LESSON 1: Nursing Pharmacology: A Patient- necessary to predict how much of a drug will be

centered Nursing Process Approach metabolized by the body.

PHARMACOLOGY BASICS Pharmacodynamics

• Drugs are medications or other substances • refers to the effects of drugs in the body and
that have a physiological effect when introduced the
to the body. mechanism of their action. As a drug travels
• Pharmacokinetics is the term that describes through the bloodstream, It Will exhibit a unique
the four stages of absorption, distribution, affinity for the drug receptor site— how strongly
metabolism, and excretion of drugs. it will bind to the site.
• BIOAVAILABILITY- Examination of how drugs
ADME and receptor sites create a lock and key system
• Absorption occurs after medications enter the is helpful to understand how drugs work and the
body and travel from the site of administration amount of drug that may be left circulating within
into the body's circulation. the bloodstream.
• Distribution is the process by which medication
is distributed throughout the body. Pharmacogenetics
• Metabolism is the breakdown of a drug • is defined as the study of how people's genes
molecule. affect their response to medicines.
• Excretion is the process by which the body
eliminates waste. Pharmacokinetics
• Absorption occurs after drugs enter the body
TRUE OR FALSE and travel from the site of administration into the
• Scientists do not have the ability to actually see body's circulation. Medications can enter the
where a drug is going or how long it is active body through various routes of administration.

Answer: FALSE ABSORPTION

Identify the following routes of Administration
• Mathematical models and precise • swallowing an aspirin tablet - ORAL
measurements of blood and urine to determine • administering to the GI tract such as via a NG
where a drug goes and how much of the drug (or tube - ENTERAL
breakdown product) remains after the body • administering an acetaminophen (Tylenol]
processes it suppository) - RECTAL
• Other indicators, such as blood levels of liver • breathing in medication from an inhaler -
enzymes, can help predict how much of a drug is INHALATION
going to be absorbed. • getting a flu shot in the deltoid muscle -
INTRAMUSCULAR
PHARMACOKINETICS • injecting insulin into the fat tissue beneath the
• Interactions between drug and body molecules skin) - SUBCUTANEOUS
are really just a series of chemical reactions • wearing a nicotine patch – TRANSDERMAL OR
• Understanding the chemical encounters INTRADERMAL
between drugs and biological environments is
LIFESPAN CONSIDERATIONS contents, gastric emptying rate, dietary
contents, and presence of other drugs.
Neonate & Pediatric •First pass effect: Blood containing the absorbed
• The acid-producing cells of the stomach are drug passes through the liver, which can
immature until around the age of one to two deactivate a substantial amount of the drug and
years. decrease its bioavailability (the percentage of
• Gastric emptying may be decreased because dose that reaches the systemic circulation).
of slowed or irregular peristalsis (forward bowel
movement). 2. Parenteral Injection
• The liver of a neonatal or pediatric patient •Subcutaneous and intramuscular
continues to mature, experiencing a decrease in administration:
first-pass elimination, resulting in higher drug Can be difficult for patients to self-administer at
levels in the bloodstream home or to administer on a daily basis.
They can be costly and painful. v cause a break
Older Adult: in skin that is an important
• decreased blood flow to tissues within the Gl barrier to infection
tract. can cause fluctuation in drug levels. can cause
changes in the gastric (stomach) pH that may localized side effects to skin.
alter the absorption of
certain medications •Intravenous (IV):
meiatians is analate play prorete ins, which can IV drugs are fully available to tissues after
impact drug levels of administration into the bloodstream, offering
• use of subcutaneous and intramuscular complete bioavailability and an immediate
injections in older patients experiencing effect.
decreased cardiac output * requires intravenous access that can be painful
Decreased drug absorption of medications can to the patient and also increases risk for
occur when peripheral circulation is decreased. infection.
have less body fat, resulting in decreased * Medications must be administered in sterile
absorption of medication from transdermal fashion
patches that require adequaté subcutaneous fat * if two products are administered
stores for proper absorption. simultaneously, their compatibility must be
verified.
ROUTES OF ADMINISTRATION * There is also an increased risk of toxicity.

1. Oral (PO) or Enteral (NGT, GT, OGT) 3. Pulmonary inhalation

Ingestion •allows for rapid absorption of drugs in gaseous,
•Oral route is a convenient route for vaporized, or aerosol form.
administration of solid as well as liquid •Absorption of particulates/aerosols depends on
formulations. particle/droplet size, which influences depth of
•Additional variables include enteric coating or entry through the pulmonary tree to reach the
extended-release formulations, acidity of gastric alveoli.
•The ability of the patient to create successful • Drugs are designed to primanly cause one
inhalation, especially in the presence of effect, meaning they bind more strongly to one
bronchospasm, may also influence depth of specific receptor site and predictably cause or
entry in the pulmonary tree block an action.
• side effects can occur when the drug binds to
TRUE OR FALSE other sites in addition to the target tissue,
• Medication administration route does NOT causing secondary side effects.
impact drug absorption. • these side effects can range from tolerable to
ANSWER: FALSE unacceptable resulting in the discontinuation of
the medication
• A patient with damage to the outer layer of skin • Ex. Tylenol for pain- can cause stomach
(or stratum corneum) may experience a more irritation
rapid absorption of medication with topical
application. BLOOD FLOW
ANSWER: FALSE • Factors that can affect the blood flow and
delivery of medication
• The first-pass effect impacts absorption of decreased flow (due to dehydration)
medications administered via the: blocked vessels (due to atherosclerosis),
A. Pulmonary route constricted vessels (due to uncontrolled
B. Oral route hypertension),
C. Topical route • weakened pumping by the heart muscle (due to
D. Parenteral route heart failure). A
Ex. when administering an antibiotic to a patient
COMMON FACTORS with diabetes with an infected toe, it may be
• blood flow difficult for the antibiotic to move through the
• plasma protein binding blood vessels all the way to the cells of the toe
• lipid solubility that is infected.
• the blood-brain barrier • Once the drug is in the bloodstream, a portion
• the placental barrier of it may exist as free drug, dissolved in plasma
• capillary permeability water.
• differences between blood/tissue • Some of the drug will be reversibly taken up by
• volume of distribution. red cells,
• some will be reversibly bound to plasma
PHARMACOKINETICS proteins- 95-98%.
• drug distribution- SECOND STAGE • This Is important because it is the free drug that
• Distribution is the process by which medication traverses cell membranes and produces the
is dispersed throughout the body via the desired effect.
bloodstream. • It is also important because a protein-bound
drug can act as a reservoir that releases the drug
• Distribution of a medication can also cause slowly and thus prolongs its action.
unintended adverse or side effects.
• amount & free drue thiat Is readly available to Therefore, it is imperative to always consult a
tissues, as well as the potential drig reserve that healthcare provider regarding the safety of
may be released over time. medications for use during pregnancy.
• with drug distribution, it is imoortant to
consider both the amount of free drug that is • Older Adult: The aging adult patient will
readily available to tissues, as well as the experience a decrease in total body water and
potential drug reserve that may be released over muscle mass.
time. Body fat may increase and subsequently result in
a longer duration of action for many
Protein-Binding medications.
• Albumin is one of the most important proteins Serum albumin often also decreases, resulting in
in the blood. Albumin levels can be decreased by more active free drug within the body. This is one
several factors such as malnutrition and liver reason why many older adult patients require
disease. A certain percentage of almost every lower levels of medication
drug gets bound to plasma proteins when it
initially enters the bloodstream and starts to • Older Adult: The aging adult patient will
circulate. experience a decrease in total body water and
muscle mass.
Blood-Brain Barrier Body fat may increase and subsequently result in
• This blockade is built from a tightly woven a longer duration of action for many
mesh of capillaries that protect the brain from medications.
potentially dangerous substances, such as Serum albumin often also decreases, resulting in
poisons or viruses. Only certain medications more active free drug within the body. This is one
made of lipids (fats) or have a "carrier" can get reason why many older adult patients require
through the blood-brain barrier. lower levels of medication
Placental Barrier
• The placenta is permeable to some Other Factors that Impact Drug Distribution
medications, while others have not been 1) Tissue differences in rates of uptake of drugs.
specifically studied in pregnant patients. Some • Blood flow: distribution occurs most rapidly
drugs can cause harm to the unborn fetus during into tissues with a greater number of blood
any trimester. vessels that allow high blood flow (lungs,
Therefore, it is imperative to always consult a kidneys, liver, brain) and least rapidly in tissues
healthcare provider regarding the safety of with fewer numbers of blood vessels resulting in
medications for use during pregnancy. low blood flow (fat).
• Capillary permeability: permeability of
Placental Barrier capillaries is tissue dependent. Distribution rates
• The placenta is permeable to some are relatively slower or non-existent into the CNS
medications, while others have not been because of the tight junction between capillary
specifically studied in pregnant patients. Some endothelial cells and the blood-brain barrier.
drugs can cause harm to the unborn fetus during Capillaries of the liver and kidney are more
any trimester. porous, allowing for greater permeability.
2) Differences in tissue/blood ratios at • Neonate & Pediatric: The developing liver in
equilibrium infants and young children produces decreased
• Dissolution of lipid-soluble drugs in adipose levels of microsomal enzymes.
tissue • This may result in a decreased ability of the
• Binding of drugs to intracellular sites young child or neonate to metabolize
• Plasma protein-binding medications.
• In contrast, older children may experience
Pharmacokinetics increased metabolism and require higher doses
• Metabolism- the breakdown of a drug molecule of medications once the hepatic enzymes are
usually involves two steps that take place fully produced
primarily in the body's chemical processing
plant: the liver In • Older Adult: Hepatic metabolism may
• Everything that enters the bloodstream- experience a significant decline in the older
whether swallowed, injected, inhaled, absorbed adult. As a result, dosages should be adjusted
through the skin, or produced by the body itself- according to the patient's liver function and
is carried to this largest internal organ. anticipated metabolic rate. First-pass
metabolism is also decreased with aging
Pharmacokinetics therefore, older adults may have higher
• Metabolism- the breakdown of a drug molecule "free" criculating drug concentrations and be at
usually involves two steps that take place higher risk for side effects and toxicities.
primarily in the body's chemical processing
plant: the liver Pharmacokinetics
• Everything that enters the bloodstream- • Excretion is the final stage of a medication
whether swallowed, injected, inhaled, absorbed interaction within the body.
through the skin, or produced by the body itself-
is carried to this largest internal organ. ROUTES OF EXCRETION

Lifespan Considerations KIDNEY

• Neonate & Pediatric: The developing liver in • The most common route of excretion
infants and young children produces decreased • The rate of excretion can be estimated by taking
levels of microsomal enzymes. into consideration several factors: age, weight,
• This may result in a decreased ability of the biological sex, and kidney function.
young child or neonate to metabolize • Kidney function is measured by lab values such
medications. as serum creatinine, glomerular filtration rate
• In contrast, older children may experience (GFR), and creatinine clearance.
increased metabolism and require higher doses
of medications once the hepatic enzymes are LIVER
fully produced • some drugs and their metabolites are actively
transported by the hepatocytes (liver cells) to
Lifespan Considerations bile
• If a patient is experiencing decreased liver
function, their ability to excrete medication is
affected and drug dosages must be decreased. • Pharmacokinetics is comprised of four main
Lab studies used to estimate liver function are processes to describe the movement of drugs
called liver function tests and include within the body.
measurement of the ALT and AST enzymes that ANSWER: TRUE
the body releases in response to damage or
disease. • Medications enter the body through the oral
route alone.
OTHER ROUTES ANSWER: FALSE
• Sweat
• Tears • Which of the following is not one of the main
• reproductive fluids (such as seminal fluid) processes of pharmacokinetics?
• breast milk a. Absorption
b. Management
LIFESPAN CONSIDERATIONS c. Distribution
• Neonate & Pediatrics: Young patients have d. Metabolism
immature kidneys with decreased glomerular
filtration, resorption, and tubular secretion. As a PHARMACODYNAMICS
result, they do not clear medications as
efficiently from the body. • Mr. Jones visits his provider with complaints of
• Dosing is commonly based on weight in low back pain following a long weekend raking
kilograms, and a smaller dose is usually leaves.
prescribed He receives instruction to take 400mg of
• may have higher levels of free circulating ibuprofen every 4 to 6 hours as needed to
medication than anticipated and may become alleviate the discomfort. He takes his first dose
toxic quickly. of ibuprofen and experiences nausea. His
• Frequent assessment of infants and children is nausea is
vital for early identification of drug toxicity. ล.
• Observe child within one minute of • A. Therapeutic effect
administration. • B. Adverse effect
• C. Side effect
• Older Adult: Kidney and liver function often
decrease with age, which can lead to decreased • mechanism of action
excretion of medications. - how a medication functions within the body, is
• medication may have a prolonged half-life with essential to understanding the processes
a greater potential for toxicity due to elevated medications go through to produce the desired
circulating drug levels. effect
• Smaller doses of medications are often Ade agonist binds tightly to a receptor to
recommended for older patients due to these produce a desired
factors, which is commonly referred to as “Start • A drug antagonist competes with other
low and go slow”. molecules and blocks a
specific action or response at a receptor site.
True or False
• For example, the cardiac medication atenolol The nurse is reviewing dietary supplements and
(Tenormin) is a hypertension or near oisease, recalls that under the DSHEA, manufacturers of
Bela ne pepio an vagonist. medications like dietary supplements are required to:
atenolol produce several effects by blocking
beta-1 receptors: a negative inotropic effect a. follow FDA standards for quality control
occurs by b. prove efficacy and safety of dietary
weakening the contraction of the heart, thus supplements.
causing less work c. identify the active ingredients on the label.
of the heart muscle. a negative chronotropic d. obtain FDA approval before the products are
eifect occurs when the heart rate is decreased: marketed
occurs when the conduction or the electrical
one n the heart ediaon allows the nuise to When educating patients about the safe use of
anicipate expected actions or the medication herbal products, the nurse remembers to
and the patient response. include which concept?

Activity a. Herbal and over-the-counter products are

approved by the FDA and under strict regulation.
a. Prescription Medications b. Herbal products are tested for safety by the
b. Generic Medications FDA and the U.S. Pharmacopeia.
c. Over-the-Counter Medications c. No adverse effects are associated with these
d. Herbals & Supplements products because they are natural and may be
purchased without a prescription.
A. 1. Include brand-name medications and d. Take the product with caution because labels
generic medications may not contain reliable information.
B. 2. can be safe and effective alternatives to
their brand-name counterparts and often at a When taking a patient's drug history, the nurse
reduced cost asks about the use of over-the-counter drugs.
The patient responds by saying. "Oh. I frequently
B. 3. must have the same chemically active take aspirin for my headaches, but I didn't
ingredient in the same, however, the excipients mention it because aspirin is nonprescription."
or the flavoring can be different. What is the best response from the nurse?

C. 4. can be bought at a store and may be used a. "That's true, over-the-counter drugs are
by multiple individuals. generally not harmful."
b. "Aspirin is one of the safest drugs out there."
D. 5. may include a wide variety of substances c. "Although aspirin is over the counter, it's still
including vitamins, minerals, enzymes, and important to know why you take it, how much
botanicals you take, and how often."
d. "We need you to be honest about the drugs
SAMPLE QUESTIONS you are taking. Are there any others that you
haven't told us about?"
When making a home visit to a patient who was SCENARIO
recently discharged from the hospital. the nurse • A 67-year-old female post-operative patient
notes that she has a small pack over her chest rings the call light to request medication for pain
and that the pack has a strong odor. She also is related to the hip replacement procedure she
drinking herbal tea. had earlier that day. She notes her pain is
When asked about the pack and the tea, the excruciating, a definite 9 out of 10." Her brow is
patient says, "Oh, my grandmother never used furrowed, and she is grimacing in obvious
medicines from the doctor. She told me that this discomfort. As the nurse providing care for the
plaster and tea were all I would need to fix patient, you examine her post-operative
things." Which response by the nurse is most medication orders and consider the pain
appropriate? medication options available to you.

a. "You really should listen to what the doctor Duration and Dosing
told you if you want to get better." • the duration of medication is correlated
b. "What's in the plaster and the tea? with the elimination
• If a medication has a short half-life (and
When do you usually use them?"
thus eliminated more quickly from the
c. "These herbal remedies rarely work, but if you body), the therapeutic effect is shorter.
want to use them; then it is your choice." • medications may require repeated dosing
d. "It's fine if you want to use this home remedy, throughout the day in order to achieve
as long as you use it with your prescription steady blood levels of active free drug and
medicines." a sustained therapeutic effect.
• Other medications have a longer half-life
(and thus longer therapeutic duration)
EXAMINING EFFECT and are only given once or twice per day.
• to ensure its appropriateness.
• Dosing considerations play an important role in • EXAMPLE
understanding the effect that a medication may • oxycodone immediate release is prescribed
have on a patient. During administration, the every 4 to 6 hours for the therapeutic effect of
nurse must pay close attention to the desired immediate relief of severe pain, whereas
oxycodone ER (extended release) is prescribed
effect and therapeutic patient response, as well
every 12 hours for the therapeutic effect of
as the safe dose range for any medication. sustained relief of severe pain.

• Onset: the onset of medication refers to when MEDICATION SAFETY

the medication first begins to take effect
• Peak: the peak of medication refers to the 1. Effective Concentration
2. Therapeutic Window - most desirable
maximum concentration of medication in the
outcome of medication administration
body, and the patient shows evidence of greatest 3. Toxic concentrations
therapeutic effect
• Duration: the duration of medication refers to Peak and Trough Levels
the length of time the medication produces its A peak drug level is drawn at the time when the
desired therapeutic effect medication is being administered and is known
to be at the highest level in the bloodstream
A trough level is drawn when the drug is at its blood levels achieved in the person taking
lowest in the bloodstream right before the next it.
dose is given.
Therapeutic Index
• Medications have a predicted reference • EXAMPLE
range of normal values for peak and
• patients who start taking phenytoin to control
trough levels.
• These numbers assist the pharmacist and seizures have the drug levels in their blood
provider in gauging how the body is stream measured frequently.
metabolizing, protein-binding, and
excreting the drug, and assist in the Preparing for Administration
adjustment of the prescribed drug doses • As medications are administered, the nurse
to keep the medication within the
should perform careful patient assessments,
therapeutic window.
trend the assessment results, and monitor for
Therapeutic Index side effects or toxic adverse effects. Drug
dosages should be evaluated for potency in
• Therapeutic Index is a quantitative
action.
measurement of the relative safety of a drug. It is
a comparison of the amount of drug that
• Potency refers to the amount of the drug
produces a therapeutic effect versus the amount
required to produce the desired effect. A drug
of drug that produces a toxic effect.
that is highly potent may require only a minimal
dose to produce a desired therapeutic effect,
Peak and Trough Levels
whereas a drug that has low potency may need
• When administering IV medications that
to be given at much higher concentrations to
require peak or trough levels, it is vital for the
produce the same effect.
nurse to time the administration of the
• opioid versus non-opioid medications for pain
medication according to the timing of these
control. Opioid medications often have a much
blood draws.
higher potency in smaller doses to produce pain
relief; therefore, the overall dose required to
Therapeutic Index
• A large (or high) therapeutic index number produce a therapeutic effect may be much less
means there is a large therapeutic than for other analgesics.
window between the effective
concentration and the toxic • Selectivity- refers to how readily the drug
concentration of a medication, so the targets specific cells to produce an intended
drug is relatively safe.
therapeutic effect. Drugs that are selective will
• A small (or low) therapeutic index number
means there is a small therapeutic search out target sites to create a drug action,
window between the effective whereas non-selective drugs may impact many
concentration and the toxic different types of cells and tissues, thus
concentration. A drug with a narrow potentially causing side effects.
therapeutic range (i.e., having little
difference between toxic and therapeutic
• A side effect occurs when the drug produces
doses) often has the dosage titrated
according to measurements of the actual effects other than the intended effect. A side
effect, although often undesirable, is generally LESSON 2: NURSING PHARMACOLOGY
anticipated by the provider and is a known ANTIMICROBALS
unintended consequence of the medication
therapy. ANTIMICROBIALS
Bacteria may be identified when a patient has an
• adverse effects- occasional occurrences of infection by using a culture and sensitivity test or
unanticipated effects that are dangerous to the a gram stain test..
patient. Adverse effects are relatively In addition to antibiotics, antimicrobials also
unpredictable, severe, and are reason to include medications used to treat viruses and
discontinue the medication. fungi.

SHORT QUIZ CULTURE AND SENSITIVITY

1. An unintended pharmacological effect that A culture is a test performed to examine

occurs when a medication is administered different body substances for the presence of
correctly. ADVERSE EFFECT bacteria or fungus.«These culture samples are
2. The "sine qua non" of drug effect. Simply put, commonly collected from a patient's blood,
as the dose of drug increases, the response urine, sputum, wound bed, etc.
should increase. DOSE RESPONSE
3. Refers to the dose required to produce a A sensitivity analysis is often performed to
specific intensity of effect. POTENCY select an effective antibiotic to treat the
4. The movement of drugs within the body. microorganism. If the organism shows
PHARMACOKINETICS resistance to the antibiotics used in the test,
5. The science of dealing with actions of drugs on those antibiotics will not provide effective
the body. PHARMACOLOGY treatment for the patient's infection.
6. This is the maximum effect of which the drug
is capable. EFFICACY GRAM POSITIVE VS GRAM NEGATIVE
7. Effect of a drug, other than the desired effect,
sometimes in an organ other than the target A gram stain is another type of test that is used to assist
in classifying. A gram stain is another type of test that is
organ. SIDE EFFECT.
used to assist in classification of pathogens. Gram stains
8. A molecule that prevents the action of other are useful for quickly identifying if bacteria are
molecules, often by competing for a cellular "gram positive" or "gram negative," based on the
staining patterns of their cellular
receptor; opposite of agonist. ANTAGONIST walls.
9. The breakdown of orally administered drugs in
the liver and intestines. FIRST PASS EFFECT Utilizing gram stain allows microbiologists to look for
characteristic violet (Gram +) or red/pink (Gram -)
10. The science of drug preparation. PHARMACY staining patterns when they examine the organisms
under a microscope. Identification of bacteria as gram
positive or gram negative assists the healthcare
provider in quickly selecting an appropriate antibiotic
to treat the infection.
Sample Gram Negative Infections Antifungal
• Antifungal, or antimycotic agents, are
Gram negative bacteria often grow between medications that are used to treat fungal
aerobic and anaerobic areas (such as in the infections.
intestines). Some gram negative bacteria cause • These medications work by killing the cells of
severe, sometimes life-threatening disease. The the fungus or inhibiting the reproduction of the
genus Neisseria, for example, includes the cells. Unlike antibacterial and antiviral
bacteria N. gonorrhoeae, the causative agent of medications, many antifungals are applied
the sexually transmitted infection gonorrhea, topically to the affected area.
and N. meningitides, the causative agent of
bacterial meningitis. Dose Dependency/Time Dependency

Broad-Spectrum vs. Narrow-Spectrum The goal of antimicrobial therapy is to select an

Antimicrobials optimal dosage that will result in clinical cure,
•A broad-spectrum antibiotic will treat gram while reducing the patient complications or
positive and gram negative bacteria. significant side effects. Many medications m The
•A narrow-spectrum antibiotic will treat either goal of antimicrobial therapy is to select an
gram positive or gram negative bacteria. optimal dosage that will result in clinical cure,
while reducing the patient complications or
Antibacterials Actions - Bacteriostatic vs significant side effects. Many medications may
Bactericidal be dose dependent.

Bacteriostatic drugs cause bacteria to stop Other medications are time dependent. Time-
reproducing; however, they may not ultimately dependent medications have optimal bacterial
kill the bacteria. killing effect at lower doses over a longer period
of time. Time-dependent antimicrobials exert the
Bactericidal drugs kill their target greatest effect by binding to the microorganism
bacteria. for an extensive length of time.

Antiviral ROUTE
Antiviral drugs directly impact interaction and It is also important to consider the route of drug
reproduction of the offending microorganism. administration within the patient's body.
Antibacterial medications are required for Most convenient: oral
treating bacterial infections; antivirals treat Fastest absorption: intravenous
specific viral infections. For example, oseltamivir
(Tamiflu) is commonly prescribed to treat Nursing Process: Assessment
influenza. Unlike antimicrobials, antiviral Antimicrobials are given to prevent or treat
medications do not kill the offending virus, but infection. If a patient is prescribed an
they work to reduce replication and development antimicrobial, an important piece of the nursing
of the virus or gram negative bacteria. assessment should be to look for signs and
symptoms of infection.
Example:
Baseline of vital signs Mechanism of Action: Cephalosporins are
Check for IV patency typically bactericidal and are similar to penicillin
Signs and symptoms of infection in their action within the cell wall.
Cephalosporins are sometimes grouped into
Nursing Process: Implementation of Interventions "generations" by their antimicrobial properties.
With administration of the antimicrobial medication, it
The 1st-generation drugs are effective mainly
is important for the nurse to anticipate any additional
interventions associated with the medications. against gram-positive organisms. Higher
generations generally have expanded spectra
Example: against aerobic gram-negative bacilli. The 5th-
• Patient education before oral and generation cephalosporins are active against
parenteral medications methicillin-resistant Staphylococcus
• Tepid sponge bath aureus (MRSA) or other complicated infections.
• Cold compress over swollen or infiltrated
IV Site Specific Administration Considerations:
• Continuous monitoring of vital signs • Patients who are allergic to pencillins may
• Patient teaching when giving also be allergic to cephalosporins.
antimicrobials (completing the course of • Patients who consume cephalosporins
antibiotics) while drinking alcoholic beverages may
experience disulfiram-like reactions
Nursing Process: Evaluation including severe headache, flushing,
it is important to always evaluate the patient's nausea, vomiting, etc.
response to a medication. With antimicrobial • Additionally, like penicillins,
medications, the nurse should assess for cephalosporins may interfere with
absence of or decreasing signs of infection, coagulability and increase a patient's risk
indicating the patient is improving. It is important of bleeding.
to document these findings to reflect the • Cephalosporin dosing may require
patient's trended response. adjustment for patients experiencing
renal impairment.
CEPHALOSPORINS • Blood urea nitrogen (BUN) and creatinine
Cephalosporins are a slightly modified chemical should be monitored carefully to identify
"twin" to penicillins due to their beta lactam signs of nephrotoxicity.
chemical structure. Because of these
similarities, some patients who have allergies to Patient Teaching & Education:
penicillins may experience cross-sensitivity to • Patients who are prescribed
cephalosporins. cephalosporins should be specifically
cautioned about a disulfiram reaction,
Indications: Cephalosporins are used to treat which can occur when alcohol is ingested
skin and skin-structure infections, bone while taking the medication.
infections, genitourinary infections, otitis media, • Additionally, individuals should be
and community-acquired respiratory tract instructed to monitor for rash and signs of
infections. superinfection (such as black, furry
 overgrowth on tongue; vaginal itching or patients allergic to cephalosporins. It is
discharge; loose or foul-smelling stool) important to remember that patients who are
and report to the prescribing provider. prescribed high doses of penicillin may
• It is also important to note that experience significant coagulation
cephalosporin can enter breastmilk and abnormalities. Other notable drug interactions
may alter bowel flora of the infant. Thus, include the use of diuretic therapy with
use during breastfeeding is often penicillin. Penicillin contains a significant
discouraged. amount of potassium. Patients receiving
potassium-sparing diuretics or supplementation
PENICILLINS should be monitored for signs of hyperkalemia.
Penicillin was the first antibiotic discovered and Penicillin is best absorbed on an empty
its detection came as a bit of an accident. In stomach; however, many patients may
1928, Alexander Fleming, a professor of experience GI upset and subsequently take the
bacteriology at St. Mary's Hospital in London, medication with food.
discovered penicillin accidentally growing in a
petri dish in his lab. The penicillin was the result Patient Teaching & Education: The patient should
of mold juice that had grown there inadvertently. notify the health care provider (HCP) if fever or
Fleming noted that this "mold juice" inhibited the diarrhea develops, especially if the stool
growth of Staphylococcus bacteria that was contains blood, pus, or mucus. Advise the
previously growing in the petri dish. patient not to treat diarrhea without advice from
Subsequently, the first antibiotic discovery was HCP. If Gl upset occurs, the patient may take the
made. medication with meals but should avoid taking
with citrus-based products, which can impede
Indications: Penicillins are prescribed to treat a absorption. Additionally, patients should be
variety of infectious processes such as instructed to chew oral chewable tablets
Streptococcal infections, Pneumococcal thoroughly before swallowing. The patient should
infections, and Staphylococcal infections. report a rash or any signs of superinfection
Penicillins may be administered orally, V, or (black, furry overgrowth on tongue; vaginal
intramuscularly. itching or discharge; loose or foul-smelling
stool).
Mechanism of Action: Penicillins are bactericidal Patients should be instructed to take medication
and kill bacteria by interfering with the synthesis around the clock and to finish the drug
of proteins needed in their cellular walls. When completely as directed. Doses should be spaced
the bacterial cell wall is impaired, the cell is evenly to achieve the desired therapeutic effect.
rapidly broken down and destroyed. Additionally, patients should receive instruction
to not share medication and that any sharing of
Specific Administration Considerations: In medications may be dangerous. Patients with a
addition to general antimicrobial administration history of rheumatic heart disease or valve
considerations, it is important to monitor replacement should receive instruction
patients who receive penicillins for signs of regarding the importance of using antimicrobial
superinfections such as C-diff or yeast prophylaxis before invasive medical or dental
infections. There is also a cross-sensitivity for procedures.
Female patients taking oral contraceptives
should use an alternative form of contraception
during therapy with amoxicillin and until next
period. Patients should notify their HCP if
symptoms do not improve

REVIEW

1. And 2. What are the 2 lab tests required to

identify bacteria when the patient has an
infection. CULTURE AND SENSITIVITY, GRAM
STAINING

CARBAPENEMS 3. medications used to treat trat fungi. ANTI

Carbapenems are a beta- lactam "cousin" to FUNGAL MEDICATIONS
penicillins and cephalosporins. Indications:
Carbapenems are useful for treating life- 4. 2 classifications of the spectrum of
threatening, multidrug-resistant infections due antimicrobial. These are used to treat gram-
to their broad spectrum of activity. These positive and gram-negative bacteria. BROAD
antibiotics are effective in treating gram-positive SPECTRUM
and gram-negative infections.
Because of their broad spectrum of activity, 5. Anti bacterial actions wherein drugs kill their
these medications can be especially useful for target bacteria. BACTERICIDAL
treating complex hospital-acquired infections or
for patients who are immunocompromised. 6. Penicillin, as an antimicrobial has what
Mechanism of Action: Carbapenems are antimicrobial action? BACTERICIDAL
typically bactericidal and work by inhibiting the
synthesis of the bacterial cell wall. 7. Classification of medication depending on its
Specific Administration dependency wherein we refer to the optimal
Considerations: Carbapenems are similar to bacterial killing effect for a long period of time.
cephalosporins. Cross sensitivity may occur in TIME DEPENDENT
patients allergic to pencillin or cephalosporins.
Patient Teaching & Education: Patients should 8. The first nursing process when going through
monitor for signs of superinfection and report medication. ASSESSMENT
any occurrence to the provider. If a patient
experiences fever and bloody diarrhea, they 9. If a patient is allergic to imipinem most likely
should contact the provider immediately. The they are also allergic to: CEPHALOSPORIN and
patient should also be advised that side effects PENICILLIN
can occur even weeks after the medication is
discontinued. 10. First antibiotic discovered: PENICILLIN
11. What is monitored when penicillin is taken
with potassium sparing diuretics.
HYPERKALEMIA

12. 2 signs and symptoms of superinfection.

BLACK FURRY OVERGROWTH OF THE TONGUE,
VAGINAL DISCHARGE, LOOSE FOUL SMELLING
SULFONAMIDES
STOOL
Sulfonamides are one of the oldest broad-
spectrum antimicrobial agents that work by
13. Side effects of penicillin. Nausea, vomitting,
competitively inhibiting bacterial metabolic
epigastric symptoms, signs of superinfection
enzymes needed for bacterial function.

MONOBACTAMS
Indications: Sulfonamides are used to treat
Like penicillins, cephalosporins, and carbapenems,
monobactams also have a beta-lactam ring structure. urinary tract infections, otitis media, acute
exacerbations of chronic bronchitis, and
Indications: Monobactams are narrow-
travelers' diarrhea.
spectrum antibacterial medications that are
used primarily to treat gram-negative bacteria
Mechanism of Action: This mechanism o action
such as Pseudomonas aeruginosa.
provides bacteriostatic inhibition of growth
against a wide spectrum of gram-positive and
Mechanism of Action: Monobactams are
gram-negative pathogens.
bactericidal and work to inhibit bacterial cell wall
synthesis
Specific Administration Considerations:
Allergic reactions to sulfonamide medications
Specific Administration Considerations:
are common and, therefore, patients should be
Patients taking monobactams may experience
monitored carefully for adverse effects including
adverse effects similar to other beta-lactam
delayed hypersensitivity reactions. Sulfonamide
medications, so nurses should monitor for Gl
medications increase the risk of crystalluria that
symptoms, skin sensitivities, and coagulation
can cause kidney stones or decreased kidney
abnormalities.
function; therefore, patients should increase
their water intake while taking these
Patient Teaching & Education: Patients should
medications.
monitor for signs of superinfection and report
any occurrence to the provider. If the patient
Patient Teaching & Education: The patient
experiences fever and bloody diarrhea, they
should receive education to complete the full
should contact the provider immediately. The
prescribed dose of medications and take
patient should also be advised to notify the
measures to not skip doses. If a dose is missed,
provider immediately if symptoms progress or if
the patient should take the missed dose as soon
any sign of allergic response occurs.
as possible unless it is near the next dosing time.
The medication can cause increased
photosensitivity, and patients should be
educated to use sunscreen and protective complicated UTls, pyelonephritis, plague, or post
clothing with sun exposure. The patient should Anthrax exposure and should be used cautiously
also report any rash, sore throat, fever, or mouth in pregnancy.
sores that might occur. Unusual bleeding or
bruising should also be reported to the provider. Black Box Warning: Black Box Warnings are the
If patients are receiving prolonged therapy, they strongest warnings issued by the Federal Drug
may require platelet count monitoring. Association (FDA) and signify that the medical
studies have indicated that the drug carries a
significant risk of serious or life-threatening
adverse effects.

Fluoroquinolones, including levofloxacin, have

been associated with disabling and potentially
irreversible serious adverse reactions, including:
•Tendinitis and tendon rupture
•Peripheral neuropathy
•Central nervous system effects
•Exacerbation of muscle weakness in patients
FLUOROQUINOLONES with myasthenia gravis

Indications: Fluoroquinolones may be used to In patients who experience any of these serious
treat pneumonia or complicated skin or urinary adverse reactions, discontinue the medication
tract infections. immediately, and avoid the use of
fluoroquinolones.
Mechanism of Action: Fluoroquinolones are a
synthetic antibacterial medication that work by Patient Teaching & Education: All patients on
inhibiting the bacterial DNA replication. They are fluoroquinolone therapy should be instructed to
bacteriocidal due to the action they take against avoid direct and indirect sunlight due to the
the DNA of the bacterial cell wall. Many photosensitivity that can be experienced while
fluoroquinolones are broad spectrum and on these medications. The patient should take
effective against a wide variety of both gram- measures to ensure that dosages are spaced
positive and gram-negative bacteria. evenly throughout the day and that fluid balance
is maintained. It is important to maintain an
Specific Administration Considerations: Patients intake of 1500mL-2000mL per day while taking
taking oral fluoroquinolones should avoid the the medication. The patient should be advised
use of antacid medication as antacids that medications containing calcium, aluminum,
significantly impede absorption. Patients should iron, or zinc may impair absorption and should
also be instructed to take oral fluoroquinolones be avoided. Other side effects of
with a full glass of water two hours before or after fluoroquinolones increase drowsiness.
meals to enhance absorption and prevent Additionally, the patient should be cautioned to
crystalluria. Fluoroquinolone therapy is monitor for episodes of fainting or decreased
contraindicated in children except for heart rate and report any history of prolonged QT
syndrome. If a patient notices peripheral outside, as well as to report any adverse
neuropathy occurring, this should be reported to reactions immediately. Advise patients to report
the healthcare provider. Additional side effects symptoms of chest pain, palpitations, or
to monitor include increased tendon pain, yellowing of eyes or skin. Additionally, patients
jaundice, rash, or mood changes should be advised that these medications can
cause drowsiness.

AMINOGLYCOSIDES
Aminoglycosides are a potent broad spectrum of
antibiotics that are useful for treating severe
infections. Many aminoglycosides are poorly
absorbed in the GI tract; therefore, the majority
are given IV or IM. Aminoglycosides are
potentially nephrotoxic and neurotoxic. They
should be administered cautiously. Blood peak
MACROLIDES and trough levels should be performed to titrate
Macrolides are complex antibacterial broad- a safe dose for each patient.
spectrum medications that are effective against
both gram-positive and gram-negative bacteria. Indications: Streptomycin is used for
streptococcal endocarditis and a second line
Mechanism of Action: Macrolides inhibit RNA treatment for tuberculosis. Neomycin is used in
protein synthesis and suppress reproduction of the treatment of hepatic encephalopathy as
the bacteria. Macrolides are bacteriostatic as adjunct therapy to lower ammonia levels and is
they do not actually kill bacteria, but inhibit also used as a bowel prep for colon procedures.
additional growth and allow the body's immune
system to kill the offending bacteria. Mechanism of Action: Aminoglycosides are
bactericidal and bind with the area of the
Indications: Macrolides are often used for ribosome known as the 30S subunit, inhibiting
respiratory infections, otitis media, pelvic protein synthesis in the cell wall and resulting in
inflammatory infections, and Chlamydia. bacterial death (see Figure 3.9).
Aminoglycosides may be given with beta-lactam
Specific Administration medications to facilitate transport of
Considerations: Macrolides can have significant aminoglycoside across the cellular membrane,
impact on liver function and should be used resulting in a synergistic effect and increasing
cautiously in patients with liver disease or drug effectiveness.
impairment.
Special Administration Considerations:
Patient Teaching & Education: Gl upset is Aminoglycosides can result in many adverse
common and patients can be advised to take effects for the patient and, therefore, the nurse
medication with food. Patients should also be should monitor the patient carefully for signs of
advised to avoid excessive sunlight and to wear emerging concerns. Peak and trough levels are
protective clothing and use sunscreen when used to titrate this medication to a safe dose.
Aminoglycosides can be nephrotoxic (damaging TETRACYCLINES
to kidney), neurotoxic (damaging to the nervous Tetracyclines are broad-spectrum antibiotics
system), and ototoxic (damaging to the ear). that are bacteriostatic, subsequently inhibiting
Nurses should monitor the patient receiving bacterial growth.
aminoglycosides for signs of decreased renal
function such as declining urine output and Indications: Tetracycline medications are useful
increasing blood urea nitrogen for the treatment of many gram-positive and
(BUN), creatinine, and declining glomerular gram-negative infectious processes, yet are
filtration rate (GFR). Indications of damage to the limited due to the significance of side effects
neurological system may be assessed as experienced by many patients.
increasing peripheral numbness or tingling in the
extremities. Additionally, the patient should be Special Administration Considerations:
carefully assessed for hearing loss or hearing Significant side effects of tetracycline drug
changes throughout the course of drug therapy include photosensitivity, discoloration of
administration. developing teeth and enamel hypoplasia, and
renal and liver impairment. Tetracyclines are
Patient Teaching & Education: Patients receiving contraindicated in pregnancy and for children
aminoglycosides should be advised to monitor ages 8 and under. Small amounts may be
for signs of hypersensitivity and auditory excreted in breast milk.
changes. This may include tinnitus and hearing
loss. Patients may also experience Patient Teaching & Education: Patients should be
accompanying vertigo while on the medication. instructed to avoid direct sunlight exposure and
Patients should be advised to drink plenty of wear sunscreen to prevent skin sensitivities.
fluids while taking the medication. Female Additionally, it is important for patients to be
patients should notify their provider if pregnancy educated regarding potential impaired
is planned or if they are actively breastfeeding. absorption of tetracycline with the use of dairy
products. Patients who are on oral
contraceptives should be educated that
tetracyclines may impede the effectiveness of
the oral contraceptive and an alternative
measure of birth control should be utilized while
on the antibiotic. Female patients must be aware
to immediately stop tetracycline if they become
pregnant. Expired tetracycline should be
immediately disposed of as it can become toxic.