COLLEGE OF NURSING PHARMACOLOGY MODULE I By: Lourade U. A!o"#o$ MAN$RN %. HISTORY Early drug plants, animals & minerals 2700 BB earliest recorded drug use found in Middle East & China 1550 BC Egyptians created Eers Medical !apyrus Castor oil la"ati#e $pium pain Moldy read %ounds & ruises &alen '1(1)201 *+, -oman physician. initiated common use of prescriptions 12/0 *+ introduction of apothecary system '*ra doctors, 1 st set of drug standards & measurements 'grains, drams, minims,, currently eing phased out 15 th century apothecary shops o%ned y arer, surgeons, physicians, independent merchants 10 th century small po" #accine 'y 1enner, +igitalis from fo"glo#e plant for strengthening & slo%ing of hearteat 2itamin C from fruits 13 th century morphine & codeine e"tract from opium 4ntroduction of atropine & iodine *myl nitrite used to relie#e anginal pain +isco#ery of anesthetics 'ether, nitrous o"ide, Early 20 th century aspirin from salicylic acid 4ntroduction of !henoarital, insulin, sulforamides Mid 20 th century 13/0 +isco#ery antiiotics 'penicilline, tetracycline, streptomycin,, antihistamines, cortisone 1350 disco#ery antipsychotic drug, antihypertensi#es, oral contracepti#es, polio #accine &. DEFINITION ' SUBDI(ISIONS Dru) chemical introduced into the ody to cause some changes 56$ def7 any product8sus used to modify8e"plore physiologic system8pathologic states for the enefit of the patient P*ar+a,oo)y study of the manner in %hich the function of li#ing system is affected y chemical agents8drugs 9cience concerned %ith history, sources, physical & chemical properties of drugs & the %ay in %hich drug affects li#ing system 2 Su-d./.#.o"# o! 0*ar+a,oo)y: 1: 0*ar+a,ody"a+.,# study of the iochemical & physiological effects of drugs & mechanisms of action %hat the drug does to the ody 2: 0*ar+a,o1."e2.,# deals %ith the asorption, distriution, iotransformation & e"cretion of drugs %hat the ody does to the drug (: 0*ar+a,o2*era0eu2.,# study of drugs used in the diagnosis, pre#ention, suppression, & treatment of diseases deals %ith eneficial effects of the drugs 'medicines, /: 0*ar+a,o)"o#y study of drugs in their original unaltered state. origin of drugs source of drugs e"7 penicillin from penicillium 'fungi, 5: To3.,oo)y study of iologic to"ins7 study of poison & its effects deals %ith deleterious effects of physical & chemical agents 'including drugs, in human !harmacoeconomics study of relationship of drugs & economics !harmaco#igilance science of collecting,researching, analy;ing, & e#aluating set of information aout ad#erse drug effects: -eceptor a component of the cell that interacts %ith drug, initiating a chain of iochemical e#ents leading to drugs< oser#ed effects 6uman ody %or=s through complicated series of chemical reactions & processes 4mportant aspects of nursing7 understanding ho% drug ant on ody to cause changes & apply that =no%ledge in clinical setting !atients ta=e complicated drug regimen & recei#e potentially to"ic drug 9ome manage their o%n care at home >ursing responsiilities regarding drug therapy7 *dministering drugs *ssessing drug effects 4nter#ening to ma=e drug regimen more tolerale !ro#ide patient teachings aout drugs & drug regimen ?no%ing ho% drug %or=s ))) easier to handle ))) enhances drug therapy DRUG NOMENCLATURE 1: C6EM4C*@ >*ME atomic8molecular structure of drug 2: &E>E-4C >*ME8>$>)!-$!E-AB >*ME original designation gi#en to the drug %hen the drug company applies for appro#al patents ) uni#ersally accepted & not capitali;ed. efore drug ecomes official, used in all countries ) protected y la%. not capitali;ed (: A-*+E8B-*>+8!-$!-4EAB >*ME name gi#en y the drug company that de#eloped it ) follo%ed y the symol - or AM, 1 st letter is capitali;ed chemical name acetylsalicylic acid ( generic name aspirin trade name aspilet COMMON SOURCES 45 MA6OR SOURCES 7ORIGINS8 OF DRUGS: 1: *nimal sources from organs, organ secretion or organ cells Csed to replace human chemical not produces ecause of disease or genetic prolems Ahyroid drugs & gro%th hormones preparations from animal thyroid & hypothalamus tissue 'many of these preparations are no% created synthetically safer & purer, 4nsulin from pancreas of animals 'hog, cattle, sheep,7 thru genetic engineering cld produce human insulin y altering E: coli acteria ma=ing it a etter product %ithout impurities that come %ith animal products 2: #egetale8plant sources roots, ar=, sap, lea#es, flo%ers, seeds of medicinal plants digitalis from %ildflo%er, purple fo"glo#e, dried lea#es of plant acti#e principles of plants al=aloids al=aline in reaction, itter in taste, po%erful in physiologic acti#ity o atropine & scopolamine o morphine sulfate, cocaine, Duinine, nicotine, caffeine o procaine glycosides digitalis resin solule in alcohol. e"ample colonic irritant found in la"ati#e cascara gums used in ul=)type la"ati#es7 some used in certain s=in preparations for their soothing relief oils castor oil, oil of %intergreen (: Mineral sources from free elements, oth metallic & non)metallic usually in form of acids ases, salts found in food +ilute 6C4 control8pre#ent indigestion Calcium, aluminum, fluoride, iron, gold, potassium /: synthetic sources many drugs de#eloped synthetically after chemical in plants, animals, or en#ironment ha#e een screened for signs of therapeutic acti#ity more potent, more stale, less to"ic steroids arthritis & other diseases sulfonamides8chemotherapeutic agents =ill microorganism slo% their gro%th meperidine 6C4 '+emerol, DRUG CLASSIFICATION *: y action *nti infecti#es antiseptics, disinfectants, sterilants *ntimicroials, metaolic, diagnostic materials, #itamins & minerals 2accine & serums, antifungals, antihistamines, antineoplastics, antacids B: By ody system / C>9 'E,8'), actions of neural path%ays & centers7 !henoarital *>9 go#erns se#eral odily functions so that drugs that affect *>9 %ill at the same time affect other systems functions &4A acts on mascular & glandular tissues7 loperamide -E9!4-*A$-B 9B9AEM act on resp: tract, tissues, cough center, suppress, rela", liDuefy & stimulate depth & rate of respiration Crinary system act on =idney & urinary tract Circulatory system act on heart, lood #essels, lood. metoprolol 9INDS OF DRUGS !rescription8legend drug can e dispensed if %ith prescription order. %ith specific name of drug & dosage regimen to e used y patient non)prescription drug can e dispensed o#er the)counter8%ithout prescription order ) for self treatment of #ariety of complaints ) #itamin supplements, cold8cough remedies, analgesics, antacids, heral products ) cautions in use of $AC drugs7 1: delay in professional diagnosis & treatment of serious8potentially serious condition may occur 2: symptoms may e mas=ed ma=ing the diagnosis more complicated (: clients< health care pro#ider8pharmacist should e consulted efore $AC preparations are ta=en /: laels8instructions should e follo%ed carefully 5: ingredients in $AC drug may interact %ith prescried drug F: inacti#e ingredients may result in ad#erse reactions 7: potential for o#erdose 0: multiple medication users are at ris= as more medications are added to therapy regimen 3: interactions of medications are potentially dangerous 4n#estigational drug ne% drugs undergoing clinical trails 4llicit8street drug used8distriuted illegally for non)medical purposes to alter mood of feeling GG%hen drug is ta=en y mouth, it undergoes ( phases7 1: pharmaceutic8dissolution 2: pharmaco=inetics (: pharmacodynamics I. PHARMACEUTIC4DISSOLUTION ) +rug goes into solution so that it can cross the iologic memrane ) >ot found in drug administered parenterally ) 1 st phase of drug action of agents ta=en y mouth ) *dditi#e enhances asoraility of drugs ) EHC4!4E>A97 filters & inert sustances *llo%s drugs to ta=e on particular si;e & shape Enhance drug dissolution potassium '?, ))) losartan ? 'co;aar,. sodium '>a, )))clo"acillin >a '!rostaphlin)*, 5 2 phases7 ) +isintegration rea=do%n into smaller parts ) +issolution futher rea=do%n into smaller parts in &4A asorption. dissol#ed into liDuid ) rate limiting7 time it ta=es drug to disintegrate & dissol#e to ecome a#ailale for ody to asor it ) factors affecting dissolution form of drug '@4IC4+ 29: 9$@4+, liDuid more asored than solid, already in solution, rapidly a#ailale for &4 asorption &astric ph 'acid #s al=aline, acidic media 'phJ1:2, faster disintegration & asorption *ge young #s elderly inc ph: +ec asoption Enteric coated drugs resist disintegration in gastric acid +isintegration occurs only in al=aline en#ironment 'intestine, 9hould not e crushed !resence of food interfere %ith dissolution & asorption, enhance asorption of other drugs, may e protectants of gastric mucosa 4: PHARMACO9INETICS action of ody to the drug7 %hat the ody does to the drug 9tudy of asoption 'ta=en into the ody,, distriution 'mo#ed into #arious tissues,, metaolism8iotransformation 'changed into a form that can e e"creted, & e"cretion 'remo#ed from the ody, of drugs 5hat happens to the drug %hen it enters the ody K=ineticsL mo#ement7 deals %ith drugs actions as it mo#ed through the ody *lso concerned %ith a drug<s onset of action, pea= concentration le#el, & duration of action 5 0ro,e##e# ."/o/ed7 4: A-#or02.o" route of drug ta=es from the time it enters the ody until it is asored in circulating fluids Mo#ement of drug molecules from site of administration to circulatory system Mo#ement of drug particles from &4A to ody fluids in#ol#e ( processes !assi#e asorption 'diffusion, mo#ement from higher concentration o >o energy reDuired7 occurs %hen smaller molecules diffuse across memrane o 9tops %hen drug concentration on oth sides of the memrane is eDual o MaMor process through %hich drugs are asored into the ody *cti#e asorption needs carrier 'en;ymes or protein, to mo#e against a concentration gradient o Energy is reDuired7 from lo%er concentration to higher concentration o Csed to asor electrolytes 'i:e: sodium, potassium, & some drugs 'le#odopa, !inocytosis engulfs the drug to carry it across the memrane o Aransport fat)solule #itamins '#it:*,+,E,?, F Nactors affecting asorption7 +rug soluility lipid solule drugs pass readily through &4 memrane, 5ater solule drugs need an en;yme or protein @ocal condition at site of asorption %ea= acids less ioni;ed in stomach ) ) ) readily pass through the 94 !ain 8 stress 8 solid foods 8 fatty or hot foods slo%s do%n gastric emptying time +rug concentration drugs can ta=e se#eral hours8days to reach pea= concentration le#els 'slo% rate7 rectal administration or sustained release drugs, Circulation at site of asorption poor circulation hampers asorption 'i:e: shoc=, Ahe more lood #essels, the faster the asorption E"ercise decrease lood flo% to &4 slo%s asorption *pplication of heat8massage increases lood flo%s at site Muscles area selected for 4M administration7 Blood flo%s faster through deltoid muscle 'upper arm, #s gluteal muscle 'uttoc=s, &luteal muscle can accommodate larger #olume of drug than deltoid muscle (. Me2a-o.#+ iotransformation7 essential for termination of a drug<s iologic acti#ity so can e easily e"creted 9ites of metaolism o @i#er main organ for drug metaolism Ahrough the drug metaoli;ing en;ymes 'microsomal en;ymes, non) microsomal en;ymes, 1 st pass effect hepatic 1 st pass some drugs do not directly go into circulation ut pass thru intestinal lumen to li#er #ia portal #ein ) ) drug metaoli;ed in li#er into inacti#e form ) ) decrease amount of acti#e drugs ) ) ) increase recommended dose for oral drugs @idocaine e"tensi#e 1 st pass not gi#en orally o !lasma o ?idneys o Memranes of intestine !rocess y %hich ody changes a drug from its dosage form to a more %ater)solule form that can then e e"creted Can e metaoli;ed in se#eral %ays7 o Most drugs metaoli;ed into inacti#e metaolites 'products of metaolism,, %hich are then e"creted o $ther drugs con#erted to acti#e metaolites capale of e"erting their o%n pharmacologic action May undergo further metaolism or may e e"creted from ody unchanged !rodrugs some drugs administered as inacti#e drugs %hich don<t ecome acti#e until they<re metaoli;ed 7 o !ermits the ody to inacti#e a potent drug efore it accumulates & produces to"ic effects Nactors affecting iotransformation7 o &enetic some people metaoli;e drugs rapidly, other more slo%ly o !hysiologic @i#er diseases 'cirrhosis,, heart failure dec circulation in li#er 4nfants immature li#ers dec rate of metaolism o *rea of asoring surface to %hich a drug is e"posed 'E, chemical agents may destroy the drug o Aypes of transport diffusion, acti#e, pinocytosis o -outes of administration s=in asorption slo%er than 4M *sorption %ith in seconds8minutes7 sulingual, 42, y inhalation route 9lo%er rate asorption7 oral, 4M 9C routes o Bioa#ailaility consideration of highest importance in drug effecti#eness & safety 9ucategory of asorption O of administered drug does that reaches systemic circulation $ral route P100O'usually 20)/0O,. 42 route J 100O Nactors that alter ioa#ailaility7 +rug form 'talet, capsule, -oute of administration &4 mucosa & motility Nood & other drugs 'E, food ) ) ) pord of gastric acid inc drug asorption 'i:e: Ka;oleL, Changes in li#er metaolism, li#er disorder dec li#er function inc ioa#ailaility 44: d.#2r.-u2.o" process y %hich drug ecomes a#ailale to ody fluids & tissues the %ays a drug is transported from the site of administration to the site of action 'transportation, factors affecting distriution7 o si;e of the organ o lood flo%s drug is Duic=ly distriuted to organs %ith large supply of lood 'heart, li#er, =idneys, distriution to other internal organs, s=in, fat, muscle is slo%er o soluility lipid solule drugs can also cross the lood)rain arrier & enter the rain o Binding as drug tra#els trough the ody, it comes in contract %ith proteins 'alumin,: Ahe drug can remain free or ind to protein: !ortion of drug ound to protein is inacti#e, no therapeutic affect Nree8unound portion acti#e ) ) ) ) 'E, pharmacologic response 6ighly protein ound drug ) Q 03O of drug is ound to protein +ia;epam, piro"icam, #alproic acid Moderately highly protein ound drugs 'F1)03O ound protein, Erythromycin, phenytoin 0 Moderately protein ound drugs (0)F0O *spirin, lidocaine, pindolol, theophyliine @o% protein)ound drugs ) P (0O ound to protein 'ami=acin, amo"icillin, Elderlies dec li#er si;e, lood flo%, en;yme production ) ) ) slo%s metaolism En#ironment cigarette smo=e may affect rate of some drugs o 9tressful en#ironment prolonged illness, surgery, inMury 444: E3,re2.o"4e.+."a2.o" remo#al of drug from the ody7 drug is changed into inacti#e form & e"creted y the ody -outes7 o ?idney main organ for drug elimination7 lea#es the ody through urine Nree8unound8%ater solule drugs filtered in =idney !rotein ound drug cannot e filtered in =idney o @ungs, e"ocrine 's%eat, sali#ary, mammary, glands, s=in, intestinal tract Nactors affecting drug e"cretion o Crine ph normal7 /)5:0 *cid urine promotes elimination of %ea= ase drugs i:e: cranerry Muice dec urine ph ) ) ) '), elimination of aspirin al=aline urine 'E, elimination of %ea= acid drug DISTRIBUTION BLOOD FLO: PROTEIN; BINDING BODY TISSUE AFFINITY PHARMACOLOGIC EFFECT 3 o#erdose aspirin ) ) ) gi#e >aicaronate inc urine ph ) ) ) 'E, e"cretion of drug o glomerular filtration rate '&N-, dec &N- ) ) ) drug e"cretion slo%ed8impaired can result to drug accumulation e"tent of filtration directly proportional to &N- & to fraction of unound drug to plasma o creatinine clearance most accurate test to determine renal function creatinine e"creted in =idney dec renal &N- inc serum creatinine le#el & dec urine creatinine clearance 2/ hrs urine collection & lood sample >ormal 05)1(5 ml8min. elderly F0ml8min 6alf)life8elimination half)life 't R, time it ta=es for one half of drug concentration to e eliminated o 9hort t R J /)0 hrs7 gi#en se#eral times a day 'i:e: penicillin &, o @ong t R J Q 12 hrs7 gi#en 2" or 1" 8 day 'digo"in, 44: PHARMACODYNAMICS refers to action of drug to the ody 5hat happens to the ody in response to the drug Effects of drugs on the cell<s iological & physiological functions & mechanisms of action 4nteractions et%een chemical components of li#ing systems & foreign chemicals including drugs that enter these system Mechanism of action7 means y %hich a drug produces alteration in function of their action +rug actions7 a: Ao replace8act as sustitute for missing chemicals : Ao inc or stimulate certain cellular acti#ities c: Ao depress8slo% cellular acti#ities d: Ao interfere %ith functioning of foreign cells 'i:e: in#ading microorganisms8neoplasms, chemotherapeutic *gents Aheories of +rug *ctions 10 a: +rug)receptors interaction certain portion of drug molecule 'acti#e site, selecti#e comines %ith some molecular structure 'reacti#e site, on the cell to produce a iologic effect -eceptor site drugs act at specific areas on cell mem:. react %ith certain chemicals to cause an effect %ith in cell Kloc= & =ey theoryL specific chemical 'key, approaches a cell memrane & finds a perfect fit 'the lock) at receptor site affects en;ymes system %ithin a cell produce certain effects 9pecificity selecti#ity theory +rug action may e7 *gonists drugs that produce a response o insulin reacts %ith specific insulin receptor site to change cell memrane permeaility ) ) ) 'E, mo#ement of glucose into cell competiti#e antagonist act %ith receptor sites to loc= normal stimulation producing no effect o curare use on spear in *ma;on to paraly;e prey & cause death7 occupies receptor sites for *cetylcholine 'needed in muscle contraction & mo#ement, ) ) ) pre#ents ner#e stimulation causing paralusis o noncompetiti#e antagonist ) pre#ent reaction of another chemical %ith different receptor site on that cell : drug)en;ymes interaction interferes %ith en;yme systems that act as catalyst from #arious chemical reations en;yme systems cascade effect. one en;yme acti#ating another ) ) ) causing cellular reaction if single step in one of en;yme system is loc=ed normal cell function is disrupted e"7 aceta;olamide 'diamo", diuretic that loc= caronic anhydrase alters 6E & 62$ e"change systems in =idneys & eye 11 c: nonspecific drug interaction act y iophysical means that do not affect cellular en;ymatic reactions d: selecti#e to"icity all chemotherapeutic agent %ould act only on 1 en;yme system needed for life of a pathogen or neoplastic cell & %ill nor affect healthy cells e"7 penicillin unfortunately most of it cause destruction of normal human cells +rug response may e7 1: primary al%ays desirale 8 physiologic effects 2: secondary desirale or undesirale e"7 diphenhydramine 'enadryl, 1 st effect7 antihistamine, treat symptoms of allergy. 27 C>9 depression ) ) ) dro%siness desirale7 %hen gi#en at edtime7 undesirale7 %hen client is dri#ing Ca##.!.,a2.o" o! dru) a,2.o"7 1: rapid fe% seconds to minutes '42, 9@, inhalation, 2: intermediate 1)2 hrs after administration '4M, 9C, (: +elayed8slo% se#eral hrs after administration 'rectal, oral, Para+e2er# o! Dru) A,2.o": 1: onset of action latent period7 inter#al et%een time drug is administered & 1 st sign of its effect time it ta=es to reach the minimum effecti#e concentration 'MEC, after a drug is administered time from drug administration to 1 st oser#ale effect SA0 A1, 2: duration of action period from onset until drug effect is no longer seen length of time the drug e"erts pharmacologic effect 'A1 A(, (: peak action drug reaches its highest lood 8 plasma concentration 'A0 A2, Termination of action point from onset at %hich drug effect is no longer seen Minimal effective concentration lo%est plasma concentration that produces the desire effect Peak plasma level highest plasma concentration attained from a dose Toxic level plasma concentration at %hich a drug produces ad#erse effects Therapeutic range range of plasma concentration that produces the desire effect %ithout to"icity 'range et%een minimal effecti#e concentration & to"ic le#el, Loading dose olus of drug gi#en initially to attain rapidly a therapeutic plasma concentration 12 large initial dose. %hen immediate drug response is desired gi#en to achie#e a rapid MEC in the plasma i:e: digo"in ) ) ) reDuires @+ Maintenance dose amount of drug necessary to maintain a steady therapeutic plasma concentration Dose response relationship et%een minimal #s: ma"imal amount of drug dosed needed to produce desired drug response i:e: some clients respond to lo%er drug dose %hile others need a high dose Maximal efficacy (maximum drug effect) all drugs gi#e a ma"imum drug effect 'ma"imal efficacy, i:e: sim#astatin /0mg #s rou#astatin 10mg Dru);re#0o"#e rea2.o"#*.0: Biologic half-life (t!", J time reDuired to reduce to R amount of unchanged drug that is in the ody short t182 drugs need to e administered more often than one %ith a longer t182 Lethal dose '@+50, dose lethal to 50O of animals tested #ffective dose 'E+50, dose reDuired to produce therapeutic effect on 50O animals tested Therapeutic index 'A4, ratio et%een @+50 and E+50. the closer the ratio is to 1, the greater the danger in#ol#ed in gi#ing the drug to humans estimates the margin of safety of a drug through the use of a ratio that measures the effecti#e 'therapeutic or concentration, dose 'E+, in 50O of persons8animals 'E+50, & lethal dose in 50O of animals '@+50, A4J@+508E+50 lo% therapeutic inde"7 narro% margin of safety. might need to adMust drug dose & plasma drug le#els need to e monitored high therapeutic inde"7 %ide margin of safety less danger of producing to"ic effects 5 Ca2e)or.e# o! Dru) A,2.o": 1: stimulation8depression stimulation inc rate of cell acti#ity8secretion from the gland depression dec cell acti#ity & function of a specific organ 1( 2: replacement replaces essential ody compounds. i:e: insulin (: inhiition8=illing of organism interfere %ith acterial cell gro%th . i:e: antiiotics /: irritation i:e: la"ati#e irritate inner %all of colon ) ) ) inc peristalsis ) ) ) inc defecation Dru) 0o2e",y relati#e amount of drug reDuired to produce desired response also used to compare a drug lo% dose lo% response dosage increased produce slight increase response, as dose further increases, drug response increases mar=edly, at certain point ho%e#er, inc dose yield little or no inc in response ) ) ) drug ha#e reached Ma"imum Effecti#eness Fa,2or# A!!e,2.") Do#e Re#0o"#e 7 ) nurse must e a%are that human factor has tremendous influence on %hat actually happens %hen it enter the ody ) no 2 people react in e"actly the same %ay to any gi#en drug 1: %eight hea#ier patient larger dose to get therapeutic effect 'more tissue to perfuse & inc receptor site in some reacti#e tissues, ) dec %eight dec dose 2: age children 'immune system for handling drugs, & older adults ) older patients7 less asorption, distriution et%een fe%er plasma proteins & less efficient perfusion7 geriatric dosages ) nurse should monitor closely for desired effects 'may adMust dose, (: to"icity /: pharmacogenetics effect of a drug action that #aries from a predicted drug response ecause of genetic factors or hereditary influence people ha#e different genetic ma=eup do not al%ays respond identically to a drug dosage or planned drug therapy e"7 *frican *mericans do not respond as %ell as %hites to some classes of antihypertensi#e medications 5: route of administration F: emotional factors 7: pre)e"isting disease state li#er disease 0: drug history drug interaction synergistic8e"cretion 3: tolerance 1/ 10: cumulati#e effect 11: drug) drug interaction 12: BM- inc BM- inc drug metaolism & e"cretion Dru) I"2era,2.o" 1: *dditi#e effect 2 drugs %ith similar actions are ta=en for a douled effect 'desirale8undesirale, '1 E 1 J 2, 4uprofen E paracetamol E added analgesic effect 2: 9ynergistic comined effect of 2 drugs is greater than sum of the effect or each drug gi#en alone '1 E 1 J (, *spirin E codeine J greater analgesic effect (: potentiation a drug that has no effect enhances the effect of a 2 nd drug '0 E 1J 2, /: *ntagonistic one drug inhiits the effect of another drug '1 E 1 J 0, Aetracycline E antacid J dec asorption of tetracycline SIDE EFFECTS !hysiologic effects not related to desired drug effects *ll drugs ha#e side effects +esirale7 diphenhydramine 'Benadryl, at edtime s8e7 dro%siness Cndesirale -esult mostly from drugs that lac= specificity Might e used interchangealy %ith ad#erse reactions >ot a reason to discontinue drug therapy >urse<s role7 teach clients to report any side effects AD(ERSE REACTIONS More se#ere than side effects -ange of unto%ard effects 'unintended, occurring at normal doses, of drug that cause mild)se#ere side effects7 anaphyla"is 'cardio#ascular collapse, *l%ays undesirale Must al%ays e reported & documented ecause they represent #ariances from planned therapy: TO<IC EFFECT4TO<ICITY 15 Can e identified y monitoring the plasma 'serum, therapeutic range of the drug >arro% A4 'aminoglycoside & antiiotics, therapeutic range is monitored 5hen drug le#el e"ceeds therapeutic range, to"ic effects are li=ely to occur from o#erdosing or drug accumulation: