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Chapter 1

Drugs/Agents and Factors Affecting Their Action

- study of the history, sources, and physical and chemical properties of drugs
- Also looks at the ways in which drugs affect living systems
- Various subdivisions of pharmacology have evolved
- study of the biochemical and physiological effects of drugs
- study of drugs’ mechanisms of action
- study of the absorption, distribution, biotransformation (metabolism), and excretion
of drugs
- Four steps
 Absorption
 Distribution
 Metabolism
 Excretion
- study of how drugs may best be used in the treatment of illnesses
- study of which drug would be most appropriate or least appropriate to use for a
specific disease; what dose would be required; etc.
- the study of drugs derived from herbal and other natural (plant and animal) drug
- studying compositions of natural substances helps to gain knowledge for developing
synthetic versions
- study of poisons and poisonings
- all drugs have the potential to become toxic.
History of Pharmacology
 Ancient Egypt: the cradle of pharmacology
These medical sources listed over 700 different remedies for different ailments.
 First century: Dioscorides prepared De Materia Medica:
Listed and classified 600 different plants used for medicinal purposes; first time plants were
ever classified
Sources of Drugs
Drugs derived from:
 Natural sources
 Semisynthetic sources
 Synthetic sources
Drug Uses
 Symptomatic treatment
 Prevention
 Diagnostic drugs
 Curative
 Health maintenance
 Contraception

Dosage Forms
 Tablets
 Timed or sustained release
 Tablets or controlled release
 Capsule
 Troches
 Suppositories
 Solutions
 Douche
 Suspensions
 Emulsions
 Topicals
o Patches
 Drug implants
 Parenteral Product Packaging
 Ampules
o Sterile
o Sealed glass or plastic container
o Contain a single liquid dose
 Vials: either single or multiple dose
o Glass or plastic container
o Sterile liquid dose
o Sealed with a rubber diaphragm
Drug Names
 Chemical name
- The drug’s chemical composition and molecular structure
 Generic name (nonproprietary name)
- Name given by the United States Adopted Names Council
- Allows the drug to be marketed
 Brand Name
- Also called trade name (proprietary name)
- The drug has a registered trademark; use
of the name is restricted by the drug’s owner
(usually the manufacturer)
- Allows the drug to be commercially distributed
- The superscript ® is registered by the U.S. Patent Office and approved by the FDA (Food and
Drug Administration)
Drug Names: Examples
Chemical name
- (+/-)-2-(p-isobutyl phenyl) propionic acid
Generic name
- Ibuprofen
Trade name
- Motrin
- U.S. Drug Legislation
- Pure Food and Drug Act of 1906
o Required all drugs to meet minimal standards
- Federal Food, Drug, and Cosmetic Act of 1938
o Required the drug to be safe before being distributed over state lines
- U.S. Drug Legislation
o 1970: Comprehensive Drug Abuse Prevention and Control Act
o Also known as Controlled Substance Act: classified drugs according to their abuse potential
o Regulates the manufacture and distribution of drugs causing dependence

Controlled Substances Schedules

Schedule I High potential for abuse No medical use Heroin

Schedule II High potential for abuse Accepted medical use Morphine
Schedule III Lower potential for abuse Accepted medical use Librium, Valium, hydrocodone,
Tylenol with codeine

Schedule IV Lower potential for abuse Accepted medical use Librium


Schedule V Lowest potential for abuse Accepted medical use Lomotil

Robitussin A-C
Prescription Drugs
Prescription drugs = legend drugs
Drugs prescribed by:
 Physician
 Nurse practitioner
 Physician’s assistant
 Dentist
 Veterinarian
 Others

Principles of Drug Action

 Drugs
 Alter existing cellular or chemical functions
 Exert their action by forming a chemical bond with specific receptors within the body
 Referred to as a lock and key effect
 Receptors
o The better the fit, the stronger the drug’s affinity, thus
o Drug effect occurs at lower doses

Drug receptor interaction. Binding with specific receptors occurs only when
the drug and its receptors have a compatible chemical shape.

Principles of Drug Action

 Agonist effect
 Antagonistic effect
 Adverse drug effect
 Therapeutic effect

Pharmacokinetics: Absorption
 Routes
 Oral
 Parenteral
 Topical
 Metabolism: First-Pass Effect
 The metabolism of a drug and its passage from the liver into the circulation
 Metabolism occurs in the liver
o Liver enzymes react with the drug
o Increases the dosage requirement
 The same drug—given IV—bypasses the liver, preventing the first-pass effect from taking place, and
more drug reaches the circulation.
 Pharmacokinetics: Distribution
The transport of a drug in the body by the bloodstream to its site of action
 Elimination/Excretion
The elimination of drugs from the body
 Kidneys (main organ)
 Liver
 Bowel
Renal excretion of drugs. Note sites where drugs
are secreted and reabsorbed.

Pharmacokinetics: Measuring Drug Action

 Half-life
 The time it takes for one half of the original amount of a drug to be removed from the body

Chapter 2
Principles and Methods of Drug Administration

Nursing Process
 Assessment
 Nursing diagnosis
 Planning
 Implementation
 Evaluation

Administering Medication
 Assessment
 Nursing diagnosis
 Planning
 Implementation
 Evaluation

The Five (or Seven) Rights of Medications

1. Right drug
2. Right dose
3. Right client
4. Right time
5. Right route
6. Right documentation
7. Client’s right to refuse

Parenteral Medications
 Intramuscular administration
 Subcutaneous administration
 Intradermal administration
 Intravenous administration

Additional Methods of Administration

 Vaginal
 Rectal
 Ear
 Eye
 Nasal
 Nasogastric
 Epidural
 Transdermal patches

Chapter 3
Nursing Clients Receiving Drugs Intravenously

Intravenous Administration
 Collect materials needed.
o Select IV tubing.
o Select IV needle.
 Explain the procedure.
 Prepare the site.
 Secure the site.
 Infiltration
 Extravasation
 Thrombophlebitis
 Pain
 Fluid overload
 Pyrogenic reactions
 Tissue necrosis

 Total number of milliliters to be infused = Time in hours
 mL/hr = mL/min
time in minutes
 mL/min x SDF = gtt/min

IV Administration at Home
 Home care/client teaching
 Home health nurses
o Provide written guidelines
o Teach IV complications
o Teach when to call the nurse
o Teach dressing change guidelines
o Teach how to heparinize and flush a catheter
 Have the client return demonstrate skills

Chapter 5
Drug Therapy for Pediatric Clients

Pediatric Drug Therapy

 Approximately 75% of all prescription drugs in the U.S. lack full approval by the FDA because most
drugs are not studied on children.
 Studying the effects of drugs in children is a problem.

 Gastric acid (hydrochloric acid) secretion in infants
 Choosing the intramuscular injection site
 Topical drug absorption
 Intravenous drug administration
 Dependent upon the amount of water and/or fat present in the child, as well as plasma affinity of the
drug and protein-binding activity
 Water-soluble drugs effectively utilized
 Protein binding capacity is less

 Difficult to predict
 Maternal drug history is important

 Kidney maturation
 Excretion increases as the kidney matures
 Drug toxicity decreases as the kidney matures

Pediatric Drug Sensitivity

 Central nervous system drugs
 Barbiturates and morphine
 Depressant effects are exaggerated
 Lowering body temperature
 Acetaminophen
• Becomes toxic easily with large doses
 Salicylates
• Do not give to children under the age of 12.
Pediatric Dosages
 Determined by using a nomogram
 Nomograms are generally accurate after the attainment of mature liver and kidney function.
 Rights to Follow
 Allow adequate time for drug administration.
 Gain the child’s trust.
 Never lie to the child.
 Consider the child’s developmental level.
 Prevent choking.

Administration Methods
 Liquid medications are administered using an infant dropper, syringe without a needle, or a small

Parenteral Medications
 Explain the procedure to the child and to the parents.
 Use additional materials such as:
 Booklets
 Coloring books
 Puppets
 Dolls
 IV setup with colored water

Pain Procedure
 Allow the parents to stay.
 Painful procedures should be done in a separate room designated as the “owie” room.
 Use a firm positive manner.
 Assemble equipment first.
 Maintain the child’s safety.

Intramuscular Injections
 Vastus lateralis is the preferred site for children under the age of 3.
 Ventrogluteal site is the preferred site for children over the age of 3.
 The child should be walking.
Anterior view of the location of the vastus lateralis
muscle in a young child.

Final Step in Administering Drugs

 Evaluate drug action
 Remember
 Children are vulnerable.
 Be kind and patient.
 Enjoy the children; you will receive more than you give.

Chapter 6
Drug Therapy for Geriatric Clients

Drug Consumption
 Age ≥ 65 = increasing population growth
 Elderly are estimated to consume approximately 1/3 of all prescription drugs
 Estimate elderly use 3/4 of over-the-counter drugs
 Diminishes with increased age
 GI concerns
 Reduced stomach acid (HCl)
 GI absorptive surface area is reduced
 Prolonged gastric emptying rate
 Blood flow to the intestines is reduced
 Reduced muscle tone in the stomach and intestines

 Water loss
 Muscle loss
 Fatty tissue increase
 Protein binding: decreased capacity

 General decline as age increases
 Causes are obscure; possibly due to:
 Reduced blood flow to the liver

 Measure creatinine function
 Blood flow to the kidneys reduced
 Renal function is reduced
 Loss of intact nephrons

Drug Receptors
 Internal drug receptors may change
 Results in diminished or greater responses
 Close monitoring is required
Other Factors
 Memory loss
 Sensory loss
 Multiple health problems
 Multiple medications at multiple times
 Use of multiple pharmacies
 Economic factors
 Lack of education
 Communication problems
 Cultural considerations
 Diet therapy

 Oral medications
 Position for administration: high Fowler’s
 Speak clearly and slowly.
 Offer the most important medication first.
 Have plenty of liquid available.
 Do not rush the elderly client.

Intramuscular Medications
 Use ventrogluteal site.
 Avoid deltoid muscle.
 Avoid vastus lateralis because of loss of muscle mass.

 Safe storage of medications
 Keep out of the reach of grandchildren and other young children.

 Evaluate
 Communication: Does client understand?
 Drug action

Promoting Health
 Prevent infections.
 Improve nutrition.
 Encourage exercise and activity.
 Facilitate social interaction.
 Promote restful sleep.

Chapter 7
Antimicrobial Agents

Anti-infective Therapy
 Modern age
 Discovery of sulfanilamide in 1936
 Commercial introduction of penicillin in 1941

Antimicrobial Therapy
 Original antimicrobials: derived from microorganisms
 Newer agents: chemically synthesized

Factors Leading to Infection

 Age: young and elderly
 Increased exposure to pathogenic organisms
 Disruption of the normal barriers
 Inadequate immunological defenses
 Impaired circulation
 Poor nutritional status

Sources of Infection
 Bacteria
 Fungi
 Viruses

Administering Antimicrobial Agents

Consider the following:
 Location of the infecting organism in the body
 Status of the client’s organ function
 Age of the client
 Pregnancy and/or lactation
 Likelihood of developing organisms resistant to the antimicrobial agent
 Overuse of antimicrobial agents can lead to the development of severely resistant organisms.
 Promoted the development of organisms that are not affected by any of the available therapies

Resistant Organisms
 MRSA/VRSA: methicillin/vancomycin-resistant Staphylococcus aureus
 VRE: vancomycin-resistant Enterococcus
 ORSA: oxacillin-resistant Staphylococcus aureus

Antimicrobial Therapy
 Prevent infections.
 Use Universal Precautions.

 Antimicrobial agents are classified based on the following factors:
 Bactericidal or bacteriostatic
 Site of action
 Narrow or broad spectrum
 Adverse effects

Antimicrobial Classes
 Sulfonamides
 Penicillins
 Cephalosporins
 Tetracyclines
 Macrolides
 Aminoglycosides
 Fluoroquinolones
 Carbapenem
 Ketolides

First group of antibiotics
 General action
 Bacteriostatic effect
 Inhibit para-aminobenzoic acid (PABA)
• PABA is essential for bacterial growth
 Broad spectrum
Sulfonamides: Therapeutic Uses
 Treatment of urinary tract infections
 Otitis media
 Certain vaginal infections
 Some respiratory infections
Sulfonamides: Adverse Effects
 Hypersensitivity
 Renal dysfunction
 Hematological changes
Sulfonamides: Nursing Implications
 Consume at least 1 liter of fluid/day
 Avoid sunlight and tanning beds
 Reduce the effectiveness of oral contraceptives
Sulfonamide Combinations
Sulfonamides also combined with:
 Antimicrobials, diuretics, oral hypoglycemics, and carbonic anhydrase inhibitors

 Part of a large group of chemically related antibiotics
 Derived from fungus or mold
 Cephalosporins currently used instead of the penicillins
Penicillins: Action
 Inhibit synthesis of the bacterial cell wall
 Most effective on newly forming and actively growing cell walls
 Some of the penicillins are rapidly destroyed in the stomach.
 Given IM or IV

Action of penicillin on bacteria (from

Medicines and You, U.S. Department of
Health and Human Services

Resistance to Penicillins
 Frequent early use of penicillin caused:
 Penicillinase
 The bacteria to produce penicillin-destroying enzymes
 Potassium clavulanate inhibits penicillinase: combined with penicillin
Penicillins: Therapeutic Uses
Prevention and treatment of gram (+) bacterial infections:
 Enterococcus, Streptococcus, and Staphylococcus bacteria
Penicillins: Adverse Effects
 Hypersensitivity
 Gastrointestinal symptoms
 Neurotoxicity
 Renal dysfunction

 Chemically and pharmacologically related to penicillins
 Action: prevent bacterial cell wall synthesis
Cephalosporins: Action
 Either bactericidal or bacteriostatic; depends on:
 Susceptibility of organism
 Dose of drug
 Tissue concentration
 Rate of bacteria multiplication
Classes of Cephalosporin
 Include several generations:
 First: good gram-positive coverage
 Second: good gram-positive coverage; some gram-negative coverage
 Third: less gram-positive coverage; more gram-negative coverage
 Fourth: good gram-negative coverage
Treatment with Cephalosporins
 Treat infections of:
 Skin
 Bone
 Heart
 Blood
 Respiratory tract
 Gastrointestinal tract
 Urinary tract
Cephalosporins: Adverse Effects
 Hypersensitivity
 Cross-sensitivity reaction to penicillin
 Thrombophlebitis (when given IV)
 Sterile abscess (when given IM)
 Nephrotoxicity

 Action: inhibit protein synthesis in the bacterial cell; bacteriostatic
 Broad spectrum
 Bacteria: gram – and gram +
 Effective against: protozoa, Mycoplasma, Rickettsia, Chlamydia, syphilis, Lyme disease
Tetracyclines: Nursing Implications
 Bind to Ca2+, Mg2+, and Al3+ ions and form insoluble complexes
 Do not give tetracycline with:
 Dairy products, antacids, or iron salts
Tetracyclines: Toxic Effects
 Do not give to children.
 Affects tooth development from:
 Fourth month of fetal development to 8 years old
 Temporary and permanent discoloration of developing teeth
 Photosensitivity
 Superinfection

 Action
 Bacteriostatic: inhibits protein synthesis in the bacterial cell
 Primarily used for respiratory, gastrointestinal, urinary, skin, and soft tissue infections
Treatment with Macrolides
 Treat both gram + and some gram – organisms
 Erythromycin: preferred (pertussis)
 Primarily metabolized by the liver and excreted in the urine
Macrolides: Adverse Effects
 Hypersensitivity
 Gastrointestinal effects
 Hepatotoxicity
 Jaundice
 Poor oral absorption
 Given intravenously, not orally
 Action
 Bactericidal: inhibit cell wall protein synthesis
 Effective: gram – and some gram +
 Narrow therapeutic range
 Potent antibiotics with serious toxicities!
Aminoglycosides: Toxicities
 Serious toxicities: caution
 Nephrotoxicity
 Ototoxicity
 Block neuromuscular action, which can lead to respiratory paralysis
 Monitor drug levels, both peak and trough

 First oral antibiotics effective against gram-negative bacteria
 Excellent oral absorption
Fluoroquinolones: Action
 Bactericidal: alter DNA
 Broad spectrum: effective against gram-negative organisms and some gram-positive organisms

Treatment with Fluoroquinolones

Treat infections of:
 Lower respiratory tract
 Bone and joint
 Infectious diarrhea
 Urinary tract
 Skin
 Sexually transmitted diseases
Fluoroquinolones: Nursing Implications
Consume at least 1 liter of fluid/day

 Action: Inhibit synthesis of the bacterial cell wall
 Broad spectrum
 Effective:
 Gram negative
 Gram positive
 Treat community acquired pneumonia
Carbapenems: Nursing Considerations
 Given intravenously and intramuscularly
 Cross-sensitivity to penicillins
 Advantage
 Given once every 24 hours
Carbapenems: Adverse Effects
 Hypersensitivity
 Diarrhea
 Local reactions at intramuscular and intravenous sites

 FDA approved in 2004
 New class
 Developed from macrolides
 Semisynthetic
 Treat macrolide-resistant strep pneumonia
Ketolides: Adverse Effects
 Hypersensitivity
 Headache
 Diarrhea
Urinary Tract Anti-infectives
 Trimethoprim
 Most common
 Blocks the synthesis of folate in bacteria, thus inhibiting formation of nucleic acid and protein
 Others
 Methenamine products: produces local bactericidal effect
 Nitrofurantoin: stops CHO metabolism
 Produces yellow-brown urine
Antimicrobial Therapy
 General nursing implications
 Instructions take as prescribed:
 Length of time: do not stop before antimicrobials are gone
 Assess for signs and symptoms of returning infection
Antimicrobials: Nursing Implications
 Obtain cultures from appropriate sites before beginning therapy.

Antitubercular Agents
 Tuberculosis (TB)
 Mycobacterium tuberculosis
 An aerobic bacillus
 Requires oxygen to survive
 Antitubercular agents treat all forms of Mycobacterium

 TB close to eradication; new resistant strain developed in immunocompromised individuals and
immigrants to the U.S.
 Drug therapy is given in two forms:
 Preventive therapy
 Active therapy
TB: Preventive Therapy
 Preferred agent
 INH (Isoniazid)
 Known as chemoprophylaxis
 Safest
 Low cost
 Action: tuberculostatic and tuberculocidal
 Treatment: 18 months to 2 years
 Action: inhibits the synthesis of mycolic acid
Adverse effects of INH
 Hepatotoxicity: jaundice
 Peripheral neuritis
 Nausea
 Skin rashes
Multiple Drug Therapy
 Required: combination of two or three agents
 Helps prevent development of resistant strains
Antitubercular Therapy
Effectiveness depends on:
 Where
 Strain
 Effective drug combination
 Sufficient duration
 Effective drug compliance
Antitubercular Agents: Nursing Implications
 Client education is critical.
 Therapy may last for up to 24 months.
 Take medications exactly as ordered.
 Emphasize the importance of strict compliance.
 Do not consume alcohol.
 Diabetic: monitor blood glucose levels
 INH and rifampin:
 Oral contraceptives ineffective

Lyme Disease
 Spirochete Borrelia burgdorferi
 Transmitted from a deer tick
 Rash
 Flulike symptoms, followed by arthritis and fatigue
Treatment for Lyme Disease
 Oral doxycycline
 Adults: 100 mg b.i.d
 Length: 10 to 14 days
Adverse effect
 Photosensitivity

 Air
 Skin to skin
Due to normal flora being killed off:
 Antibiotics
 Corticosteroid therapy
 Antineoplastic agents
 Suppressed immune system

Mycotic Infections
Three general types
 Cutaneous
 Subcutaneous
 Systemic (can be life threatening)

Antifungal Agents
 Antibiotic therapy will not work.
 Requires prolonged treatment
 Human cell structure resembles fungi cell structure.
 Antifungal agents take advantage of the slight differences of the cell structures.

Antifungal Agents: General Adverse Effects

 Topical: irritation and redness
 Oral: nausea, vomiting, and diarrhea
 May potentiate antihistamines
Antifungal Agents: Adverse Effects
 IV: hepatotoxicity, renal toxicity, and phlebitis
 IV drugs must be diluted and administered slowly: amphotericin B
Antifungal Agents: Nursing Implications
 IV
 Monitor vital signs every 15 to 30 minutes.
 Monitor input and output.
 Monitor urinalysis findings.

Antiviral Agents
Viruses cause many infectious disorders:
 Acute: common cold
 Chronic: herpes
 Slow growing: AIDS
Available vaccines
 Polio, rabies, and smallpox
Viral Replication
 A virus cannot replicate on its own.
 It must attach to and enter a host cell.
 Uses the host cell’s energy to synthesize protein: DNA and RNA

 Normally, interferons protect the cells from infecting viruses.
 Interferon: continuous research
 Recent antifungal agents end in “vir”
Antiviral Agents: Key Characteristics
 Inhibit viral replication by interfering with:
 Viral nucleic acid synthesis and/or regulation
 Ability of virus to bind to cells

Treatment with Antiviral Agents

 Antiviral agents treat:
 Influenzae A
 Herpes simplex
Antiviral Agents: Adverse Effects
 Bone marrow suppression
 Nephrotoxicity
 Hepatotoxicity
 Gastrointestinal effects
 Central nervous system effects
 Antiviral Agents: Nursing Implications
 Be sure to teach proper application:
 Ointments
 Aerosol powders
 Emphasize hand washing.
 Wear gloves for topical application.
Antiviral Agents: Nursing Implications
 Usually not a cure
 Replications cease: remain in nerve fibers
 Therapeutic effects vary
 Range from delayed progression of AIDS and ARC to decrease in flulike symptoms
 Frequency of herpes-like flare-ups decrease

Chapter 8
Antiparasitic Drug Therapy

Antiparasitic Therapy
 Millions of people worldwide are infected with protozoal organisms.
 Protozoa: a single-celled microorganism
Protozoal Illnesses
 Protozoal diseases are prevalent in tropical regions and in immuno-compromised hosts
 Exposure: international travel and immigration from areas where such infections are endemic
 Malaria causes high morbidity and mortality
 Protozoa called Plasmodium
 Resides in the red blood cell of humans
Signs and symptoms
 Fever, prostration, and recurrent chills
Transmission of Malaria
 Malaria is transmitted by the bite of a female mosquito.
 Malaria is also transmitted via infected blood during blood transfusions.
 Has become more common in the United States
Treating Malaria
 Humans: antimalarial agents work during the asexual cycle of the parasite
 Mosquito: antimalarial agents do not work during the sexual cycle
Antimalarial Agents
 Quinine sulfate: action is still unknown
 Declining in use because of toxic effects
 Mefloquine (Lariam): synthetic analogue of quinine sulfate
 Used as preventive therapy and has fewer side effects
 Chloroquine (Aralen): safe and effective
 Used for acute treatment
 Fewer side effects
 Given orally and intramuscularly

Treatment with Antimalarials

 Clients
 Take antimalarial agents 1 to 2 weeks before travel to designated geographic areas
 Lab follow-up: monitor for low WBC
 Note reduction in neutrophils
 Administer with food; causes GI irritation
Other Protozoal Infections
 Amebiasis Entamoeba histolytica
 Contaminated food and drink
 Signs and symptoms: diarrhea
 Treatment: metronidazole (Flagyl)
 Trichomoniasis
 Sexually transmitted disease of the vagina
 Treatment: metronidazole (Flagyl)
Antiprotozoal Agents
 Metronidazole (Flagyl): bactericidal, amebicidal, and trichomonacidal; it also kills some anerobic
Adverse effects: N&V, convulsions, peripheral neuropathy, blurred vision, metallic taste, diarrhea, darkened
urine, bone marrow depression, and rash

Chapter 9
Antiseptics and Disinfectants

- An agent that kills or inhibits the growth of microorganisms
- Used on skin
- An agent that rapidly destroys pathogenic microorganisms, thus preventing infection
- Used on inanimate objects
- A general term for agents capable of destroying microorganisms
Actions of Agents
 Cell wall protein is destroyed; cell death occurs
 Cell membrane permeability increases and vital contents leak out; cell death occurs
 Metabolism is disrupted; cell death occurs
 Cell components become oxidized; cell death occurs
Antiseptics and Disinfectants
 Phenolic agents
 Alcohols and aldehydes
 Acids
 Iodine and iodophors
 Chlorine and chlorophors
 Mercury compounds
 Silver compounds
 Surface-active agents
 Oxidizing agents
 Chlorhexidine

Properties of the Agents

What agent are you cleaning with?
Is the offending organism killed or inactivated?
Is skin application acceptable?
How corrosive is the cleaning agent to the skin?
Does the cleaning agent have adverse effects on the skin or inanimate object?

Chapter 10
Analgesics and Antipyretics

- When nerve signals are sent to the brain (CNS) after feeling a hurtful sensation inside or outside the
body, the brain perceives these signals as pain.
 When the client complains of pain, it is important for the nurse to treat it.
- Pain: the fifth vital sign
Pain Transmission
Tissue injury causes the release of:
 Bradykinin
 Histamine
 Prostaglandins
 Serotonin
 These substances stimulate nerve endings, starting the pain process.
Pain Transmission Gate Theory
Most common and well-described theory of pain
Uses the analogy of a gate to describe how impulses from injured tissues are sensed in the brain
Pain Transmission in the Spinal Cord
 A fibers
 Myelin sheath
 Large fiber size
 Conduct quickly
 Sharp and well-localized
 C fibers
 No myelin sheath
 Small fiber size
 Conduct slowly
 Dull and nonlocalized
 Body has endogenous neurotransmitters
 Endorphins
 Enkephalins
 Produced by body to fight pain
 Marathon runners and cyclists
 Bind to opioid receptors
 Inhibit transmission of pain by closing the gate
Management of Pain
 Treat the cause.
 Select a safe analgesic.
 Select the analgesic that provides effective relief.
 Provide psychological support.
 Nursing actions: position change
and back rub
Analgesic drugs relieve pain without causing loss of consciousness.
Opioid Analgesics
- Opium has been used for thousands of years to alleviate pain.
- Opium is derived from the poppy plant.
- Opium produces pain relief by attaching to pain receptors.
- Narcotics are derivatives of opium.
- Narcotics are strong pain relievers.
Classifications of Opioid Analgesics
Classifications based on their actions:
 Agonist
 Agonist-antagonist
 Partial agonist
Uses for Opioid Analgesics
 Main use: to alleviate moderate to severe pain
 Opioids are also used for:
 Cough suppression
 Diarrhea treatment
Effects of Opioid Analgesics
 Euphoria
 Nausea and vomiting
 Respiratory depression
 Urinary retention
 Diaphoresis and flushing
 Pupil constriction (miosis)
 Constipation
Complications of Opioid Analgesics
 Respiratory implications
 Constipation concerns
Opioid Analgesics: Nursing Assessments
 Perform a thorough history.
 Obtain baseline vital signs and assessments.
 Assess for potential contraindications and drug interactions.
Opioid Analgesics: Nursing Implications
 Oral forms–take with food
 Ensure safety measures

Opiates: Opioid Tolerance

 A common response to chronic opioid treatment
 Larger dose of opioids is required
Opiates: Physical Dependence
 Physiologic adaptation to the presence of an opioid
 If in need of pain relief, give the medication
Opiates: Psychological Dependence (Addiction)
 A pattern of compulsive drug use when the medication is not needed for physical pain relief
Opioid Analgesics: Nursing Implications
 Law: narcotics must be kept under a double lock
 Pain management approaches
 Medical/nursing
 Medicate clients before a procedure or an activity and/or
 When they are complaining of pain
 Nursing
 Back rub, musical therapy, and relaxation therapy
Opioid Analgesics: Therapeutic Effects
 Monitor for therapeutic effects
 Increased comfort
 Activities of daily living improved

Opiate Antagonists
 Naloxone (Narcan) and naltrexone (ReVia)
 Opiate antagonists
 Bind to opiate receptors and prevent a response
 Used for reversal of opioid-induced respiratory depression
Opioid Analgesics: Nursing Implications
 Rotate site for IM injections.
 Follow proper guidelines for IV administration, such as dilution and rate of administration.
 Check dosages carefully.
Opioid Analgesics: Nursing Implications
 Prevent constipation.
 Provide fluid and fiber.
 Prevent respiratory depression.
 Provide instruction for clients.
 Drug administration
 Position changes

Analgesic Agents
 Analgesic agents
 Salicylates (ASA)
 Acetaminophen (Tylenol)
 Combination narcotic and non-narcotic analgesics
 Anti-inflammatory analgesic agents
 Nonsteroidal anti-inflammatory drugs (NSAIDs)

ASA (Acetylsalicylic Acid)

 Used for more than 100 years
 Action: peripherally interferes with synthesis of prostaglandins and chemical substances released from
injured tissue
 Treats mild to moderate pain
 Antipyretic effect
ASA: Side Effects
 Gastrointestinal irritation and bleeding
 Increases bleeding time
 Tinnitus
 Children: Reye’s syndrome

Analgesic Agents: Acetaminophen

 Mechanism of action
 Blocks pain impulses peripherally
 Relieves pain
 Reduces a fever–antipyretic
 Weak anti-inflammatory
 Minimal effect on the central nervous system
Acetaminophen: Side Effects
 Acute overdose causes hepatic necrosis.
 Doses of 150 mg/kg
 Long-term ingestion of large doses can result in nephropathy
Acetaminophen: Acute Overdose
 Treatment: acetylcysteine
 Oral form
 IV form now approved
 Prevents the formation of hepatotoxic metabolites.
Chapter 11

- Defined as a group of drugs used to block the transmission of nerve conduction so that the sensation of
pain is not perceived by the brain
Two classifications
 General
 Regional

General Anesthetics
 Produce balanced anesthesia
 Gas and injection
 Prevent pain during surgery
Administration of Anesthetics
 Administered
 Gas or volatile liquid–inhalation
 Injection
 Surgery–secession of use
 Induction gas—first stage
 Intravenous injection—second stage
Risks of Gas Anesthetics
 Most are explosive
 Nausea and vomiting
 Coughing
 Renal and liver toxicity
Risks of Injected Anesthetics
 Blood pressure changes
 Emergence delirium
 Malignant hyperthermia

Regional Anesthesia
Extent anesthetized
 Surface area
 Drug concentration
Adjuncts to General Anesthesia
 Narcotic opioid analgesics
 Benzodiazepines
 Antiemetics
Presurgical Nursing Interventions
Administer preanesthetic medications
 Provide safety.
 Monitor vital signs.
 Maintain NPO status.
 Educate the client.
 Promote confidence.
Postsurgical Nursing Interventions
 Monitor for hypotension.
 Monitor for rapid pulse rate.
 Monitor for gastrointestinal upset.
 Monitor for urinary retention.
 Monitor for hyperthermia.
Chapter 12
Anti-inflammatory Agents

Nonsteroidal Anti-inflammatory Drugs

 Group of frequently prescribed drugs
 Treat pain
 Common drug
 Acetylsalicylic acid (ASA)
 Hermann Kolbe
Uses for NSAIDs
 Analgesic (mild to moderate)
 Antigout
 Anti-inflammatory
 Antipyretic
 Relief of vascular headaches
 Platelet inhibition
How NSAIDs Work
 Stop the activation of the arachidonic acid pathway
 Reduce:
 Pain
 Headache
 Fever
 Inflammation
 Reduce pain by blocking prostaglandins
 Inhibit prostaglandin E2 in the brain
Inflammation Relief
 Inhibit either the:
 Leukotriene pathway
 Prostaglandin pathway
 Or both pathways
Pain Relief
 Relief of mild to moderate pain
 Bone, joint, and muscle pain
 Osteoarthritis
 Rheumatoid arthritis
 Juvenile rheumatoid arthritis
 Dysmenorrhea
Common NSAIDs
 Common drugs that are used:
 Ibuprofen (Motrin, Advil)
 Ketoprofen (Orudis)
 Ketorolac (Toradol)
 Naproxen (Naprosyn)
Gastrointestinal Side Effects
 First-generation NSAIDs
 Dyspepsia, heartburn, epigastric distress, nausea
 Gastrointestinal bleeding
 Mucosal lesions (erosions or ulcerations)
 Second-generation NSAIDs
 Called COX-2 inhibitors
 More specific in their action
 Reduce gastrointestinal distress
Cardiovascular Side Effects
 Second-generation NSAIDs
 Serious side effects:
- Cardiac arrhythmias
- Heart attack
- Stroke
 Celecoxib (Celebrex) may be removed
 Rofecoxib (Vioxx) removed from market by the FDA
 First and second generation
 Do not take if you:
 Have or had stomach ulcers and bleeding
 Have had asthma
 Have had an allergic response to aspirin or sulfa
 Have severe kidney problems
 Have severe liver problems
 Are pregnant
Renal Side Effects
 Creatinine clearance reduced
 Renal failure
 Acute tubular necrosis
Nursing Assessment
 Before beginning therapy, perform thorough assessment for:
 Gastrointestinal lesions or peptic ulcer disease
 Bleeding disorders
 Heart disorders
 Perform lab studies
 CBC, platelet count, cardiac, renal, and liver
Medical History
 Medication history
 Serious drug interactions
 Alcohol
 Heparin and warfarin (Coumadin)
 Phenytoin
 Steroids
 Sulfonamides
 Do not give salicylates to children under age 12.
 Reye’s syndrome
 Give with food and milk.
Client Education
 Educate clients about precautions.
 Watch for:
 Unusual bleeding, abdominal pain, and cardiac problems
 Enteric-coated tablets should not be crushed or chewed.
Therapeutic Effects
 Monitor for:
 Decrease in swelling
 Decrease in pain
 Decrease in joint tenderness

Chapter 13
Agents Used to Treat Hyperuricemia and Gout

- Gout is a metabolic disease associated with the development of high uric acid in the blood.
- It is a metabolic defect and is not caused by excessive intake of meat and alcohol.
Uric Acid
- Uric acid is formed from the breakdown of proteins.
- The accumulation of uric acid causes a problem in the joints and kidneys:
 Kidney stones
 Kidney failure
 Gouty arthritis
 Hyperuricemia
Acute Attacks
 Acute attacks of gout are treated with:
 Nonsteroidal anti-inflammatory drugs (NSAIDs)
 Corticosteroids
 Colchicine: intravenously or orally
Agents Used
 Corticosteroids and NSAIDs actions
 Produce anti-inflammatory effects
 Produce analgesic effects
 Colchicine’s action is unclear
 Reduces leukocyte production of lactic acid
 Reduces phagocytic activity
 Not a first-line agent because of its adverse side effects
Major adverse effects:
 Nausea, vomiting, and diarrhea
 Gastrointestinal bleeding
 Neuritis
 Myopathy
 Alopecia
 Bone marrow depression
Long-term Control
 Most commonly used agent for gout:
 Allopurinol: prevents formation of uric acid
 Adverse effects: hepatotoxicity and skin rash
Gouty Arthritis
 Most commonly used agent
 Indomethacin (Indocin)
 Naproxen (Aleve)
 Sulindac (Clinoril)
Uricosuric Agents
 Increase excretion of uric acid
 Probenecid (Benemid)
 Side effects
• Headaches
• Dizziness
 Sulfinpyrazone (Anturane)
 Side effects
• Nausea and vomiting
• Diarrhea
Therapeutic Effects
 Monitor for:
 Decreased inflammation
 Decreased pain
 Ease of movement
 Monitor lab values of uric acid
 Monitor urine output
Chapter 14
Antihistamines and Nasal Decongestants

Common Cold
 Virus infection
 Rhinovirus
 Influenza virus
 Initiates the inflammatory response
 Cough reflex
 Irritant stimulates sensory receptors
 Removes
 Respiratory secretions
 Foreign object
Inflammatory Response
 Mucosal irritation
 Release of several inflammatory and vasoactive substances
 Histamine
 Dilating small blood vessels in the nasal sinuses
 Produces nasal congestion
Symptomatic Treatment
 Combined use of:
 Antihistamines, nasal decongestants, antitussives, and expectorants
Antihistamines and Nasal Decongestants
 Compete with histamine for receptor sites
 Two histamine receptors
 H1 (histamine 1)
 H2 (histamine 2)
Vasodilatation—GI effects
 Increase gastrointestinal and respiratory secretions
 Increase capillary permeability
 The binding of H1 and H2 blockers to histamine receptors prevent histamine stimulation
H1 Antagonists
 Respiratory antihistamines
 Effects
 Antihistaminic
 Mild anticholinergic
 Parasympathetic nervous system
 Sedative
 Antihistamines
 Cardiovascular: small blood vessels
Histamine effects
 Dilation
 Permeability
Antihistamine effects
 Prevent dilation
 Prevent increased permeability
 Skin
 Prevent itching
 Wheal and flare

 Anticholinergic
 Drying effect
 Sedative
 Drowsiness
 Management of:
 Nasal allergies
 Seasonal or perennial allergic rhinitis
 Allergic reactions
 Motion sickness
 More effective in prevention
 Give early
 Prevent binding of histamine receptors
Classes of Antihistamines
 Two types
 Traditional: sedating
 Nonsedating
Traditional Antihistamines
 Older
 Work both peripherally and centrally
 Anticholinergic properties
Examples: diphenhydramine (Benadryl) and chlorpheniramine (Chlor-Trimeton)
Nonsedating/Peripherally Acting Antihistamines
 Work peripherally
 Eliminate sedation
 Longer duration of action
 Increases compliance
Examples: fexofenadine (Allegra) and loratadine (Claritin)
Antihistamines: Nursing Implications
 Assess allergy history
 Contraindicated
 Asthma attacks
 Chronic obstructive pulmonary disease
 Cardiovascular disease
Client Teaching
 Instruction for traditional/sedating antihistamines
 Avoid driving
 No alcohol
 No central nervous system depressants
Nasal Decongestants
 Two main types are used:
 Adrenergics (largest group)
 Constrict dilated blood vessels
• Nasal mucosa
 Corticosteroids
 Reduce inflammation
Goal of Nasal Decongestants
 To reduce congestion
 Two dosage forms
 Oral
 Topical
 Nasal spray
Oral Decongestants
 Prolonged effects
 Less potent
 No rebound congestion
 Exclusively adrenergics
Example: pseudoephedrine (Sudafed)
Topical Decongestants
 Adrenergics
 Prompt onset
 Sustained use–rebound congestion
 Both adrenergics and steroids
 Potent; work well
Nasal Steroids
 Decrease inflammation
 Relieve nasal congestion

Nasal Decongestants
 Adrenergics
 Ephedrine (Vicks)
 Naphazoline (Privine)
 Oxymetazoline (Afrin)
 Phenylephrine (Neosynephrine)
 Intranasal steroids
 Beclomethasone dipropionate
 Beconase
 Vancenase
 Flunisolide(Nasalide)
Nasal Decongestants: Side Effects
 Adrenergics
 Nervousness
 Insomnia
 Palpitations
 Tremors
 Steroids
 Local mucosal dryness and irritation
Treatment with Nasal Decongestants
 Acute or chronic rhinitis
 Common cold
 Sinusitis
 Hay fever
 Other allergies
Nasal Decongestants: Nursing Implications
 Avoid decongestants in the following clients:
 Heart disease
 Hypertensive disease
 Respiratory disease
 Assess for drug allergies

Chapter 15
Expectorants and Antitussive Agents

Expectorants and Antitussive Agents

 Drugs that aid in the expectoration (removal) of mucus
 Reduce the viscosity of secretions
 Stimulate the flow of respiratory secretions
 By loosening and thinning sputum and bronchial secretions, the tendency to cough is indirectly
Cough Relief
 Relief of nonproductive coughs:
 Pertussis
 Common cold
 Bronchitis
 Laryngitis
 Sinusitis
 Influenza
 Pharyngitis
Expectorants: Side Effects
 Common side effects
 Guaifenesin
 Nausea, vomiting
 Gastric irritation
 Terpin hydrate
 Gastric upset (elixir has high alcohol content)
Expectorants: Nursing Implications
 Use with caution.
 Elderly
 Encourage client to drink fluids.
 Monitor for therapeutic effects.
 Report a fever lasting longer than a week.
 Drugs used to control coughing
 Opioids and nonopioids
 Narcotics
 Used for nonproductive coughs
Opioid Antitussives
 Suppress the cough reflex by direct action on the cough center in the medulla
 Example: codeine + guiafenesin = Robitussin AC
Non-narcotic Antitussives
 Dextromethorphan
 Suppresses the cough reflex by direct action on the cough center in the medulla; a chemical
derivative of the opiate narcotics
 Result: diminished cough
 Produces no respiratory depression, analgesia, or dependence
Example: Robitussin-DM
 Benzonatate
 A derivative of procaine (local anesthetic action); impairs the sensation of the stretch receptors
in the respiratory tract
 Example
 Tessalon
Antitussive Agents: Side Effects
 Benzonatate
 Dizziness, headache, sedation
 Dextromethorphan
 Dizziness, drowsiness, nausea
 Opioids
 Sedation, nausea, vomiting, lightheadedness, constipation
Antitussive Agents: Nursing Interventions
 Perform respiratory assessment.
 Instruct clients to:
 Avoid driving or operating heavy equipment
 Not drink liquids for 30 to 35 minutes after taking a cough syrup or using a cough lozenge
Antitussive Agents: Client Teaching
 Report any of the following symptoms to the health care professional:
 Cough that lasts more than 2 weeks
 A persistent headache
 Fever
 Rash