Nurses and Criminal Liabilities

Felonies - act or omission punishable by law (RPC)

1. omission - inaction; failure to perform a (+) duty; there should be a law requiring to
perform the act
2. intent - purpose to use a particular means to effect a result ( deliberate intent -
freedom and in intelligence)
3. motive - moving power which impels one to act for a definite result

Stages of execution
1. Consummated when all the elements necessary for its execution and
accomplishment are present
2. Frustrated when the offender performs all the acts or execution which will
produce the felony as a consequence but which nevertheless produce it by the reason
of causes independent to the will of the perpetuator
3. Attempted when the offender commences the commission of the same directly by
overt acts and does not perform the acts which shall produce the felony.

conspiracy - two or more person agreed and committed the felony, a means by which
another person is held liable for the commission of a crime; each criminal is responsible
for the acts of his associates provided such act is a result of a common plan
proposal - a person who decided to commit a felony proposes its execution to another

Persons criminally liable
1. Principal
by direct participation
by inducement
by indispensable cooperation
2. Accomplice - accessory before the fact
3. Accessory - accessory after the fact
profiting themselves or assisting others to profit
concealing, destroying body of the crime, effects, instruments to prevent its discovery
harboring concealing, assisting the escape of the principal

Felonies according to degree of punishment

Grave offense, 1
st
offense - punishable of dismissal
1. Dishonesty
2. Gross neglect of duty
3. Grave misconduct
4. Notoriously undesirable
5. Conviction of a crime involving moral turpitude
6. Falsification of documents
7. Physical and mental incapacity due to vicious habits
8. Receiving for personal use of a fee and gift
9. Contracting loans or money from persons whom the office of the employee has
business relations
10. Soliciting or accepting directly or indirectly any gift, favor etc.
11. Disloyal to RP
12. Nepotism

Grave offense, 1
st
offense punishable with suspension without pay for six
months and 1 day to 1 yr; 2
nd
offense punishable with dismissal
1. Oppression
2. Disgraceful/immoral conduct
3. Incompetent/inefficient
4. Habitual absenteeism exceeds 2.5 days monthly allowable leave for at least in 3
months in a semester or at least 3 consecutive months in a year
5. Habitual tardiness regardless of the number of minutes, 10 times a month for at
least 2 months in a semester or at least 2 consecutive months in a yr.
6. Refusal to perform duty
7. Gross insubordination
8. Financial interest in any transaction requiring the approval of his office
9. Engaging in the private practice of his profession unless authorized by law
10. Disclosing confidential information

Less grave offense, 1
st
offense punishable with suspension without pay for 1
month and 1 day to 6 months; 2
nd
offense, punishable with dismissal
1. Simple neglect of duty
2. Simple misconduct
3. Gross discourtesy in the course of official duties
4. Gross violation of civil service law
5. Insubordination
6. Habitual drunkenness
7. Discrimination
8. Failure to file assets and liabilities

Light offense, 1
st
offense punishable with reprimand; 2
nd
offense punishable
with suspension without pay for 1 day to 30 days; 3
rd
offense punishable
withdismissal
1. Discourtesy
2. Unauthorized solicitation from subordinates
3. Violation of office rules
4. Gambling
5. Refusal to render overtime
6. Disgraceful, immoral and dishonesty prior to entering the service
7. Borrowing money from subordinates
8. Lending money at usurious rates of interest
9. Willful failure to pay debts and taxes
10. Failure to process documents and complete action in documents

Circumstances affecting criminal liability
1. Justifying Circumstances - free from criminal and civil liability
J Self - defense
1. Unlawful aggression
2. Reasonable necessity of the
3. Means employed prevent/repel it
4. Lack of sufficient provocation
5. On the person defending himself
J Defense of relatives - up to 4th degree by consanguinity; that in the case of
provocation was given by the attacked, that the one making defense had no part therein
J Defense of a stranger - defending not induced by resentment, revenge or other evil
motive
J Who acts in fulfillment of a duty or in a lawful exercise of a right or office
J Who acts in obedience to an order by a superior for some lawful purpose

2. Exempting Circumstances - no criminal liability only civil liability
1. Mistake of fact - (ignorantia facti excusat) must be committed in good faith or
under an honest belief
2. An insane or imbecile unless acted during lucid interval
3. Under 9 years of age
4. Over 9 under 15, unless acted with discernment
5. While performing a lawful act with due care causes an injury by mere accident without
fault or intention of doing it
6. Who acted under the compulsion of an irresistible force from a third person
7. Impulse of uncontrollable fear of an equal or greater injury
8. Insuperable or lawful cause

3. Mitigating Circumstances
1. Under 18 or over 70
2. No intention to commit so grave a wrong
3. Sufficient provocation or threat on the part of the offended party immediately
preceded the act
4. Voluntary surrender
5. Deaf, dumb or blind or suffering from physical defect
6. Such illness that would diminish the exercise of his will power
7. Committed in the immediate vindication of a grave offense to the one committing the
felony, his/her spouse, ascendants, descendants, legitimate, natural or adopted brothers
or sisters, relative by affinity within the same degree
8. Acted upon an impulse so powerful as naturally to have produced an obfuscation

4. Aggravating Circumstances
1. Advantage of public position
2. In contempt or insult to public authorities
3. Abuse of confidence or obvious ungratefulness
4. Committed on occasion of epidemic, conflagration, shipwreck or other calamity or
misfortune
5. In consideration of a price or reward or promise
6. Committed by means of fire, explosion, stranded of a vessel
7. With evident premeditation
8. Craft, fraud or disguise

5. Alternating (either mitigating or aggravating)
1. Relationship, intoxication, degree of education
2. Education is not mitigating in rape, forcible abduction, arson, treason, seduction, acts
of lasciviousness, heinous crimes

Criminal Negligence crime committed by means of fault (culpa)
Kinds:
1. Reckless imprudence doing or failing to do an act resulting to injuries or death
due to an inexcusable lack of precaution
2. Simple Imprudence lack of precaution; impending danger is not openly visible
Nurses and Crimes
1. Parricide killing of his father, mother or child or any of his ascendants,
descendants (legitimate or illegitimate) and spouse
2. Murder - with intent to kill
3. Homicide - without intent to kill; absence of proof on how the victim was killed
4. Infanticide - less than 3 days of age
5. Abortion - termination of pregnancy before fetus is viable (3-6 mos)

Under Philippine Law, Child Abuse refers to the maltreatment, whether habitual or
not, of the child, and such maltreatment includes any of the following:
a. Psychological and physical abuse, neglect, cruelty, sexual abuse and emotional
maltreatment
b. Any act, by deeds or words, which debases, degrades, or demeans the intrinsic worth
and dignity of a child as a human being
c. Unreasonable deprivation of the child's basic needs for survival, such as food, shelter
or
d. Failure to immediately give medical treatment to an injured child, resulting in serious
impairment of his growth and development or in his permanent incapacity or death

6. Sexual harassment - words, gestures actions which tend to annoy and verbally
abuse another person
7. Simulation of birth - crime against status by substitution of one child with another;
concealing or abandoning any legitimate child with intent to lose civil status
8. Misdemeanor - use to express every offense inferior to felony and punishable by
indictment or by particular prescribed proceedings
Example:
a. a person who practices nursing without certificate of registration
b. any person assuming or using title advertising as registered nurse without being
conferred such title
c. any person advertising any title to convey the impression that she is a nurse (e.g. using
nurse's uniform and cap)
9. Physical Injuries
Kinds:
1. Slight physical Injuries 1-9 days of incapacity/requires medical attention
2. Less serious physical injury 10 days or more
3. Serious physical injury more than 30 days

Torts - a legal wrong committed against a person or property independent of a contract
which renders the person who commits it liable for damages in a civil action

Examples
a. assault and battery
b. false imprisonment or illegal detention
c. Invasion of right of privacy and breach of confidentiality

J Assault attempt to touch or threat another person unjustifiably
J Battery willful touching of a person that may or may not cause
harm;unconsented touching of another person
J Defamation communication that is false and results in injury to the reputation of the
patient
Libel by means of print, writing or pictures
Slander spoken words
J False Imprisonment of Illegal Detention
Unjustifiable detention of a person without a legal warrant within boundaries
J Invasion of Right to Privacy and breach of confidentiality
Right to privacy is the right to be left alone
Right to be free from unwarranted publicity
Exposure to public view
Divulge information from patients chart to improper sources or unauthorized person
Jurisprudence in Nursing Practice
Imprudence deficiency of action; lack of skill
Negligence lack of foresight; deficiency of perception
Specific examples of negligence:
1. Failure to report observations to attending Physicians
2. Failure to exercise the degree of diligence which the circumstances of the particular
case demands
3. Mistaken Identity
4. Wrong medicine, wrong concentration, wrong route, wrong dose
5. Defects in the equipment such as stretchers and wheelchairs may lead to falls thus
injuring the patients

Malpractice failure to follow a reasonable professional standard of care, thereby
resulting to injury to a patient; professional negligence (Kozier, 2004)
Specific examples of malpractice:
1. Misdiagnosis of an illness, failure to diagnose or relay diagnosis
2. Birth Injuries
3. Surgical Complications
4. Prescription errors
5. Failure to provide treatment
6. Anesthesia related complications
7. Failure to follow advance directive
8. Failure of hospital or pharmacy to dispense the right medicine and dosage

Concept of Accountability
Accountability of the nurse to the patient, physician or to the public has a reference to the
quality of nursing care she renders
A contractual obligation which the nurse assumed exposes her to a certain degree of
accountability; the term accountability carries the idea of sanction or penalty.

Documentation recording/ charting
Purposes:
C Communication
A Assurance of quality
R Research purposes
L Legal document
S Statistics source

SUBPOENA an order from court
Duces Tecum
(papers) documents obj, materials, papers, chart
Ad Testificadum
(person) witness

Dos & Donts of charting

Dos Donts
F Full, factual & accurate L language unacceptable
L Legible I Improper corrections
I Immediately after procedure S Spaces, skips
P Personal notes, not delegated
A Avoid using too much abbreviations

addendum late entry

Doctrines in Nursing Practice

1. Bonus Pater Familias (good father of a family
) employer is liable on his own negligence
Culpa In Eligiendo liable for being negligent in the selection of employees
Culpa In Vigilando liable for being negligent in the supervision of employees
2. Respondeat Superior
(Let the master/superior answer) employer is responsible for the action of the employee
within the course of employment
3. Professional Negligence - Commission or omission of an act, pursuant to a duty
4. Res Ipsa Loquitor (the thing speaks for itself) Ex. Scalpel left behind after
appendectomy
5. Force Majeure event which cannot be foreseen; an act of God; unexpected event.
Ex. The nurse and the patient trapped in the elevator because of an earthquake and the
patient died despite proper intervention.
6. Damnun Absque Injuria (although there was a physical damage, there is no legal
injury) Ex. Expert IVT nurse who carefully performed her duty hurt a patient because
of the lighting that strikes the room causing injury to the patient
7. Stare Decisis (stand by decisions) court should stand with its previous decision
8. Nolo Contendere (I will not defend it) plea of guilty
9. Malfeasance performance of some act which ought not to be done
10. Misfeasance improper performance
11. Nonfeasance omission of some act which ought to be performed
12. Captain of the Ship Doctrine
13. Doctrine of Corporate Liability
14. Doctors order rule
General rule - no telephone order
Whatever is not written is not an order
Exception Emergency!
After MD says order repeat instruction on phone
Have resident MD sign within 24 hrs! Administer meds.
When MD arrives have him counter sign his order
15. Nurse as witness rule
1. Ordinary witness one who can testify as to the conditions present in the issue or
surrounding the case
2. Expert witness testify on the issue by giving his opinion or advice from the facts
presented




























INTRODUCTION TO PHARMACOLOGY

1. HISTORY
- Early drug plants, animals & minerals
- 2700 BB earliest recorded drug use found in Middle East & China
- 1550 BC Egyptians created Ebers Medical Papyrus
- Castor oil laxative
- Opium pain
- Moldy bread wounds & bruises
- Galen (131-201 AD) Roman physician; initiated common use of prescriptions
- 1240 AD introduction of apothecary system (Arab doctors)
o 1
st
set of drug standards & measurements (grains, drams, minims), currently being phased out
- 15
th
century apothecary shops owned by barber, surgeons, physicians, independent merchants
- 18
th
century small pox vaccine (by Jenner)
o Digitalis from foxglove plant for strengthening & slowing of heartbeat Vitamin C from fruits
- 19
th
century morphine & codeine extract from opium
o Introduction of atropine & iodine
o Amyl nitrite used to relieve anginal pain
o Discovery of anesthetics (ether, nitrous oxide)
- Early 20
th
century aspirin from salicylic acid
o Introduction of Phenobarbital, insulin, sulforamides
- Mid 20
th
century
1940 Discovery antibiotics (penicilline, tetracycline, streptomycin), antihistamines, cortisone
1950 discovery antipsychotic drug, antihypertensives, oral contraceptives, polio vaccine

2. DEFINITION & SUBDIVISIONS
DRUG chemical introduced into the body to cause some changes
o WHO def: any product/subs used to modify/explore physiologic system/pathologic states for the benefit of the patient
Pharmacology study of the manner in which the function of living system is
affected by chemical agents/drugs
o Science concerned with history, sources, physical & chemical properties of drugs & the way in which drug affects living system

Subdivisions of Pharmacology:
1. Pharmacodynamics study of the biochemical & physiological effects of drugs & mechanisms of action
What the drug does to the body
2. Pharmacokinetics deals with the absorption, distribution, biotransformation & excretion of drugs
o What the body does to the drug
3. Pharmacotherapeutics study of drugs used in the diagnosis, prevention, suppression, & treatment of diseases
o Deals with beneficial effects of the drugs (medicines)
4. Pharmacognosy study of drugs in their original unaltered state; origin of drugs
o Source of drugs
o Ex: penicillin from penicillium (fungi)
5. Toxicology study of biologic toxins: study of poison & its effects deals with deleterious effects of physical & chemical agents (including
drugs) in human

Pharmacoeconomics study of relationship of drugs & economics
Pharmacovigilance science of collecting,researching, analyzing, & evaluating set of information about adverse drug effects.
Receptor a component of the cell that interacts with drug, initiating a chain of biochemical events leading to drugs observed effects
- Human body works through complicated series of chemical reactions & processes
- Important aspects of nursing: understanding how drug ant on body to cause changes & apply that knowledge in clinical setting
Patients take complicated drug regimen & receive potentially toxic drug
Some manage their own care at home
- Nursing responsibilities regarding drug therapy:
1. Administering drugs
2. Assessing drug effects
3. Intervening to make drug regimen more tolerable
4. Provide patient teachings about drugs & drug regimen
- Knowing how drug works --- easier to handle --- enhances drug therapy

DRUG NOMENCLATURE
1. CHEMICAL NAME atomic/molecular structure of drug
2. GENERIC NAME/NON-PROPERTY NAME original designation given to the drug when the drug company applies for approval
patents
- universally accepted & not capitalized; before drug becomes official, used in all countries
- protected by law; not capitalized
3. TRADE/BRAND/PROPRIETY NAME name given by the drug company that developed it
- followed by the symbol R or TM, 1
st
letter is capitalized
Example:
Chemical name acetylsalicylic acid
Generic name aspirin
Trade name aspilet

COMMON SOURCES /4 MAJOR SOURCES (ORIGINS) OF DRUGS:

1. Animal sources from organs, organ secretion or organ cells
- Used to replace human chemical not produces because of disease or genetic problems
- Thyroid drugs & growth hormones preparations from animal thyroid & hypothalamus tissue (many of these preparations are now created
synthetically safer & purer)
- Insulin from pancreas of animals (hog, cattle, sheep): thru genetic engineering cld produce human insulin by altering E. Coli bacteria
making it a better product without impurities that come with animal products
2. Vegetable/plant sources roots, bark, sap, leaves, flowers, seeds of medicinal plants
- Digitalis from wildflower, purple foxglove, dried leaves of plant
- Active principles of plants
- Alkaloids alkaline in reaction, bitter in taste, powerful in physiologic activity
o Atropine & scopolamine
o Morphine sulfate, cocaine, quinine, nicotine, caffeine
o Procaine

o Glycosides digitalis
o Resin soluble in alcohol; example colonic irritant found in laxative cascara
o Gums used in bulk-type laxatives: some used in certain skin preparations for their soothing relief
o Oils castor oil, oil of wintergreen
3. Mineral sources from free elements, both metallic & non-metallic usually in form of acids bases, salts found in food
- Dilute HCI control/prevent indigestion
- Calcium, aluminum, fluoride, iron, gold, potassium
4. Synthetic sources many drugs developed synthetically after chemical in plants, animals, or environment have been screened for signs of
therapeutic activity
- More potent, more stable, less toxic
- Steroids arthritis & other diseases
- Sulfonamides/chemotherapeutic agents kill microorganism slow their growth
- Meperidine HCI (Demerol)


DRUG CLASSIFICATION
1. By Action
- Anti infectives antiseptics, disinfectants, sterilants
- Antimicrobials, metabolic, diagnostic materials, vitamins & minerals
- Vaccine & serums, antifungals, antihistamines, antineoplastics, antacids
2. By Body System
- CNS (+)/(-) actions of neural pathways & centers: phenobarbital
- ANS governs several bodily functions so that drugs that affect ans will at the same time affect other systems functions
- GIT acts on mascular & glandular tissues: leperamide
- Respiratory system act on resp. Tract, tissues, cough center, suppress, relax, liquefy & stimulate depth & rate of respiration
- Urinary system act on kidney & urinary tract
- Circulatory system act on heart, blood vessels, blood; metoprolol

KINDS OF DRUGS
1. Prescription/legend drug can be dispensed if with prescription order; with specific name of drug & dosage regimen to be used by
patient
2. Non-prescription drug can be dispensed over the-counter/without prescription order
- for self treatment of variety of complaints
- vitamin supplements, cold/cough remedies, analgesics, antacids, herbal products
- cautions in use of OTC drugs:
a. Delay in professional diagnosis & treatment of serious/potentially serious condition may occur
b. Symptoms may be masked making the diagnosis more complicated
c. Clients health care provider/pharmacist should be consulted before otc preparations are taken
d. Labels/instructions should be followed carefully
e. Ingredients in otc drug may interact with prescribed drug
f. Inactive ingredients may result in adverse reactions
g. Potential for overdose
h. Multiple medication users are at risk as more medications are added to therapy regimen
i. Interactions of medications are potentially dangerous
3. Investigational drug new drugs undergoing clinical trails
4. Illicit/street drug used/distributed illegally for non-medical purposes to alter mood of feeling

**when drug is taken by mouth, it undergoes 3 phases:
1. pharmaceutic/dissolution
2. pharmacokinetics
3. pharmacodynamics

I. PHARMACEUTIC/DISSOLUTION
- Drug goes into solution so that it can cross the biologic membrane
- Not found in drug administered parenterally
- 1
st
phase of drug action of agents taken by mouth
- Additive enhances absorbability of drugs
- EXCIPIENTS: filters & inert substances
Allows drugs to take on particular size & shape
Enhance drug dissolution potassium (K) --- losartan K (cozaar); sodium (Na) ---cloxacillin Na (Prostaphlin-A)
2 phases:
- Disintegration breakdown into smaller parts
- Dissolution futher breakdown into smaller parts in GIT absorption; dissolved into liquid
- rate limiting: time it takes drug to disintegrate & dissolve to become available for body to absorb it
- factors affecting dissolution
- Form of drug (LIQUID VS. SOLID) liquid more absorbed than solid, already in solution, rapidly available for GI absorption
- Gastric ph (acid vs alkaline) acidic media (ph=1.2) faster disintegration & absorption
- Age young vs elderly inc ph. Dec absoption
- Enteric coated drugs resist disintegration in gastric acid
o Disintegration occurs only in alkaline environment (intestine)
o Should not be crushed
o Presence of food interfere with dissolution & absorption, enhance absorption of other drugs, may be protectants of gastric mucosa


II. PHARMACOKINETICS action of body to the drug:
o Study of absoption (taken into the body), distribution (moved into various tissues), metabolism/biotransformation (changed into a form that
can be excreted) & excretion (removed from the body) of drugs
o What happens to the drug when it enters the body
o kinetics movement: deals with drugs actions as it moved through the body
o Also concerned with a drugs onset of action, peak concentration level, & duration of action

4 processes involved:
A. ABSORPTION route of drug takes from the time it enters the body until it is absorbed in circulating fluids
- Movement of drug molecules from site of administration to circulatory system
- Movement of drug particles from GIT to body fluids involve 3 processes
- Passive absorption (diffusion) movement from higher concentration
o No energy required: occurs when smaller molecules diffuse across membrane
o Stops when drug concentration on both sides of the membrane is equal
o Major process through which drugs are absorbed into the body
- Active absorption needs carrier (enzymes or protein) to move against a concentration gradient
o Energy is required: from lower concentration to higher concentration
o Used to absorb electrolytes (i.e. sodium, potassium) & some drugs (levodopa)
- Pinocytosis engulfs the drug to carry it across the membrane
o Transport fat-soluble vitamins (vit.A,D,E,K)
- Factors affecting absorption:
Drug solubility lipid soluble drugs pass readily through GI membrane,
Water soluble drugs need an enzyme or protein
Local condition at site of absorption weak acids less ionized in stomach
- - - readily pass through the SI
Pain / stress / solid foods / fatty or hot foods slows down gastric emptying time
Drug concentration drugs can take several hours/days to reach peak concentration levels (slow rate: rectal administration or sustained
release drugs)
Circulation at site of absorption poor circulation hampers absorption (i.e. shock)
The more blood vessels, the faster the absorption
Exercise decrease blood flow to GI slows absorption
Application of heat/massage increases blood flows at site
Muscles area selected for IM administration:
Blood flows faster through deltoid muscle (upper arm) vs gluteal muscle (buttocks)
Gluteal muscle can accommodate larger volume of drug than deltoid muscle
B. METABOLISM biotransformation: essential for termination of a drugs biologic activity so can be easily excreted
Sites of metabolism
- Liver main organ for drug metabolism
- Through the drug metabolizing enzymes (microsomal enzymes, non-microsomal enzymes)
- 1
st
pass effect hepatic 1
st
pass some drugs do not directly go into circulation but pass thru intestinal lumen to liver via portal vein - - drug
metabolized in liver into inactive form - - decrease amount of active drugs - - - increase recommended dose for oral drugs
- Lidocaine extensive 1
st
pass not given orally
- Plasma
- Kidneys
- Membranes of intestine
Process by which body changes a drug from its dosage form to a more water-soluble form that can then be excreted
Can be metabolized in several ways:
- Most drugs metabolized into inactive metabolites (products of metabolism), which are then excreted
- Other drugs converted to active metabolites capable of exerting their own pharmacologic action
- May undergo further metabolism or may be excreted from body unchanged
- Prodrugs some drugs administered as inactive drugs which dont become active until theyre metabolized
- Permits the body to inactive a potent drug before it accumulates & produces toxic effects
Phases of drug metabolism:
- Phase 1: endoplasmic reticulum; introduce/expose a functional group on the parent compound (i.e. alkylation, alipathic hydroxylation,
oxidation, deamination, hydrolysis, microsomal oxidases)
- Cytochrome p450 inducer inc drug metabolism, dec bioavailability
- Cytochrome p450 inhibitor dec drug metabolism, inc levels of drug prolonged effect & inc toxicity
- Phase 2 conjugation reactions that lead to formation of covalent linkage between parent compound with glucoronic acid, sulfate,
glutathione or acetate (glucoronidation, sulfation, acetylation); synthetic reactions
Factors affecting biotransformation:
- Genetic some people metabolize drugs rapidly, other more slowly
- Physiologic
- Liver diseases (cirrhosis), heart failure dec circulation in liver
- Infants immature livers dec rate of metabolism
- Area of absorbing surface to which a drug is exposed (+) chemical agents may destroy the drug
- Types of transport diffusion, active, pinocytosis
- Routes of administration skin absorption slower than IM
- Absorption with in seconds/minutes: sublingual, IV, by inhalation route
- Slower rate absorption: oral, IM SC routes
- Bioavailability consideration of highest importance in drug effectiveness & safety
- Subcategory of absorption
- % of administered drug does that reaches systemic circulation
- Oral route <100%(usually 20-40%); IV route = 100%
- Factors that alter bioavailability:
- Drug form (tablet, capsule)
- Route of administration
- GI mucosa & motility
- Food & other drugs (+) food - - - pord of gastric acid inc drug absorption (i.e. azole)
- Changes inliver metabolism, liver disorder dec liver function inc bioavailability
C. DISTRIBUTION process by which drug becomes available to body fluids & tissues
o the ways a drug is transported from the site of administration to the site of action (transportation)
o factors affecting distribution:
- size of the organ
- blood flows drug is quickly distributed to organs with large supply of blood (heart, liver, kidneys)
o distribution to other internal organs, skin, fat, muscle is slower
- solubility lipid soluble drugs can also cross the blood-brain barrier & enter the brain
- Binding as drug travels trough the body, it comes in contract with proteins (albumin). The drug can remain free or bind to protein.
o Portion of drug bound to protein is inactive, no therapeutic affect
o Free/unbound portion active - - - - (+) pharmacologic response
o Highly protein bound drug - > 89% of drug is bound to protein
Diazepam, piroxicam, valproic acid
o Moderately highly protein bound drugs (61-89% bound protein)
Erythromycin, phenytoin
o Moderately protein bound drugs 30-60%
Aspirin, lidocaine, pindolol, theophyliine
o Low protein-bound drugs - < 30% bound to protein (amikacin, amoxicillin)

Elderly dec liver size, blood flow, enzyme production - - - slows metabolism
Environment cigarette smoke may affect rate of some drugs
o Stressful environment prolonged illness, surgery, injury

D. EXCRETION/ELIMINATION removal of drug from the body: drug is changed into inactive form & excreted by the body

Routes:
o Kidney main organ for drug elimination: leaves the body through urine
Free/unbound/water soluble drugs filtered in kidney
Protein bound drug cannot be filtered in kidney
(+) kidney dose dose must be decreased
o Lungs, exocrine (sweat, salivary, mammary) glands, skin, intestinal tract
Factors affecting drug excretion
o Urine ph normal: 4-5.8
Acid urine promotes elimination of weak base drugs
i.e. cranberry juice dec urine ph - - - (-) elimination of aspirin
alkaline urine (+) elimination of weak acid drug
overdose aspirin - - - give Nabicarbonate inc urine ph - - - (+) excretion of drug
o glomerular filtration rate (GFR) dec GFR - - - drug excretion slowed/impaired
can result to drug accumulation
extent of filtration directly proportional to GFR & to fraction of unbound drug to plasma
ratio of clearance = fu x GFR - - - cleared by filtration
ratio of clearance < fu x GFR - - - cleared tubular reabsorption
ratio of clearance > fu x GFR - - - cleared by tubular secretion
o creatinine clearance most accurate test to determine renal function
creatinine excreted in kidney
dec renal GFR inc serum creatinine level & dec urine creatinine clearance
12-24 hrs urine collection & blood sample
Normal 85-135 ml/min; elderly 60ml/min
Renal clearance amount of substance removed from the blood by the kidneys
Half-life/elimination half-life (t ) time it takes for one half of drug concentration to be eliminated
o Short t = 4-8 hrs: given several times a day (i.e. penicillin G)
o Long t = > 12 hrs: given 2x or 1x / day (digoxin)

III. PHARMACODYNAMICS refers to action of drug to the body
What happens to the body in response to the drug
Effects of drugs on the cells biological & physiological functions & mechanisms of action
Interactions between chemical components of living systems & foreign chemicals including drugs that enter these system
Mechanism of action: means by which a drug produces alteration in function of their action
Drug actions:
a. To replace/act as substitute for missing chemicals
b. To inc or stimulate certain cellular activities
c. To depress/slow cellular activities
d. To interfere with functioning of foreign cells (i.e. invading microorganisms/neoplasms) chemotherapeutic Agents
Theories of Drug Actions
a. Drug-receptors interaction certain portion of drug molecule (active site) selective combines with some molecular structure (reactive site) on
the cell to produce a biologic effect
Receptor site drugs act at specific areas on cedil memb.; react with certain chemicals to cause an effect with in cell
lock & key theory specific chemical (key) approaches a cell membrane & finds a perfect fit (the lock) at receptor site affects enzymes system
within a cell produce certain effects
Specificity selectivity theory
Drug action may be:
Agonists drugs that produce a response
o insulin reacts with specific insulin receptor site to change cell membrane permeability - - - (+) movement of glucose into cell
competitive antagonist act with receptor sites to block normal stimulation producing no effect
o curare use on spear in Amazon to paralyze prey & cause death: occupies receptor sites for Acetylcholine (needed in muscle contraction &
movement) - - - prevents nerve stimulation causing paralusis
o noncompetitive antagonist - prevent reaction of another chemical with different receptor site on that cell
b. drug-enzymes interaction interferes with enzyme systems that act as catalyst from various chemical reations
enzyme systems cascade effect; one enzyme activating another - - - causing cellular reaction
if single step in one of enzyme system is blocked normal cell function is disrupted
ex: acetazolamide (diamox) diuretic that block carbonic anhydrase alters H+ & H2O exchange systems in kidneys & eye
c. nonspecific drug interaction act by biophysical means that do not affect cellular enzymatic reactions
d. selective toxicity all chemotherapeutic agent would act only on 1 enzyme system needed for life of a pathogen or neoplastic cell & will nor
affect healthy cells
ex: penicillin
unfortunately most of it cause destruction of normal human cells

Drug response may be:
1. primary always desirable / physiologic effects
2. secondary desirable or undesirable
ex: diphenhydramine (benadryl) 1
st
effect: antihistamine, treat symptoms of allergy; 2: CNS depression - - - drowsiness
desirable: when given at bedtime: undesirable: when client is driving

Classification of drug action:
1. rapid few seconds to minutes (IV, SL, inhalation)
2. intermediate 1-2 hrs after administration (IM, SC)
3. Delayed/slow several hrs after administration (rectal, oral)

Parameters of Drug Action:
1. onset of action latent period: interval between time drug is administered & 1
st
sign of its effect
time it takes to reach the minimum effective concentration (MEC) after a drug is administered
time from drug administration to 1
st
observable effect _T0 T1)
2. duration of action period from onset until drug effect is no longer seen
length of time the drug exerts pharmacologic effect (T1 T3)
3. peak action drug reaches its highest blood / plasma concentration (T0 T2)

Termination of action point from onset at which drug effect is no longer seen
Minimal effective concentration lowest plasma concentration that produces the desire effect
Peak plasma level highest plasma concentration attained from a dose
Toxic level plasma concentration at which a drug produces adverse effects
Therapeutic range range of plasma concentration that produces the desire effect without toxicity (range between minimal effective
concentration & toxic level)
Loading dose bolus of drug given initially to attain rapidly a therapeutic plasma concentration
large initial dose; when immediate drug response is desired
given to achieve a rapid MEC in the plasma
i.e. digoxin - - - requires LD
Maintenance dose amount of drug necessary to maintain a steady therapeutic plasma concentration
Dose response relationship between minimal vs. maximal amount of drug dosed needed to produce desired drug response
i.e. some clients respond to lower drug dose while others need a high dose
Maximal efficacy (maximum drug effect) all drugs give a maximum drug effect (maximal efficacy)
i.e. simvastatin 40mg vs rouvastatin 10mg

Drug-response relationship:
Biologic half-life (t1/2) = time required to reduce to amount of unchanged drug that is in the body
short t1/2 drugs need to be administered more often than one with a longer t1/2
Lethal dose (LD50) dose lethal to 50% of animals tested
Effective dose (ED50) dose required to produce therapeutic effect on 50% animals tested
Therapeutic index (TI) ratio between LD50 and ED50; the closer the ratio is to 1, the greater the danger involved in giving the drug to
humans
estimates the margin of safety of a drug through the use of a ratio that measures the effective (therapeutic or concentration) dose (ED) in
50% of persons/animals (ED50) & lethal dose in 50% of animals (LD50) TI=LD50/ED50
low therapeutic index: narrow margin of safety; might need to adjust drug dose & plasma drug levels need to be monitored
high therapeutic index: wide margin of safety less danger of producing toxic effects

4 Categories of Drug Action:
1. stimulation/depression
stimulation inc rate of cell activity/secretion from the gland
depression dec cell activity & function of a specific organ
2. replacement replaces essential body compounds; i.e. insulin
3. inhibition/killing of organism interfere with bacterial cell growth ; i.e. antibiotics
4. irritation i.e. laxative irritate inner wall of colon - - - inc peristalsis - - - inc defecation

Drug potency relative amount of drug required to produce desired response
also used to compare a drug
dose response curve graphical representation of relationship between dose of drug & response it produces
low dose low response
dosage increased produce slight increase response, as dose further increases, drug response increases markedly, at certain point however,
inc dose yield little or no inc in response - - - drug have reached Maximum Effectiveness

Factors Affecting Dose Response Curve:
- nurse must be aware that human factor has tremendous influence on what actually happens when it enter the body
- no 2 people react in exactly the same way to any given drug
1. weight heavier patient larger dose to get therapeutic effect (more tissue to perfuse & inc receptor site in some reactive tissues)
- dec weight dec dose
2. age children (immune system for handling drugs) & older adults
- older patients: less absorption, distribution between fewer plasma proteins & less efficient perfusion: geriatric dosages
- nurse should monitor closely for desired effects (may adjust dose)
3. toxicity
4. pharmacogenetics effect of a drug action that varies from a predicted drug response because of genetic factors or hereditary influence
people have different genetic makeup do not always respond identically to a drug dosage or planned drug therapy
ex: African Americans do not respond as well as whites to some classes of antihypertensive medications
5. route of administration
6. emotional factors
7. pre-existing disease state liver disease
8. drug history drug interaction synergistic/excretion
9. tolerance
10. cumulative effect
11. drug- drug interaction
12. BMR inc BMR inc drug metabolism & excretion

Drug Interaction
1. Additive effect 2 drugs with similar actions are taken for a doubled effect (desirable/undesirable) (1 + 1 = 2)
Ibuprofen + paracetamol + added analgesic effect
2. Synergistic combined effect of 2 drugs is greater than sum of the effect or each drug given alone (1 + 1 = 3)
Aspirin + codeine = greater analgesic effect
3. potentiation a drug that has no effect enhances the effect of a 2
nd
drug (0 + 1= 2)
4. Antagonistic one drug inhibits the effect of another drug (1 + 1 = 0)
Tetracycline + antacid = dec absorption of tetracycline

SIDE EFFECTS
Physiologic effects not related to desired drug effects
All drugs have side effects
Desirable: diphenhydramine (Benadryl) at bedtime s/e: drowsiness
Undesirable
Result mostly from drugs that lack specificity
Might be used interchangeably with adverse reactions
Not a reason to discontinue drug therapy
Nurses role: teach clients to report any side effects

ADVERSE REACTIONS
More severe than side effects
Range of untoward effects (unintended, occurring at normal doses) of drug that cause mild-severe side effects: anaphylaxis (cardiovascular
collapse)
Always undesirable
Must always be reported & documented because they represent variances from planned therapy.

TOXIC EFFECT/TOXICITY
Can be identified by monitoring the plasma (serum) therapeutic range of the drug
Narrow TI (aminoglycoside & antibiotics) therapeutic range is monitored
When drug level exceeds therapeutic range, toxic effects are likely to occur from overdosing or drug accumulation.