over the distribution, storage, and
use of these drugs.
Orphan Drug Act of 1983
Provided incentives for the development of
orphan drugs for treatment of rare diseases.
SAFETY DURING PREGNANCY
Food and Drug Administration Pregnancy Categories
CATEGORY
Adequate studies in pregnant women have not
demonstrated a risk to the fetus in the first trimester of
pregnancy, and there is no evidence of risk in later
trimesters.
CATEGORY B
Animal studies have not demonstrated a risk to the
fetus but there are no adequate studies in pregnant
women, or animal studies have shown an adverse
effect, but adequate studies in pregnant women have
not demonstrated a risk to the fetus during the first
trimester of pregnancy, and there is no evidence of risk
in later trimesters.
CATEGORY C
 Animal studies have shown an adverse effect on the
fetus but there are no adequate studies in humans.
 The benefits from the use of the drug in pregnant
women may be acceptable despite its potential
risks, or there are no animal reproduction studies
and no adequate studies in humans.
CATEGORY D
There is evidence of human fetal risk, but the potential
benefits from the use of the drug in pregnant women
may be acceptable despite its potential risks.
CATEGORY X
Studies in animals or humans demonstrate fetal
abnormalities or adverse reaction; reports indicate
evidence of fetal risk.
The risk of use in a pregnant woman clearly outweighs
any possible benefit.
IMPORTANT NOTE
Regardless of the designated Pregnancy Category or
presumed safety, no drug should be administered
during pregnancy unless it is clearly needed.
CONTROLLED SUBSTANCES
These are drugs with abuse potential.
Controlled Substances Act of 1970 established
categories for ranking of the abuse potential of various
drugs.
This same act gave control over the coding of drugs and
the enforcement of these codes to the FDA and the
Drug Enforcement Agency (DEA).
The FDA studies the drugs and determines their abuse
potential; the DEA enforces their control.
Each prescriber has a DEA number, which allows the
DEA to monitor prescription patterns and possible
abuse.
These drugs are divided into five DEA schedules based
on their potential for abuse and physical and
psychological dependence.
FIVE DEA SCHEDULES
Schedule I (C-I): High abuse potential
and no accepted medical use (heroin,
marijuana, LSD)
Schedule II (C-II): High abuse potential
with severe dependence liability
(narcotics, amphetamines, and
barbiturates).
Schedule III (C-III): Less abuse
potential than schedule II drugs and
moderate dependence liability
(nonbarbiturate sedatives,
nonamphetamine stimulants, limited
amounts of certain narcotics).
Schedule IV (C-IV): Less abuse
potential than schedule III and
limited dependence liability
(some sedatives, antianxiety
agents, and nonnarcotic
analgesics).
Schedule V (C-V):
 Limited abuse potential.
 Primarily small amounts of narcotics (codeine) used
as antitussives or antidiarrheals.
 Limited quantities of these drugs may be purchased
without a prescription.
 The purchaser must be at least 18 years of age and
must furnish suitable identification.
 All such transactions must be recorded by the
dispensing pharmacist.
The Nursing Process in Drug Therapy and Patient
Safety
THE NURSING PROCESS
Application of the nursing process with drug therapy
ensures that the patient receives the best, safest, most
efficient, scientifically based, holistic care.
1.) ASSESSMENT
A.) Patient's history
Knowledge of this important information
before beginning drug therapy will help to promote safe
and effective use of the drug and prevent adverse
effects, clinically important drug–drug, drug–food, or
drug–alternative therapy interactions, and medication
errors.
History of Chronic Conditions
 It can affect the pharmacokinetics and
pharmacodynamics of a drug.
 Certain conditions like renal disease, heart disease,
diabetes, chronic lung disease may be
contraindications to the use of a drug.
 These conditions may require cautious use or dose
adjustment when administering a certain drug.
History of Drug Use
 Prescription drugs, over-the-counter (OTC) drugs,
street drugs, alcohol, nicotine, alternative therapies,
and caffeine may have an impact on a drug’s effect.
 Always ask specifically about all types of
medications that the patient might use including
contraceptives.
History of Allergies
 Past exposure to a drug or other allergens can
provoke a future reaction or necessitate the need
for cautious use of the drug, food, or animal
product.
 Obtain information about the allergic reaction to
determine whether the patient has experienced a
true drug allergy or was experiencing an actual
effect or adverse effect of the drug.
Level of Education and Understanding
 It provides a baseline from which the nurse can
determine the appropriate types of teaching
information to use with the patient.
 Stress, disease, and environmental factors can all
affect a patient’s learning readiness and ability.
Social and Financial Support
Discharge planning involves determining what support
is available to the patient at home.
Financial constraints may cause a patient not to follow a
prescribed drug regimen.
 Referral to appropriate community resources must be 2.) NURSING DIAGNOSIS
considered.
It is simply a statement of the patient’s status from a
nursing perspective.

Pattern of Healthcare The nurse analyzes the information gathered during

assessment to arrive at some conclusions that lead to a
 Knowing how a patient seeks health care provides
particular goal and set of interventions.
the nurse with valuable information to include
when preparing the patient’s teaching plan. It shows actual or potential alterations in patient
 Does this patient routinely seek follow-up care, or function based on the assessment of the clinical
does he or she wait for emergency situations? situation.
 Does the patient tend to self-treat many
Diagnoses that are related to drug therapy must be
complaints, or is every problem brought to a health
incorporated into a total picture of the patient.
care provider?
EXAMPLES:
B.) Physical Examination
1. Knowledge deficit
These determine if any conditions exist that would be
2. Impaired swallowing
contraindications or cautions for using the drug and to
3. Risk for impaired liver function
develop a baseline for evaluating the effectiveness of
4. Impaired oral mucous membrane .....
the drug and the occurrence of any adverse effects.
5. Impaired memory
Weight 6. Nausea
7. Non-compliance
It helps to determine whether the recommended drug
8. Risk for poisoning .....
dose is appropriate. Because the recommended dose
9. Ineffective role performance .....
typically is based on a 150-pound adult man, patients
10. Self-care deficit .....
who are much lighter or much heavier often need a
11. Stress overload .....
dose adjustment.
EXAMPLES:
Age
1. Ineffective therapeutic regimen management
 Patients at the extremes of the age spectrum—
2. Ineffective family therapeutic regimen management
children and older adults—often require dose
3. Wandering
adjustments based on the functional level of the
4. Impaired urinary elimination
liver and kidneys, the responsiveness of other
organs and other existing medical conditions. 3.) IMPLEMENTATION
 The child’s age and developmental level will also
 Interventions involve ensuring effective response to
alert the nurse to possible problems with drug
drug therapy, minimizing adverse effects, and
delivery, such as the ability to swallow pills or follow
understanding the drug regimen.
directions related to other delivery methods.
 Three types of nursing interventions: drug
Physical Parameters Related to Disease or Drug Effects administration, provision of comfort measures, and
patient/family education.
 Assessing these factors before drug therapy begins
provides a baseline level to which future A.) Proper Drug Administration
assessments can be compared to determine the
 Correct drug and patient
effects of drug therapy.
 Correct storage of drug
 If a patient is being treated for chronic pulmonary
 Correct and most effective route
disease, his or her respiratory status and reserve
 Correct dose and preparation
need to be assessed, especially if a drug is being
 Correct timing
given that is known to affect the respiratory tract.
 Correct recording of administration
B.) Comfort Measures
A patient is more likely to be compliant with a drug
regimen if the effects of the therapy are not too
uncomfortable or overwhelming.
PLACEBO EFFECT
 The anticipation that a drug will be helpful has
proved to have tremendous impact on the
actual success of drug therapy.
 The nurse’s attitude and support can be a
critical part of drug therapy. For example, a
back rub, a kind word, and a positive approach
may be as beneficial as the drug itself.
MANAGING ADVERSE EFFECTS
drug–food, drug–alternative therapy, or drug–
laboratory test interactions.
 The efficacy of the nursing interventions and
the education program also are evaluated.
 The nurse evaluates the patient simply by
reapplying the beginning steps of the nursing
process and then analyzing for changes, either
positive or negative.
 The process of evaluation may lead to changes
in the nursing interventions being used to
provide better and safer patient care.
MEDICATION SAFETY
PREVENTION OF ERRORS

 Interventions can be directed at promoting patient

The Nurse's Role- The monumental task of ensuring
safety and decreasing the impact of the anticipated
medication safety with all of the potential problems
adverse effects of a drug.
that could confront the patient can best be managed by
 Such interventions include environmental control
consistently using the “rights” of medication
(e.g., temperature, light), safety measures (e.g.,
administration.
avoiding driving, avoiding the sun, using side rails),
and physical comfort measures (e.g., skin care, 1. Right drug
laxatives, frequent meals). 2. Right client/ patient
3. Right route
4. Right dose
LIFESTYLE ADJUSTMENT 5. Right frequency/ time
6. Right assessment
Some medications and their effects require that a 7. Right approach
patient make changes in his or her lifestyle. 8. Right evaluation
The change in lifestyle that is needed can have a 9. Right documentation
tremendous impact on the patient and can affect his or 10. Right to refuse
her ability to cope and comply with any medical 11. Right principle of care
regimen. 12. Right prescription
13. Right nurse clinician
14. Right education
C.) Patient and Family Education PREVENTION OF ERRORS
 It is essential that they have all of the The Patient's Role- Encourage patients to be their own
information necessary to ensure safe and advocates and to speak up and ask questions.
effective drug therapy at home.
 In fact patients are now given written Only the patient really knows what is being taken and
information. when, and can report the actual as opposed to the
prescribed drug regimen being followed.
4.) EVALUATION

 The patient is continually evaluated for

therapeutic response, occurrence of adverse
drug effects, and occurrence of drug–drug,
TEACHING POINTS
 Keep a written list of all medications you are
taking, including prescription, OTC, and herbal
medications.
 Know what each of your drugs is being used to
treat.
 Read the labels, and follow the directions.
 Store drugs in a dry place, away from children
and pets.
 When in doubt, do not hesitate to ask
questions.
 Never use adult medications to treat a child.
 Measure liquid medications using appropriate
measuring devices.
 Call your health care provider immediately if
your child seems to get worse or seems to be
having trouble with a drug.
PRESCRIPTIONS AND MEDICATION ORDERS
INTRODUCTION
 The primary means in which a physician
communicate with other health care team members
regarding the desired treatment regimen for a
patient.
 It can be handwritten, typed, preprinted, verbal or
entered in a computer system.
 Prescriptions are used in the OPD or ambulatory
setting whereas medication orders and used in
inpatient setting.
 A legal order that can be used for medications,
devices, laboratory test, special procedures and the
like.
COMPONENTS
The following information must be present:
1. Name, address, age, birthdate, date of issue
2. Drug, dosage and form
3. Frequency, route of administration
4. Duration, quantitY
5. Height and weight (for pediatric client)
6. Physician's DEA number (for controlled drugs)
RULES ON WRITING AN ORDER
1. Do not use trailing zeros for doses expressed as
whole numbers.
2. Use a decimal point when the dose is less than a
whole unit.
3. Use commas for dosing units at or above 1,000
or use words such as 1 thousand to improve
readability.
4. Place adequate space between entries.
TYPES OF MEDICATION ORDER
1.) PRN Order
 medications are given on "as needed" or “when
necessary” basis for specific signs and symptoms
within a designated number of hours
 It can be prescription medications or over-the-
counter medications.
 Cannot have multiple medications with same reason
such as both Tylenol and morphine “PRN for pain”.
Example:
 Tylenol 650 mg PO every four hours PRN for pain or
fever.
 Mary complains of headache. You have check the
therapeutic or medication sheet and found that she
have not received any Tylenol within the past 4
hours.
 According to the order, the medication is for “pain”
and “fever”.
 This means that you can give Mary Tylenol for her
headache.
2.) SINGLE/ ONE TIME ORDER
medications to be given only once and are ordered to
be given at a specific time and then discontinued.
Example:
 Pen-vee K 1000 mg PO 1 hour pre-op dental
surgey
 Seconal 100 mg HS before surgery
3.) STAT ORDER
 medications need to be given immediately or
NOW.
Example:
 Demerol 100 mg IM now
 Tramadol 50 mg/ml IV now
4.) ROUTINE/ STANDING
ORDER
Detailed order for a
medication given on a
routine or regularly
scheduled basis.
Example:
1. Ciprofloxacin 500 mg 1 tab
2. PO BID x 7 days
3. Vancomycin 1500 mg IV q
4. 12 hrs for 3 days
IMPORTANT NOTE
Do not accept medication orders that state “continue
previous medications” or “same medications” because
they are not complete medication orders.
5.) ANCILLARY ORDER
It refers to information other than medication that
allow the nurse to do certain things to a patient.
EXAMPLES OF ANCILLARY ORDER
1. Catheterize with a 16 French, 5 ml, indwelling
catheter. If residual is greater than 75 ml, leave the
catheter in place and notify the physician; if less than 75
ml, remove and notify the physician.
2. Encourage fluids to 2000 ml daily unless restricted by
order; keep accurate I and O; perineal care with soap
and water twice daily; replace catheter every 30 days or
if no drainage in 4 hours, irrigate with 50 ml saline once.
3. Attempt irrigation with 60 ml saline; if leaking
continues, remove the catheter and replace with one
size larger except Supra Pubics.
6.) HIDDEN ORDER
 Drugs that have been administered outside of the
facility (Emergency Room visit, Dental visits,
specialist appointments).
 Drugs that may be administered during a procedure
in the facility but not documented in the patient’s
chart (example: Lidocaine w Epi).
Drugs that may be part of a bundled procedure such as
a Prep kit for a colonoscopy.
Drugs that may be used as part of a protocol but not
individually documented on the chart.
STOP ORDER PROCEDURES
Medications not specifically prescribed as to time and
number of doses will be automatically discountinued on
the following days:
VERBAL/ TELEPHONE ORDERS
1. Are minimized whenever possible.
2. Immediately write down and “read back” to
verify (NOT REPEAT).
3. Must be counter signed within 24hours.
Client Education on Drug Therapy
ASPECTS OF EDUCATION
1. The purpose of the medication
2. The dosage of the medication
3. The side effects of the medication
4. The possible adverse effects of the medication
5. When to call the doctor about any side effects
6. How and where the medication should be safely
stored, such as in the refrigerator or in a dark place,
for example.
7. The importance of and the method for checking the
medication's label for the name, dose, and
expiration date.
8. Special instructions such as shaking the medication,
taking the medication with meals or between meals
and on an empty stomach, for example.
9. The importance of taking the medication as
instructed.
10. The need to continue the medication unless the
doctor discontinues it
11. Information about foods, supplements and other
medications, including over the counter
medications and preparations, that can interact
with the ordered medication
12. The safe disposal of unused and expired
medications.
13. The importance of keeping medications in a secure
place that would not place a curious child or a
cognitively impaired adult at risk for taking
medications not intended for them.
14. The proper and safe disposal of any biohazardous
equipment such as used needles that the client uses
for insulin andother medications.
Age Specific Route, Forms & Dosage Consideration
INFANTS
Use a syringe, dropper for oral liquid medications.
Use the vastus lateralis, rectus femoris and
ventrogluteal muscle sites
for intramuscular injections and not the deltoid or the
gluteus maximus muscles because these muscles have
not yet developed.
TODDLERS
Liquid oral medications are given with a spoon or a cup,
the vastus lateralis, rectus femoris and ventrogluteal
sites are used for intramuscular injections.
The gluteus maximus muscle can be used after the
toddler has been walking for at least a year, flavors can
be used to improve the taste of oral medications, and
the dosages continue to be based on kilograms of
weight.
PRE SCHOOL/ SCHOOL-AGED CHILDREN
Able to take capsules and tablets, the gluteus maximus
muscle and the deltoid muscle can now be used for
intramuscular injections, in addition to the vastus
lateralis, rectus femoris and ventrogluteal intramuscular
injection sites, and dosages continue to be based on
kilograms of weight.
ADOLESCENTS AND ADULTS
Adolescents get adult dosages, routes and forms of
medications as prescribed by the physician.
ELDERLY
Dosages may be decreased because the normal
physiological changes of the aging process makes more
susceptible to side effects, adverse drug reactions, and
toxicity and over dosages.
Recording and Reporting
KEY POINTS
 Use double locked cabinets to secure controlled
substances. Others use more sophisticated
 bar coded entry systems to access controlled
substances.
 Double locked narcotics cabinet is used, the
contents are counted and checked by the nurse at
the beginning of the shift; this count is then
compared to the documented count that was done
by the nurse from the prior shift.
 If there are any discrepancies, these are
immediately addressed, explored and corrected if it
was a simple oversight or mathematical error.
When the narcotics count cannot be corrected, a
report must be filed according to the facility's
policies and procedures.
 If a controlled substance is wasted for any reason,
either in its entirety or only partially, this waste
must be witnessed or documented by the wasting
nurse and another nurse. Both nurses document
this wasting.
 Medications that are given, omitted, held or refused
by the patient must be documented.
DRUG ARITHMETICS
NOTE:
To determine the correct dose of a particular drug for a
patient, the nurse must consider the patient’s sex,
weight, age, and physical condition, as well as the other
drugs that the patient is taking.
MEASURING SYSTEMS
1.) Metric System- It is based on the decimal system, so
all units are determined as multiples of 10.
Uses the gram as the basic unit of solid measure and the
liter as the basic unit of liquid measure.
2.) Apothecary System- Uses the minim as the basic
unit of liquid measure and the grain as the basic unit of
solid measure.
It uses Roman numerals placed after the unit of
measure to denote amount.
For example, 15 grains would be written “gr xv.” 1 oz = 30 mL = 2 tbsp

3.) Household System- found in recipe books and uses 1 g = 1,000 mg

the teaspoon as the basic unit of fluid measure and the
1 mg = 1,000 mc
pound as the basic unit of solid measure.
1 cm = 10 mm
4.) Avoirdupois System-
1 tbsp = 15 mL
Another older system that was very popular when
pharmacists routinely had to compound medications. It 1 cup = 8 fl oz
is seldom used by prescribers but may be used for bulk
medications that come directly from the manufacturer. 1 pint = 2 cups

5.) Other System- Some drugs are measured in “units” 12 inches = 1 foot
that reflect chemical activity or biological equivalence. 1 L = 1.057 qt
 A “unit” usually reflects the biological activity of the 1 lb = 16 oz
drug in 1 mL of solution.
 The unit is unique for the drug it measures; a unit of 1 tbsp = 3 tsp
heparin is not comparable to a unit of insulin. Why? 60 minute = 1 hour
 Heparin is measured in Units, but these units are
not the same volume as the Units used to measure 1 cc = 1 mL
insulin or penicillin. Common concentrations of 2 pints = 1 qt
heparin are 1000 units per mL, 5000 units per mL,
and 10,000 units per mL; these can be used for I or 8 oz = 240 mL = 1 glass
s.q. dosing or diluted in a diluent liquid for IV use.
1 tsp = 60 gtt
 For heparin administration as an IV flush, common
concentrations are 2 units per mL, 10 units per mL, 1 pt = 500 mL = 16 oz
50 units per mL, or 100 units per mL.
1 oz = 30 mL
Milliequivalents (mEq) are used to measure
4 oz = 120 mL (Casey, 2018).
electrolytes. (e.g., potassium, sodium, etc).
ORAL DRUGS
 The milliequivalent refers to the ionic activity of the
drug in question; the order is usually written for a Frequently, tablets or capsules for oral administration
number of milliequivalents instead of a volume of are not available in the exact dose that has been
drug. ordered.
 International units are sometimes used to measure
The easiest way to determine dose is to set up a ratio
certain vitamins or enzymes.
and proportion equation.
 These are also unique to each drug and cannot be
converted to another measuring PARENTERAL DRUGS
Conversion Factors All drugs administered parenterally must be
administered in liquid form.
1 kg = 2.2 lb
The person administering the drug needs to calculate
1 gallon = 4 quart
the volume of the liquid that must be given to
1 tsp = 5 mL administerthe prescribed dose. INTRAVENOUS
SOLUTIONS
1 inch = 2.54 cm
Used to deliver a fluids, electrolytes, vitamins, nutrients,
1 L = 1,000 mL
or drugs directly into the bloodstream.
1 kg = 1,000 g
INTRAVENOUS SOLUTIONS CLARK'S RULE

 To calculate the drops per minute, the drop factor is
needed. The formula for calculating the IV flow rate
(drip rate) is… total volume (in mL) divided by time
(in min), multiplied by the drop factor (in gtts/mL),
which equals the IV flow rate in gtts/min
 MACRODRIP system delivers 15 drops per mililiter
and is used when a large volume must be delivered
quickly.
 MICRODRIP delivery system delivers 60 drops per
milliliter.
It uses the child’s weight in pounds to calculate the dose
and assumes that the adult dose is based on a 150-lb
person.
The child’s surface area is determined with the use of a
nomogram.
The height and weight of the child are taken into
consideration in this chart.
NOMOGRAM

Draw a straight line connecting the child’s height to the

DRIP RATES IN DROPS PER MINUTE
child’s weight.
There are two standard giving sets of drip rates.
The BSA value, which is calculated in square meters, is
Macro drop factor = 15 drops (divide by 4) found at the point where the line intersects the SA
column.
Micro drop factor = 60 drops (divide by 1)

PEDIATRIC CALCULATIONS

PEDIATRIC CONSIDERATIONS

 An adult’s body handles drugs differently and may

respond to drugs differently than a child.
 A child’s body may handle a drug differently in all
areas of pharmacokinetics—absorption,
distribution, metabolism, and excretion.
 The responses of the child’s organs to the effects of
the drug may vary because of the immaturity of the
organs.
 Most of the time a child requires a smaller dose of a
drug to achieve the comparable critical
concentration as that for an adult.

FRIED'S RULE

A calculation method that applies to a child younger

than 1 year of age.

The rule assumes that an adult dose would be

appropriate for a child who is 12.5 years (150 months)
old.

A calculation method that applies to children 1 to 12

years of age.