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.

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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 Fastest
syrups
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
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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.1ALTERATION 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.2CHANGES 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.3CHANGES 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.4DRUG 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.5THERAPEUTIC, 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.6HYPERSENSITIVITY 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

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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.7DRUG 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
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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.8PRECAUTIONS 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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