Universidad de Zamboanga

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

Key Words and Concepts: pharmacology, pharmacokinetics, pharmacodynamics,

pharmaceutics,

Background

Curricula in Respiratory Therapy 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.
DEFINITION OF TERMS:

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

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

 Pharmaceutics are the various pharmaceutical properties a drug possesses

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

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

Drug Form Rate of Absorption

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

Drugs can be given in three dosage forms: enterally, parentally, and topically.
 Enteral forms are given via the intestinal tract either orally, sublingually
(under the tongue), buccally (between the gums and cheek), or rectally.
 Drugs that require quick absorption may be given sublingually or buccally
because the rich supply of blood vessels in the mouth and the ease of
transport through the mucous membranes supports immediate absorption by
the body.
 Parenteral forms are given outside the gastrointestinal tract. They are given
intradermally, intramuscularly, subcutaneously, or intravenously. These forms
allow for immediate absorption by the body bypassing the gastrointestinal
track and the need for dissolution.
  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
B. PHARMACOKINETICS
 Pharmacokinetics refers to how drugs travel through the body where they
undergo a variety of biochemical processes that result in absorption,
distribution, metabolism, and excretion.

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

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

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

IMPLICATIONS
 Respiratory Therapist 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 RT
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, RTs are responsible for a deep understanding of the drugs they are
giving to administer drugs in a safe and evidence-based manner.
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, pharmaco therapeutics, and toxicology is essential in drug therapy
and to safe, quality practice. Application of pharmacologic principles enables the RT 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.