Responsibilities

The nurse should observe the following points when giving an oral drug:
 

• Place the patient in an upright position. It is difficult, as well as dangerous, to swallow a solid or liquid when lying down.
• Make sure that a full glass of water is readily available.
• Assess the patient’s need for assistance in removing the tablet or capsule from the container, holding the container, holding a medicine cup, or holding a glass of water. Some patients with physical disabilities cannot handle or hold these objects and may require assistance.
• Advise the patient to take a few sips of water before placing a tablet or capsule in the mouth.
• Instruct the patient to place the pill or capsule on the back of the tongue and tilt the head back to swallow a tablet or slightly forward to swallow a capsule. Encourage the patient first to take a few sips of water to move the drug down the esophagus and into the stomach, and then to finish the whole glass.
• Give the patient any special instructions, such as drinking extra fluids or remaining in bed, that are pertinent to the drug being administered.
• Never leave a drug at the patient’s bedside to be taken later unless there is a specific order by the primary care provider to do so. A few drugs (eg, antacids and nitroglycerin tablets) may be ordered to be left at the bedside.
• Patients with a nasogastric feeding tube may be given their oral drugs through the tube. Dilute and flush liquid drugs through the tube. However, crush tablets and dissolve them in water before administering them through the tube. Before administration, check the tube for placement. Flush the tube with water after the drugs are placed in the tube to completely clear the tubing.
• Instruct the patient to place buccal drugs against the mucous membranes of the cheek in either the upper or lower jaw. These drugs are given for a local, rather than systemic, effect. They are absorbed slowly from the mucous membranes of the mouth. Examples of drugs given buccally are lozenges and troches.
• Certain drugs are also given by the sublingual (placed under the tongue) route. These drugs must not be swallowed or chewed and must be dissolved completely before the patient eats or drinks. Nitroglycerin is commonly given sublingually.

General Principles of Drug Administration

The nurse must have factual knowledge of each drug given, the reasons for use of the drug, the drug’s general action, the more common adverse reactions associated 18 UNIT I Foundations of Clinical Pharmacology with the drug, special precautions in administration (if any), and the normal dose ranges.
 

Some drugs may be given frequently; the nurse becomes familiar with pharmacologic information about a specific drug. Other drugs may be given less frequently, or a new drug may be introduced, requiring the nurse to obtain information from reliable sources, such as the drug package insert or the hospital department of pharmacy. It is of utmost importance to check current and approved references for all drug information. It also is important for the nurse to take patient considerations, such as allergy history, previous adverse reactions, patient comments, and change in patient condition, into account before administering the drug.
 

Before giving any drug for the first time, the nurse should ask the patient about any known allergies and any family history of allergies. This not only includes allergies to drugs but also to food, pollen, animals, and so on. Patients with a personal or family history of allergies are more likely to experience additional allergies and must be monitored closely.
 

If the patient makes any statement about the drug or if there is any change in the patient, these situations are
carefully considered before the drug is given. Examples of situations that require consideration before a drug is given include:
 

• Problems that may be associated with the drug,such as nausea, dizziness, ringing in the ears, and difficulty walking. Any comments made by thepatient may indicate the occurrence of an adverse reaction. The nurse should withhold the drug until references are consulted and the primary caregiver contacted. The decision to withhold the drug must have a sound rationale and must be based on knowledge of pharmacology.
• Comments stating that the drug looks different from the one previously received, that the drug was just given by another nurse, or that the patient thought the primary care provider discontinued the drug therapy.
• A change in the patient’s condition, a change inone or more vital signs, or the appearance of newsymptoms. Depending on the drug being administeredand the patient’s diagnosis, these changes may indicate that the drug should be withheld andthe primary care provider contacted.

Drug Dispensing Systems

There are a number of drug dispensing systems for the nurse to use to dispense medication after it has been ordered for the patient. A brief description of three methods is given below.
 

Computerized Dispensing System
 

Automated or computerized dispensing systems are used in many hospitals or agencies dispensing drugs. Drugs are dispensed in the pharmacy from drug orders that are sent from the individual floors or units. Each
floor or unit has a medication cart in which medications are placed for individual patients. Medication orders are filled in the hospital pharmacy and are placed in the drug dispensing cart. When orders are filled, the cart is delivered to the unit. To administer the drugs, nurses enter the patient’s name and the drug to be administered. The drug is dispensed and automatically recorded into the computerized system. After drugs are dispensed and the cart is almost empty, it goes back to the pharmacy to be refilled and for new drug orders to be placed.
 

Unit Dose System
 

The unit dose system is a method of dispensing medications in which drug orders are filled and medications dispensed to fill each patient’s medication order(s) for a 24-hour period. The pharmacist dispenses each dose (unit) in a package that is labeled with the drug name and dosage. The drug(s) are placed in drawers in a special portable medication cart with a drawer for each patient. Many drugs are packaged by their manufacturers in unit doses. That is, each package is labeled by the manufacturer and contains one tablet or capsule, a premeasured amount of a liquid drug, a prefilled syringe, or one suppository. Hospital pharmacists also may prepare unit doses. The pharmacist restocks the cart each day with the drugs needed for the next 24-hour period. The nurse takes the drug cart into each patient’s room (Figure 2-4).
 

Some hospitals are using a bar code scanner in the administration of unit dose drugs. To use this system, a bar code is placed on the patient’s hospital identification band when the patient is admitted to the hospital. The bar codes, along with bar codes on the drug unit dose packages, are used to identify the patient and to record and charge routine and PRN drugs. The scanner also keeps an ongoing inventory of controlled substances, which eliminates the need for narcotic counts at the end of each shift.
 

Floor Stock
 

Some agencies, such as nursing homes or small hospitals, use a floor stock method to dispense drugs. Some special units in hospitals, such as the emergency department, may use this method. In this situation, drugs most frequently prescribed are kept on the unit in containers in a designated medication room or at the nurses’ station. The nurse takes the medication from the appropriate container and administers the drug to the patient and records the drug in the patient’s administration record

Educating the Client on the Use of Herbs and Nutritional Supplements

The use of herbs and nutritional supplements to treat various disorders is common. Herbs are used for various effects, such as to boost the immune system, treat depression, and for relaxation. Individuals are becoming more aware of the benefits of herbal therapies and nutritional supplements. Advertisements, books, magazines, and Internet sites abound concerning these topics. People, eager to cure or control various disorders, take herbs, teas, megadoses of vitamins, and various other natural products. Although much information is available on nutritional supplements and herbal therapy, obtaining the correct information sometimes is difficult.
 

Medicinal herbs and nutritional substances are available at supermarkets, pharmacies, health food stores, specialty herb stores, and through the Internet. The potential for misinformation abounds. Because these substances are “natural products,” many individuals may incorrectly assume that they are without adverse effects. When any herbal remedy or dietary supplement is used, it should be reported to the nurse and the primary health care provider. Many of these botanicals have strong pharmacological activity, and some may interact with prescription drugs or be toxic in the body. For example, comfrey, an herb that was once widely
used to promote digestion, can cause liver damage. Although it may still be available in some areas, it is a
dangerous herb and is not recommended for use as a supplement.
 

When obtaining the drug history, the nurse must always question the patient about the use of herbs, teas, vitamins, or other nutritional or dietary supplements. Many patients consider herbs as natural and therefore safe. It is also difficult for some to report the use of an herbal tea as a part of the health care regimen. Display 1-4 identifies teaching points to consider when discussing the use of herbs and nutritional supplements with patients. Although a complete discussion about the use of herbs is beyond the scope of this book, it is important to remember that the use of herbs and nutritional supplements is commonplace in many areas of the country. To help the student become more aware of herbal therapy and nutritional supplements, Appendix B gives CHAPTER 1 General Principles of Pharmacology 13 an overview of selected common herbs and nutritional supplements. In addition, Herbal Alerts are placed in various chapters throughout the book, giving the student valuable information or warnings about the use of herbs.

Center for Complementary and Alternative Health

In 1992, the National Institutes of Health established an Office of Alternative Medicine to facilitate the study of alternative medical treatments and to disseminate the information to the public. In 1998, the name was changed to National Center for Complementary and Alternative Medicine (NCCAM). This office was established partly because of the increased interest and use of these therapies in the United States. It has been estimated that approximately 40% of all individuals in the United States use some form of complementary/alternative therapy. In 1997, Americans spent more that $27 billion on these therapies. Among the various purposes of the NCCAM, one is to evaluate the safety and efficacy of widely used natural products, such as herbal remedies and nutritional and food supplements. Although the scientific study of CAM is relatively new, the Center is dedicated to developing programs and encouraging scientists to investigate CAM treatments that show promise. The NCCAM budget has steadily grown from $2 million in 1993 to more than $68.7 million in 2000. This funding increase reflects the public’s interest and need for CAM information that is based on rigorous scientific research.

Dietary Supplement Health and Education Act

Because herbs cannot be sold and promoted in the United States as drugs, they are regulated as nutritional or dietary substances. Nutritional or dietary substances are terms used by the federal government to identify substances not regulated as drugs by the FDA but that are purported to be effective for use to promote health. Herbs, as well as vitamins and minerals, are classified as dietary or nutritional supplements. Because natural products cannot be patented in the United States, it is not profitable for drug manufacturers to spend the millions of dollars and the 8 to 12 years to study and develop these products as drugs. In 1994, the US government passed the Dietary Supplement Health and Education Act (DSHEA). This act defines substances such as herbs, vitamins, minerals, amino acids, and other natural substances as “dietary supplements.” The act permits general health claims such as “improves memory” or “promotes regularity” as long as the label also has a disclaimer stating that the supplements are not approved by the FDA and are not intended to diagnose, treat, cure, or prevent any disease. The claims must be truthful and not misleading and be supported by scientific evidence. Some have abused the law by making exaggerated claims, but the FDA has the power to enforce the law, which it has done, and these claims have decreased.

HERBAL THERAPY AND NUTRITIONAL SUPPLEMENTS

Botanical medicine or herbal therapy is a type of complementary/ alternative therapy that uses plants or herbs to treat various disorders. Individuals worldwide use both herbal therapy and nutritional supplements extensively. According to the World Health Organization (WHO), 80% of the world’s population relies on herbs for a substantial part of their health care. Herbs have been used by virtually every culture in the world throughout history, from the beginning of time until now. For example, Hippocrates prescribed St. Johns Wort, currently a popular herbal remedy for depression. Native Americans used plants such as coneflower, ginseng, and ginger for therapeutic purposes. Herbal therapy is part of a group of nontraditional therapies commonly known as complementary/alternative medicine (CAM). Unfortunately, CAM therapies are not widely taught in medical schools. A 1998 survey revealed that 75 of 117 US medical schools offered elective courses in CAM or included CAM topics in required courses. Complementary therapies are therapies such as relaxation techniques, massage, dietary supplements, healing touch, and herbal therapy that can be used to “complement” traditional health care. Alternative therapies, on the other hand, are therapies used in place of or instead of conventional or Western medicine. The term complementary/alternative therapy often is used as an umbrella term for many therapies from all over the world.
 

12 UNIT I Foundations of Clinical Pharmacology Although herbs have been used for thousands of years, most of what we know has been from observation. Most herbs have not been scientifically studied for safety
and efficacy (effectiveness). Much of what we know about herbal therapy has come from Europe, particularly Germany. During the last several decades, European scientists have studied botanical plants in ways that seek to identify how they work at the cellular level, what chemicals are most effective, and adverse effects related to their use. Germany has compiled information on 300 herbs and made recommendations for their use.

Drug—Food Interactions

When a drug is given orally, food may impair or enhance its absorption. A drug taken on an empty stomach is absorbed into the bloodstream at a faster rate than when the drug is taken with food in the stomach. Some drugs (eg, captopril) must be taken on an empty stomach to achieve an optimal effect. Drugs that should be taken on an empty stomach are administered 1 hour before or 2 hours after meals. Other drugs, especially drugs that irritate the stomach, result in nausea or vomiting, or cause epigastric distress, are best given with food or meals. This minimizes gastric irritation. The nonsteroidal anti-inflammatory drugs and salicylates are examples of drugs that are given with food to decrease epigastric distress. Still other drugs combine with a drug forming an insoluble food–drug mixture. For example, when tetracycline is administered with dairy products, a drug–food mixture is formed that is unabsorbable by the body. When a drug is unabsorbable by the body, no pharmacologic effect occurs.

Drug—Drug Interactions

A drug–drug interaction occurs when one drug interacts with or interferes with the action of another drug.
For example, taking an antacid with oral tetracycline causes a decrease in the effectiveness of the tetracycline. The antacid chemically interacts with the tetracycline and impairs its absorption into the bloodstream, thus reducing the effectiveness of the tetracycline. Drugs known to cause interactions include oral anticoagulants, oral hypoglycemics, anti-infectives, antiarrhythmics, cardiac glycosides, and alcohol. Drug–drug interactions can produce effects that are additive, synergistic, or antagonistic.
 

ADDITIVE DRUG REACTION. An additive drug reaction occurs when the combined effect of two drugs is equal to the sum of each drug given alone. For example, taking the drug heparin with alcohol will increase bleeding. The equation one one two is sometimes used to illustrate the additive effect of drugs.
 

SYNERGISTIC DRUG REACTION. Drug synergism occurs when drugs interact with each other and produce an effect that is greater than the sum of their separate actions. The equation one + one = four may be used to illustrate synergism. An example of drug synergism is when a person takes both a hypnotic and alcohol. When alcohol is taken simultaneously or shortly before or after the hypnotic is taken, the action of the hypnotic increases. The individual experiences a drug effect that is greater than if either drug was taken alone. On occasion, the occurrence of a synergistic drug effect is serious and even fatal.
 

ANTAGONISTIC DRUG REACTION. An antagonistic drug reaction occurs when one drug interferes with the action of another, causing neutralization or a decrease in 10 UNIT I Foundations of Clinical Pharmacology the effect of one drug. For example, protamine sulfate is a heparin antagonist. This means that the administration of protamine sulfate completely neutralizes the effects of heparin in the body.

Drug Tolerance

Drug tolerance is a term used to describe a decreased response to a drug, requiring an increase in dosage to
achieve the desired effect. Drug tolerance may develop when a patient takes certain drugs, such as the narcotics and tranquilizers, for a long time. The individual who takes these drugs at home increases the dose when the expected drug effect does not occur. The development of drug tolerance is a sign of drug dependence. Drug tolerance may also occur in the hospitalized patient. When the patient receives a narcotic for more than 10 to 14 days, the nurse suspects drug tolerance (and possibly drug dependence). The patient may also begin to ask for the drug at more frequent intervals.

Drug Idiosyncrasy

 Drug idiosyncrasy is a term used to describe any unusual or abnormal reaction to a drug. It is any reaction
that is different from the one normally expected of a specific drug and dose. For example, a patient may be given a drug to help him or her sleep (eg, a hypnotic). Instead of falling asleep, the patient remains wide awake and shows signs of nervousness or excitement. This response is an idiosyncratic response because it is different from what the nurse expects from this type of drug. Another patient may receive the same drug and dose, fall asleep, and after 8 hours be difficult to awaken. This, too, is abnormal and describes an overresponse to the drug. The cause of drug idiosyncrasy is not clear. It is believed to be due to a genetic deficiency that makes the patient unable to tolerate certain chemicals, including drugs.

FEDERAL DRUG LEGISLATION AND ENFORCEMENT

Many laws have been enacted over the last century that affect drug distribution and administration. Those
included here are the Pure Food and Drug Act; Harrison Narcotic Act; Pure Food, Drug, and Cosmetic Act; and the Comprehensive Drug Abuse Prevention and Control Act. These laws control the use of the three categories of drugs in the United States (prescription, nonprescription, and controlled substances).
 

Pure Food and Drug Act
 

This act, passed in 1906, was the first attempt by the government to regulate and control the manufacture, distribution, and sale of drugs. Before 1906, any substance could be called a drug, and no testing or research was required before placing the drug on the market. Before this time, drug potency and the purity of many drugs were questionable, and some were even dangerous for human use.
 

Harrison Narcotic Act
 

This law, passed in 1914, regulated the sale of narcotic drugs. Before the passage of this act, any narcotic could be purchased without a prescription. This law was amended many times. In 1970, the Harrison Narcotic Act was replaced with the passage of the Comprehensive Drug Abuse Prevention and Control Act.
 

Pure Food, Drug, and Cosmetic Act
 

In 1938, Congress passed this law that gave the FDA control over the manufacture and sale of drugs, food, and cosmetics. Before the passage of this act, some drugs, as well as foods and cosmetics, contained chemicals that were often harmful to humans. This law requires that these substances are safe for human use. It also requires pharmaceutical companies to perform toxicology tests before a new drug is submitted to the FDA for approval. Following FDA review of the tests performed on animals and other research data, approval may be given to market the drug (see sections on “Drug Development”).
 

Comprehensive Drug Abuse Prevention and Control Act
 

Congress passed this act in 1970 because of the growing problem of drug abuse. It regulates the manufacture, distribution, and dispensation of drugs that have the potential for abuse. Title II of this law, the Controlled Substances Act, deals with control and enforcement. The Drug Enforcement Agency within the US Department of Justice is the leading federal agency responsible for the enforcement of this act.
 

Drug Enforcement Administration
 

The Drug Enforcement Administration (DEA) within the US Department of Justice is the chief federal agency
responsible for enforcing the Controlled Substances Act. Failure to comply with the Controlled Substances Act is punishable by fine and/or imprisonment. With drug abuse so prevalent, nurses must diligently adhere to the regulation imposed by the FDA and the Nurse Practice Act of their state. Any violation may result in the loss of the nurse’s license to practice. Nurses must also report any misuse or abuse of these substances by other nurses to their State Board of Nursing. Most states have provisions within their Nurse Practice Act to assist nurses who have problems with drug abuse.

Nonprescription Drugs

Nonprescription drugs are drugs that are designated by the FDA to be safe (if taken as directed) and obtained without a prescription. These drugs are also referred to as over-the-counter (OTC) drugs and may be purchased in a variety of settings, such as a pharmacy, drugstore, or in the local supermarket. OTC drugs include those given for symptoms of the common cold, headaches, constipation, diarrhea, and upset stomach. These drugs are not without risk and may produce adverse reactions. For example, acetylsalicylic acid, commonly known as aspirin, is potentially harmful and can cause gastrointestinal bleeding and salicylism (see Chap. 17). Labeling requirements give the consumer important information regarding the drug, dosage, contraindications, precautions, and adverse reactions. Consumers are urged to read the directions carefully before taking OTC drugs.