-          Are chemicals that inhibit a specific bacteria

-          Used to treat a wide variety of systemic and topical infections.

-          Antibacterial

Antibiotics are made in three ways:

1. By living microorganisms
2. By synthetic manufacture
3. Through genetic engineering

Major classes:

1. Aminoglycosides
2. Cephalosporins
3. Fluoroquinolones
4. Lincosamides
5. Macrolides
6. Monobactams
7. Penicillins
8. Sulfonamides
9. Tetracyclines

Bacteria

-          one-celled organisms visible only through a microscope. Bacteria live all around us and within us. The air is filled with bacteria, and they have even entered outer space in spacecraft. Bacteria live in the deepest parts of the ocean and deep within Earth. They are in the soil, in our food, and on plants and animals. Even our bodies are home to many different kinds of bacteria. Our lives are closely intertwined with theirs, and the health of our planet depends very much on their activities.

-          Bacteria can invade the body the human body through many routes, ex. Respiratory, gastrointestinal and skin.

-          The human immune response is activated when bacteria invade. Many of the sign s and symptoms of an infection are related to the immune response as the body tries to rid itself of the foreign cells. Ex. Fever, lethargy, classic sign s of inflammation (redness, swelling, heat and pain)

-          To determine which antibiotic will effectively treat a specific infection, the causative agent must be identified. Culture and sensitivity testing is performed.

Types of Bacteria

1. Gram-positive Bacteria – are those whose cell wall retains a stain, known as Gram – stain. They are commonly associated with infection of the respiratory tract. Ex Streptococcus pneumonia.
2. Gram-negative Bacteria – are those whose cell walls loose a stain. Frequently related with infections of the genitourinary or GI tract. Ex. Escherichia coli.
3. Aerobic bacteria – depends on oxygen for survival.
4. Anaerobic bacteria – does not depend on oxygen.

1. Aminoglycosides

-          Aminoglycosides are bactericidal. They’re effective against:

• Gram-negative bacilli
• Some aerobic gram-positive bacteria

Aminoglycosides currently in use include:

1. Amikacin sulfate
2. Gentamicin sulfate
3. Kanamycin sulfate
4. Neomycin sulfate
5. Streptomycin sulfate
6. Tobramycin

Pharmacokinetics

-          Because aminoglycosides are absorbed poorly from the GI tract, they’re usually given parenterally. After IV or IM administration, absorption is rapid and complete.

-          Aminoglycosides are distributed widely in extracellular fluid. They readily cross the placental barrier but don’t cross the blood brain barrier.

-          Aminoglcosides aren’t metabolized. They’re excreted primarily by the kidney’s.

Pharmacodynamics

-          Bactericidal

-          Binds to the bacteria’s 30S subunit in the ribosome inhibiting protein synthesis.

Pharmacotherapeutics

• Infections caused by gram-neagtive bacilli
• Nosocomial infections such as peritonitis and pneumonia
• UTI
• CNS infections

Adverse Reactions

• Peripheral nerve toxicity
• Ototoxicity
• Renal toxicity

Oral administration causes:

• Nausea
• Vomiting
• Diarrhea

1. Cephalosporins

-          The cephalosporins were first introduce in the 1960’s. These drugs are similar to the penicllins in structure and in activity. Over time, four generations of cephalosporins have been introduced, each group with its own spectrum of activity.

1. First Generation Cephalosporins

• Effective against gram-positive bacteria
• Also effective against some gram-negative bacteria such as Proteus mirabilis, E. Coli, and Klebsiella pneumoniae

Some of the First Generation Cephalosporins

• Cefadroxil
• Cefazolin sodium
• Cephalexin hydrochloride
• Cephradine

1. Second Generation Cephalosporins

• Effective against gram-positive bacteria
• Haemophilus influenza, Enterobacter aerogenes and Neisseria species

Some of the Second Generation Cephalosporins

• Cefaclor
• Cefrozil
• Ceftibuten
• Cefoxitin
• Cefuroxime axetil
• Cefuroxime Sodium

1. Third Generation Cephalosporins

• Effective against gram negative bacilli, as Serratia marcescens

Some of the Third Generation Cephalosporins

• Cefdinir
• Cefoperazone sodium
• Cefotaxime sodium
• Cefpodoxine proxetil
• Ceftazidine
• Ceftizoxime sodium
• Ceftriaxone sodium

1. Fourth Generation cephalosporins

• Effective against cephalosporins resistant-staphylococci and P. Aeruginosa

Some of the Fourth Generation Cephalosporins

• Cefditoren pivoxil
• Cefepine hydrochloride

Pharmacokinetics

-          Administered parenterally, because they aren’t absorbed from the GI tract.

Pharmacodynamics

-          Inhibit cell-wall synthesis by binding to the bacterial Penicillin Binding Protein enzy,es located on the cell membrane.

Adverse Reactions:

• Confusion
• Seizures
• Nausea and vomiting
• Diarrhea

1. Penicillin

-          Penicillin remain one of the most important and useful antibacterial drugs.

-          Discovered by Sir Alexander Flemming in the 1920’s

-          The Penicillin can be divided into four groups:

1. Natural Penicillin

• Penicillin G benzathine
• Penicillin G potassium
• Penicillin G procaine
• Penicillin G sodium
• Penicillin V potassium

1. Penicillinase Resistant Penicillin

• Dicloxacillin sodium
• Nafacillin sodium
• Oxacillin sodium

1. Aminopenicillins

• Ampicillin

1. Extended Spectrum Penicillin

• Amoxicillin

Pharmacokinetics

-          After oral administration, penicillin are absorbed mainly in the duodenum and upper jejunum  of the small intestine.

Factors affecting absorption of penicillin

• Types of penicillin used
• pH of the patients stomach and intestine
• presence of food in the GI tract (penicillin should be given on an empty stomach, 1 hour before meals or 2 hours after meal).

Pharmacodynamics

-          Bactericidal

-          Binds to an enzyme outside the bacterial cell wall known as penicillin-binding proteins which is involved in cell wall synthesis and cell division. Interference with these processes inhibits cell wall synthesis, causing rapid destruction of the cell.

Pharmacotherapeutics

-          No other class of antibacterial drugs provides as wide spectrum of antimicrobial activity as the penicillin

• Gram-positive
• Gram-negative
• Anaerobic organisms

Adverse Reactions

• Hypersensitivity reactions are the major reactions to penicillin
• Anaphylactic reactions
• Skin rashes
• Tongue inflammation
• Nausea and Vomiting
• Diarrhea

1. Fluoroquinilones

-          Structurally similar synthetic antibacterial drugs. They;re primarily administered to treat UTIs, upperrespiratory tract infections, pneumonia and gonorrhoea

Examples of fluoroquinilones:

• Cifrofloxacin
• Gemifloxacin
• Levofloxacin
• Moxifloxacin
• Norfloxacin
• Ofloxacin

Pharmacokinetics

-          After oral administration, fluoroquinilones are absorbed well. They aren’t highly protein bound, minimally metabolized in the liver, and are excreted primarily in the urine

Pharmacodynamics

-          Bacteriostatic

-          Fluoroquinilones interrupt DNA synthesis during bacterial replication by inhibiting DNA gyrase, an essential enzyme of replicating DNA. As a result, the bacteria can’t reproduce.

Pharmacotherapeutics

-          Fluorquinolones can be used to treat a wide variety of UTIs.

• Ciprofloxacin is used to treat lower respiratory tract infections, infectious diarrhea and skin, bone and joint infection.
• Gemifloxacin is used to treat bronchitis, community acquired pneumonia, UTIs, and gynaecologic infections.
• Levofloxacin is indicated for treatment of lower respiratory tract infections, skin infections and UTIs.
• Moxifloxacin is used to treat bacterial sinusitis and mild to moderate community acquired pneumonia.
• Norfloxacin is used to treat UTIs and prostatitis
• Ofloxacin is used to treat selected sexually transmitted diseases, lower respiratory tract infection, skin infections and prostatitis

Adverse Reactions

-          Fluoriquinilones are well tolerated by most patients, but some adverse effects may occur, including:

• Dizziness
• Nausea and vomiting
• Diarrhea
• Abdominal pain

1. Tetracycline

-          Tetracyclines are broad-spectrum antibacterial drugs.

-          They may be classified as:

• Intermediate-acting compounds, such as demeclocycline hydrochloride
• Long-acting compounds, such as doxycycline hyclate and minocycline hydrochloride

Pharmacokinetics

-          Tetracyclines are absorbed from the duodenum when taken orally.

-          They’re distributed widely into the body tsiisues and fluids and concentrated bile.

-          Tetracyclines are excreted primarily by the kidneys. Doxycyclline is also excreted in feces. Minocycline undergoes enterhepatic recirculation.

Pharmacodynamics

-          All tetracyclines are primarily bacteriostatic, meaning they inhibit the growth or multiplication of bacteria. They penetrate the bacterial cell by an energy-dependent process. Within the cell, they bind primarily to a subunit of the ribosome, inhibiting the protein synthesis required for maintaining the bacterial cell.

-          The long acting compounds doxycycline and minocycline provide more action against various organisms than other tetracyclines

Pharmacotherapeutics

-          Tetracyclines provide a broad spectrum of activity, which means they cover a wide range of organisms, including:

• Gram-positive and gram-negative aerobic and anaerobic bacteria
• Spirochetes
• Mycoplasmas
• Rickettsiae
• Chlamydiae
• Some protozoa
• Rocky Mountain spotted fever
• Q fever
• Lyme disease

1. Macrolides

-          Macrolides are used to treat a number of common infections. They include erythromycin and its derivatives, such as:

• Erythromycin estolate
• Erythromycin ethylsuccinate
• Erythromycin glucepate
• Erythromycin lactobionate
• Erythromycin stearate

Other macrolides include:

• Azithromycin
• Clarithromycin
• Dirithromycin

Pharmacokinetics

-          Because erythromycin is acid sensitive, it must be buffered or have an enteric coating to prevent destruction by gastric acid. Erythromycin is absorbed in the duodenum. It’s distributed to most tissues and body fluids except, in most cases, cerebrospinal fluid. However, as a class, macrolides can enter the CSF when menenges are inflamed.

-          Erythromycin is metabolized by the liver and excreted in bile in high concentrations; small amounts are excreted in urine. It also crosses the placental barrier and is secreted in breast milk.

Pharmacodynamics

-          Macrolides inhibit RNA-dependent protein synthesis by acting on a small portion of the ribosome.

Pharmacotherapeutics

-          Erythromycin has a range of therapeutic uses:

• It provides a broad spectrum of antimicrobial activity against gram-positive and gram-negative bacteria, including Mycobacterium, Treponema, Mycoplasma, and Chlamydia.
• It’s effective against pneumococci and group A streptococci.
• Staphylococcis aureus is sensitive to erythromycin; however, resistant strains may appear during therapy.
• It’s drug of choice for treating Mycoplasma pneumonia infections as well as pneumonia caused by Legionella pneumophila.

Adverse Reactions

• Although macrolides produces few adverse effects, they may produce:
  • Epigastric distress
  • Nausea and vomiting
  • Diarrhea
  • Rashes
  • Fever
  • Eosinophilia (an increase in the number of eosinophils, a type of WBC)
  • Anaphylaxis

• Anti-infective agents are drugs that are designed to act selectively on foreign organisms that have invaded and infected the body

• Ideally, anti-infectives would be toxic to the infecting organisms only and would have no effect on the host cell. This is known as Selective Toxixity.

• Selective Toxicity – the ability to affect certain proteins or enzyme systems that are used by the infecting organisms but not by the human cell.

• Anti-infective range from antibiotics, antifungals, antiprotozoals, antihelmintics, antivirals and antimycobacterial.

1. A.      General Mechanisms of Action of Anti-infective:

1. Some interfere with the biosynthesis of bacterial cell wall.

• Ex. Penicillins

1. Some anti-infectives prevent the cells of the invading organisms from using substances essential to their growth and development

• Ex. Sulfonamides

1. Some anti-infectives interfere with the steps involved in protein synthesis.

• Ex. Aminoglycosides

1. Some anti-infectives interfere with DNA synthesis.

• Ex. Fluoroquinolones

1. Other anti-infectives alter the permeability of the cell memebrane to allow the components to leak out.

1. B.      Anti-infective Activity:

Spectrum – range of effectiveness of an antibiotic.

1. Narrow Spectrum

-          Anti-infectives affect only a few bacterial types.

-          Ex. Early penicillins

1. Broad Spectrum

-          Anti-infectives affect many bacteria

-          Ex. Meropenem

1. Bacteriostatic

-          Anti-infectives that interfere with the ability of the cell to reproduce without killing them.

-          Ex. Tetracycline

1. Bactericidal

-          Antibiotics that can aggressively cause bacterial death.

-          Ex. Penicillin

1. C.      Anti-infective Therapy

-          The goal of anti-infective therapy is the reduction of the invading organisms to a point at which the human immune response can take care of the infection.

-          If the drug would eliminate all forms of the organisms by itself it might be toxic to the to the host itself.

-          Immuno-compromised patients have difficulty in using anti-infectives.

• Malnutrition
• Age
• AIDS

-          Anti-infective drugs cannot totally eliminate the pathogen without causing severe toxicity in the host.

-          These patients do not have the immune response on place to deal with even a few invading organisms.

1. D.      Common Adverse Reactions to Anti-infective Therapy

1. Nephrotoxicity

-          Anti-infectives that are metabolized and excreted in the kidney most frequently cause kidney damage.

-          My lead to renal damage and renal failure

-          Keep the patient well hydrated

-          Ex. Aminoglycosides

1. Gastro-intestinal toxicity

-          Direct toxic effect to the cells of the GI tract

-          Some anti-infectives are toxic on the mucosal lining of the GIT and can cause nausea, vomiting, stomach pain or diarrhea

-          Some drugs are toxic to liver cells and can cause hepatitis or liver failure

1. Neurotoxicity

-          When drugs can pass through the brain barrier and accumulate in the nervous tissues, they can interfere with neural function.

-          Ex. Aminogycosides

• Accumulates in the 8^th cranial nerve causing dizziness, vertigo and loss of hearing

-          Ex. Chloroquine

• Accumulates in the retina and optic nerves causing blindness

1. Hypersensitivity

-          Most antibiotics can induce the body’s immune response to produce allergic responses.

-          Allergic reactions

1. Super-infections

-          Broad spectrum anti-infecties can destroy the normal flora which can cause oppurtunustic microorganisms to be active.

1. E.     Resistance

-          Indiscriminate use of anti-infectives drugs has serious consequences.

-          Unnecessary exposure of organisms to these drugs lead to the development of resistant strain.

Acquiring Resistance

1. Producing an enzyme that deactivates the anti-infective drugs.

-          Ex. Penicillinase

1. Changing cellular permeability to prevent the drug from entering the cell.
2. Altering binding sites on the membrane which no longer accept the drug.

Producing a chemical that act as an antagonist t

-          Chemotherapeutic drugs are agents that affect cells.

• By altering cellular function or disrupting cellular integrity, causing cell death.
• By preventing cellular reproduction, eventually leading to cell death.

-          Chemotherapeutic drugs are used to destroy:

• Organisms that invade the body (bacteria, viruses, parasites protozoa, fungi)
• Abnormal cells within the body (neoplasm, cancers)

-          To understand the actions and the adverse effects caused by chemotherapeutic agents, it is important to understand the basic functioning of the cell.

The Cell

• The cell is the basic structural unit of the body.
• The cell that make up a living organisms, are arranged into tissues and organs, all have the same basic structure
• Each Cell has a:

ü  Nucleus

ü  Cell Membrane

ü  Cytoplasm

1. A.      Cell Nucleus

• “Anything that works, works best when it is controlled”
• “Headquarters” or the control center. Contains the genetic material “DNA”.
• DNA is a blueprint that contains all the instructions needed for building the whole body.
• The nucleus of a cell contains all of the genetic that is necessary for cell reproduction and for regulation of cellular production of proteins.
• The nucleus of a cell contains all of the genetic that is necessary for cell reproduction and for regulation of cellular production of proteins.

-          The Cell Nucleus is Composed of:

1. Nuclear Membrane

• The nucleus is bound by a double membrane barrier called the nuclear membrane or nuclear envelope.
• The nuclear membrane encloses a jellylike fluid called nucleoplasm in which the nucleoli and chromatin are suspended.

1. Nucleoli/Nucleolus

• The nucleus contains one or more small, dark staining, essentially round bodies called nucleoli.
• Nucleoli are the sites where ribosomes are assembled

1. B.      Cell Membrane

• The cell is surrounded by a thin barrier called the cell membrane
• Separates the intracellular fluid from the extracellular fluid.
• The membrane is essential for cellular integrity, and is equipped with many mechanisms for maintaining cell homeostasis.

-          Lipoproteins

• Composed of a lipid layer and a protein layer.
• The two components are arranged in a freely moving double layer.
• Polar region mix well with water and non-polar regions repels water.
• These properties allow the membrane to act as a barrier, keeping the cytoplasm within the cell and regulating what can enter the cell.

-          Receptor Sites

• Embedded in the lipoprotein membrane are a series of peripheral proteins with several functions.
• One type of protein located in the cell membrane is known as receptor site.
• Receptor sites are locations on the cell surface where molecules attach to stimulate a reaction within the cell.

-          Channels

• Channels are pores within the cell membranes made by protein in the cell wall that allow the passage of small substances in or out of the cell.
• There are specific channels for sodium, potassium, calcium, chloride, bicarbonate, and water.
• Some drugs are designed to affect certain channels specifically.
• For example, calcium channel blockers prevent the movement of calcium into a cell through the calcium channels.

1. C.      Cytoplasm

• The cell’s cytoplasm within the cell membrane.
• Consists of the cell materials outside the nucleus and inside the cell membrane
• The site of most cellular activities
• “Factory area” of the Cell
• The cytoplasm is consist of 2 major components:

1. Cytosol

• Semitransparent liquid which suspends the other elements
• The cytosol is largely composed of water and different nutrients.

1. Organelles

• Means “little organs”
• Specialized cellular components
• Each performing its own job to maintain the life of the cell.

Organelles

• Ribosomes
  • Tiny round, dark bodies made of proteins.
  • Actual sites of protein synthesis in the cell.
• Endoplasmic Reticulum
  • System of fluid filled-filled tubules or canals
  • Serves as a minicirculatory system for the cell because it provides a network of channels for carrying substances primary proteins.
• Golgi Apparatus
  • A series of flattened sacs.
  • Site of processing and packaging of protein in the cell.
• Mithocondria
  • “powerhouse” of the cell
  • Rod-shaped power plants within each cell that produce energy in the form of ATP.
• Lysosome
  • “digestive system” of the cell
  • Contains specific digestive enzymes that can break down proteins, nucleic acids, carbohydrates, and lipids.
• Cytoskeleton
  • “skeletal system” of the cell
  • Acts as a cell’s “bones and muscles” by furnishing an internal network that determines cell shape, supports other organelles, and provides the machinery needed for intracellular transport  and various types of cellular movements.

-          There are 3 systems of measurements

• Metric system
  • Was developed in the late 18^th century
  • The internationally accepted system of measure
  • Apothecary system
    • Was replaced by the metric system
    • Dates back to the middle ages and had been used in England since the 17^th century.
  • Household system
    • Commonly used in community and home settings.

Metric System

-          The metric system is a decimal system based on the power of 10.

-          The basic units of measure are gram (g, gm, G, Gm) for weight; liter (l, L) for volume; and meter (m, M) for length.

Apothecary System

-          Common system used by most practitioner s before the universal acceptance of the International Metric System

-          Now all pharmaceuticals are manufactured using the metric system, and the apothecary system is no longer included on any drug labels.

-          All medication should be prescribed and calculated using metric measures, but occasionally the use of the fluid ounce and grains is found. For those rare circumstances, nurses should have a general understanding of the apothecary system.

-          The apothecary system uses Roman numerals instead of arbic numbers to express the quantity. The roman numeral is placed after the symbol or abbreviation for the unit of measure.

• Ex. gr x stands for 10 grains.

-          In the apothecary system, the unit of weight is the grain (gr), and the units of fluid volume are the ounce (fluidounce), the dram (fluidram), and the minim (min).

Household System

-          Uses household containers such as spoons, cups and glasses as measuring devices.

-          Not as accurate as metric system  because of the lack of standardization.

1. Methods for Calculation

-          The four general methods for the calculation of drug dose are the (1) basic formula, (2) ration and proportion, (3) fractional equation, (4) and dimensional analysis.  These methods are used to calculate oral and injectable drug doses.

-          For drugs that require individualized dosing, calculation by body weight (BW) or by body surface area (BSA) may be necessary.

-          Before calculating drug doses, all units of measure must be converted to a single system.

Interpreting Oral and Injectable drug Labels

-          Pharmaceutical companies usually label their drugs with the brand name of the drug in large letters and the generic name in smaller letters.

-          The dose per tablet, capsule, or liquid (for oral and injectable doses) is printed on the drug label.

1. Method 1: Basic Formula (BF)

-          The basic formula is easy to recall and is most frequently used in calculating drug dosages.

D x V = A

H

-          D = desired dose (drug dose ordered by the health care provider)

H = on hand dose (drug dose on label of container)

V = vehicle (drug form in which the drug comes (tablet, capsule, liquid)

A = the amount calculated to be given to the client

1. Method 2: Ratio and Proportion

-          The ratio and proportion method is the oldest method currently used in the calculation of drug dosages.

H        :        V    ::    D        :        x                                                    

-          D = desired dose (drug dose ordered by the health care provider)

H = on hand dose (drug dose on label of container)

V = vehicle (drug form in which the drug comes (tablet, capsule, liquid)

x = the amount calculated to be given to the client

1. Method 3: Fractional Equation

-          The fractional equation method is similar to ratio and proportion except it is written as a fraction.

H = D

V    x

-          H = dosage on hand

V = vehicle

D = desired dosage

X = unknown

-          Cross – multiply and solve for x

1. Method 4: Dimensional Analysis

-          Dimensional analysis is a calculation method known as units and conversions. The advantage of DA is that it decreases a number of steps required to calculate a drug dosage. It is set up as one equation.

1. Identify the unit/form (tablet, capsule, ml) of the drug to be calculated. If the drug comes in tablet, then tablet = (equal sign)
2. The known dose and unit/form from the drug label follows the equal sign.

Order:  amoxicillin 500 mg

On the drug label: 250 mg per 1 capsule

Capsule =       1cap

                       250 mg

1. The mg (250 mg) is the denominator and it must match the next numerator, which is 500 mg (desired dose or order). The NEXT denominator would be 1 or blank.

Capsule =       1cap       X    500 mg  =

                       250 mg               1

1. Cancel out the mg, 250 and 500. What remains is the capsule and 2. Answer is 2 capsules

1. Method 5: Body Weight

-          The body weight method of calculation allows for the individualization of the drug dose and involves the following three steps:

1. Convert pounds to kilograms if necessary (lb / 2.2 = kg)
2. Determine drug dose per BW by multiplying as follows:

Drug dose x body weight = clients dose per day

1. Follow the basic formula, ratio and proportion, fractional equation, or dimensional analysis method to calculate the drug dosage.

1. Method 6 : Body surface area (BSA)

-          The body surface area (BSA) method is considered the most accurate way to calculate the drug dose for infants, children, older adults, nd cliets who are on antineoplastic agents or whose BW is low. The BSA, in square meters, is determined by where the person’s height and weight intersect the nomogram scale. To calculate the drug dosage the BSA method, multiply the drug dose ordered by number of square meters.

100 mg x 1.8 m2 (BSA) = 180 mg/day

Factors that influence the ability to maintain and achieve mental health:
 engaging in interpersonal communication
 significant others or support people
 personal strategies
 resorting to “human hiding places” or ego defense mechanisms
Ego Defense Mechanism
 mental processes first described by Sigmund Freud (1946).
 methods of attempting to protect the self and cope with basic drives or emotionally painful thoughts, feelings, or events.
 usually unconscious, specific intrapsychic adaptive efforts which are employed by the person to resolve emotional conflict and to cope with anxiety.
Characteristics
 it is automatic
 it is not the defense mechanism that is pathological but it is the frequency of its use
 used by both mentally healthy and mentally ill individuals
Purposes
 Self security protection
 Anxiety (or fear) reduction
 Mental conflict resolution
 Esteem (self) protection

1. REPRESSION
o An involuntary, automatic submerging of painful, unpleasant thoughts and feelings into the unconscious.
o Unconcious forgetting
o Ex. Woman has no memory of the mugging she suffered yesterday.
o Ex. Woman has no memory before age 7, when she was removed from abusive parents.

2. SUPPRESSION
o Intentional exclusion of forbidden ideas and anxiety producing situations from the unconscious level
o A voluntary forgetting or postponing
o The only DM operating at the conscious level.
o Students decides not to about a parent’s illness to study for a test.
o Woman tells a friend she cannot think about her son’s death right now.
o “I rather not talk about it, right now!”

3. CONVERSION
o Transferring of mental conflict or emotional anxiety into physical symptom to release tension.
o Emotional problems are converted to physical symptoms.
o Teenager forbidden to see X-rated movies is tempted to do so by friends and develops blindness, and the teenager is unconcerned about the loss of sight.
o A soldier experiences sudden blindness after witnessing his best friend dying from a grenade blast
o Diarrhea before exam.

4. SYMBOLIZATION
o An object, idea, or act represents another through some common aspect and carries the emotional feeling associated with the other.
o External becomes representations of internal.
o Allows emotional self-expression.
o Engagement ring symbol of love.
o A man who was spurned by a librarian develops a dislike of books and reading.

5. DISSOCIATION
o The act of separating and detaching a strong, emotionally charged conflict from one’s consciousness.
o Dealing with emotional conflict by a temporary alteration in consciousness or identity.
o This detached information is blocked from conscious awareness, which allows the person to defer or postpone experiencing an emotional impact or painful feelings.
o Amnesia that prevents recall of yesterday’s auto accident.
o Adult remembers nothing of childhood sexual abuse.
o A woman raped found wandering a busy highway – traumatic amnesia.

6. IDENTIFICATION
o “the imitator”
o Attempting to pattern or resemble the personality of an admired, idealized person.
o Nursing student becoming a critical care nurse because this is the specialty of an instructor she admires.

7. INTROJECTION
o Accepting another person’s attitude, beliefs, and values as one’s own.
o Incorporate feelings & emotions, values & beliefs, traits and personality.
o Symbolic assimilation or taking into oneself a love/hated object.
o Persons who dislikes guns becomes an avid hunter, just like a best friend.
o Acting & dressing like Jesus Christ.

8. SUBLIMATION
o Re-channeling of consciously intolerable or socially unacceptable behaviors or impulses into personally or socially acceptable.
o Person who has quit smoking sucks on hard candy when the urge to smoke arises.
o Person goes for a 15-minute walk when tempted to eat junk food.
o An aggressive person joins debate team.

9. COMPENSATION
o The act of making up for a real or imagined deficiency with a specific behavior ( by concentrating or developing other attributes.
o Overachievement in one area to offset real or perceived deficiencies in another area.
o Napoleon complex: diminutive man becoming emperor.
o Nurse with low self-esteem works double shifts so her supervisor will like her.

10. RATIONALIZATION
o Excusing own behavior to avoid guilt, responsibility, conflict, anxiety, or loss of self-concept.
o Attempting to justify or modify unacceptable needs and feelings to the ego, in an effort to maintain self respect and prevent guilt.
o Student blame failure on teacher being mean.
o Man says he beats his wife because she doesn’t listen to him.
o “It wasn’t worth it, anyway, it is all for the best.”

11. PROJECTION
o Attributing ones own unacceptable feelings and thoughts to others.
o Unconscious blaming of unacceptable inclinations or thoughts on an external object.
o “scapegoat”
o Man who has thought about same-gender sexual relationship, but never had one, beats a man who is gay.

12. DISPLACEMENT
o Feelings are transferred, re-directed or discharged from the appropriate person or objects to less threatening person or object.
o Ventilation of intense feelings towards persons less threatening than one who aroused those feelings.
o Person who is mad at the boss yells at his spouse.
o Child who is harassed by a bully at school mistreats a younger sibling.

13. UNDOING
o RESTITUTION
o Exhibiting acceptable behavior to make up for or negate unacceptable behavior.
o Person who cheats on a spouse brings the spouse a bouquet of roses.
o Man who is ruthless in business donates large amount of money to charity.

14. STEREOTYPING
o GENERALIZATION
o SPLITTING
o Viewing people as all good, and others as all bad.

15. REACTION FORMATION
o Person exaggerates or overdevelops certain actions by displaying exactly the opposite behavior, attitude, or feeling from what he or she normally would show in a given situation.
o OVERCOMPENSATION
o Woman who never wanted to have children becomes a super-mom.
o Person who despises the boss tells everyone what a great boss she is.
o Student hating her CI may act very courteously towards her.

16. REGRESSION
o Temporarily retreating to past levels of behavior that reduce anxiety, allow one to feel more comfortable, and permit dependency.
o Moving back to a previous developmental stage to feel safe or have needs met.
o Five-year-old asks for a bottle when new baby brother is being fed.
o Man pouts like a 4-year-old if he is not at the center of his girlfriend’s attention.
o A 27 year old acts like a 17 y.o. on her first date with a fellow employee

17. FIXATION
o Permanent or persistence into later life of interests and behavior patterns appropriate to an early age, without stressors.
o Immobilization of a portion of the personality resulting from unsuccessful completion of tasks in a developmental stage.
o Never learning to delay gratification.
o Lack of clear sense of identity as a adult.

18. INTELLECTUALIZATION
o The act of transferring emotional concerns into the intellectual sphere.
o Separation of the emotions of a painful event or situation from the facts involved; acknowledging the facts but not the emotions.
o Exaggeration of intellect.
o Person shows no emotional expression when discussing serious car accident.
o “Dear John” Letter the groom is trying to figure out with his room mate why his fiancée changed her mind – to avoid confronting her.

19. ACTING – OUT
o Dealing with emotional conflicts or stressors through actions rather than through reflection or feelings to feel temporarily less helpless or powerless.
o Physical or verbal aggression.

20. DENIAL
o Failure to acknowledge an unbearable condition
o Failure to admit reality of a situation or how one enables the problem to continue.
o Blocking the awareness of reality.
o Diabetic eating chocolate candy.
o Spending money freely when broke.
o Waiting 3 days to seek help for severe abdominal pain.

21. FANTASY
o Imagined events or mental images to express unconscious conflicts, gratify unconcious wishes or prepare for anticipated future events.
o Wishful thinking.
o Temporary flight from reality to ↓ anxiety.
o Daydreaming.

22. SUBSTITUTION
o The unconscious act of replacing a goal when it is blocked.
o The replacement of a highly valued unacceptable object that is more acceptable to ego.
o Replacing the desired unattainable goal with one that is attainable.
o Woman who would like to have her own children opens a day care center.

Mental Illness
 A state of imbalance characterized by a disturbance in persons’ thoughts, feelings and behavior.
 A mental disorder or condition manifested by disorganization and impairment of function that arises from various causes such as psychological, neurobiological and genetic factors.
 Illness or syndrome with psychologic or behavioral manifestations and / or impairment in functioning due to a social, psychologic, genetic, physical / chemical or biologic disturbance.
Population at risk for mental illness
 with familial or genetic predisposition to mental illness.
 with poor access to health care
 disadvantages (homeless and poor)
 misusing substance
 undergoing lifestyle
 victims of violence
 elderly poor
Misconceptions about Mental Illness
 Abnormal behavior is different or odd, easily recognized.
 Abnormal behavior can be predicted and evaluated.
 Internal forces are responsible for abnormal behavior.
 People who exhibit abnormal behavior are dangerous.
 Maladaptive behavior is always inherited.
 Mental Illness is incurable.

A. Drug Actions:
a. To replace or act as substitutes for missing chemicals.
b. To increase or stimulate certain cellular activities.
c. To depress or slow cellular activities.
d. To interfere with the functioning of foreign cells, such as invading microorganisms or neoplasm.
B. Theories of Drug Actions
a. Drug Receptors Interaction
o Receptor sites – location on a cell surface where certain molecules such as enzymes, hormones, drugs attach to interact with cell component.
o Receptor sites react with certain chemicals to cause an effect within the cell.
o “lock and key theory”
o Drug action may be:
1. Agonist
• Drugs interact directly with receptor sites to cause the same activity that natural chemicals would cause at that site.
• Ex. Insulin
2. Antagonist
• A drug has an affinity for a receptor but displays little or no intrinsic activity.
a. Competitive antagonist
o Competes with the agonist for receptor sites
b. Non-competitive antagonist
o Binds to receptor sites and blocks the effects of the agonist

b. Drug Enzyme Interactions
o Interferes with enzyme systems that act as catalyst from various chemical reactions.
o 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
o Ex. ACE inhibitors, inhibiting the release of angiotensin converting enzyme in the lungs, preventing the conversion of Angiotensin I to Angiotensin II which is a powerful vasocontrictor, preventing an increase in blood pressure.

c. Selective Toxicity
o All chemotherapeutic agent would act only on 1 enzyme system needed for life of a pathogen or neoplastic cell & will nor affect healthy cells.
o Ex. Penicillin

C. Classifications of Drug Action (in terms of speed of action)
a. Rapid
o few seconds to minutes.
o intravenous, sub-lingual, inhalation
b. Intermediate
o 1-2 hours after administration
o intramuscular, subcutaneous
c. Delayed/Slowed
o Several hours after administration
o oral and rectal

D. Parameters of Drug Action
Parameters – notable characteristics
a. Onset of action
o Latent period, interval between time the drug is administered and 1st sign of its effect.
b. Duration of action
o Period from onset until drug effect is no longer seen.
o Length of time the drug exerts pharmacologic effect.
c. Peak of action
o drug reaches its highest blood / plasma concentration
d. Termination of action
o point from onset at which drug effect is no longer seen

A. Absorption

- In order to reach reactive tissues, a drug must first make its way into the circulation.
- Absorption refers to what happens to a drug from the time it is introduced to the body until it reaches the circulating fluids.
- Drugs can be absorbed from many different areas in the body:
o GIT
o Mucous membranes
o Through the skin
o Through the lungs
o Through the muscle
o Through subcutaneous tissues

a. Cell Absorption
- Drugs can be absorbed into cells through various processes

1. Passive Absorption (diffusion)
o Movement of drug particles from an area of higher concentration to an area lower 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
o Oral drugs use passive transport
2. Active Absorption
o Movement of drugs particles from an area of low concentration to an area of high concentration.
o Energy is required
o Used to absorb electrolytes (Ex. sodium, potassium)
o
3. Pinocytosis
o Cells engulf the drug to carry it across the membrane.
o Transport fat-soluble vitamins (vitamin A,D,E,K)

b. Factors Affecting Drug Absorption
1. Blood Flow
2. Pain
3. Stress
4. Foods (High fat and solid foods)
5. Exercise
6. Solubility
7. Nature of the absorbing surface
8. pH
9. Concentration
10. Dosage form

c. Oral Administration of Drug

B. Distribution

- Process by which drug becomes available to body fluids & tissues
- The ways a drug is transported from the site of absorption to the site of action (transportation)
- Happens in the circulation (circulatory system)

a. Factors Affecting Distribution
1. Size of the organ
2. Blood flows
 drug is quickly distributed to organs with large supply of blood (heart, liver, kidneys)
 distribution to other internal organs, skin, fat, muscle is slower
3. Solubility
 Lipid-soluble or non lipid-soluble
 Lipid-soluble drugs can cross the blood-brain barrier & enter the brain
4. Protein binding

b. Protein Binding
- as drug travels trough the body, it comes in contract with proteins (albumin)
- the drug can remain free or bind to protein
- Portion of drug bound to protein is inactive, no therapeutic affect

1. Free/unbound portion
 (+) pharmacologic response
2. Highly protein bound drug
 89% of drug is bound to protein
 diazepam, piroxicam, valproic acid
3. Moderately high protein bound drugs
 61-89% bound protein
 Erythromycin, phenytoin
4. Moderately protein bound drugs
 30-60% bound to protein
 aspirin, lidocaine, pindolol, theophyline

5. Low protein-bound drugs
 30% bound to protein
 amikacin, amoxicillin

C. Metabolism/Biotransformation

- Also called detoxification.
- Refers to the bodies ability to change a drug from its dosage form to a more water soluble form that can be excreted
- A sequence of chemical events that change a drug to a less active form after it enters the body
- Permits the body to inactivate a potent drug before it accumulates & produces toxic effects
- Drugs can be metabolized several ways:
o Most drugs metabolized into inactive metabolites (products of metabolism), which are then excreted
o 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 don’t become active until they’re metabolized

a. Sites of Metabolism
1. Liver
 Through the drug metabolizing enzymes (microsomal enzymes, non-microsomal enzymes)
 1st pass effect/hepatic 1st pass – some drugs do not directly go into circulation but pass thru intestinal lumen to liver via portal vein
2. Plasma
3. Kidneys
4. Membranes

b. Factors Affecting Drug Metabolism
1. Diseases
 Liver cirrhosis and heart failure
2. Genetics
 People metabolize drugs rapidly, other more slowly.
3. Environment
 Smoking and stressful environment
4. Age
 Infants have immature livers that reduce the rate of metabolism.
 Elderly patients experience a decline in liver size, blood flow and enzyme production that also slows metabolism
5. Nutrition
 Liver enzymes involved in metabolism rely on adequate amounts of amino acids, lipids, vitamins and carbohydrates.
6. Insufficient amounts of major body hormones
 Decrease amounts of insulin and adrenal corticosteroids can reduce metabolism of drugs in the liver.

D. Excretion

- Removal of drug from the body
- Is the process by which drugs are eliminated from the body
- Drug is changed into inactive form & excreted by the body

a. Sites of Excretion
1. Kidney
 Free/unbound/water soluble drugs are filtered in kidneys
 Protein bound drug cannot be filtered in kidney
2. Lungs, exocrine (sweat, salivary, mammary) glands, skin, intestinal tract
b. Factors Affecting Excretion
1. Urine pH
 Normal urine pH is 4 – 5.8
 Acidic urine promotes elimination of weak base drugs
• Ex. Cranberry juice decreases urine pH
 Alkaline urine promotes elimination of weak acid drugs
• Ex. Nabicarbonate increases urine pH, use to eliminate as excess aspirin in the system due to overdose
2. Glomerular Filtration Rate
 The amount of glomerular filtrate in the glomerulus
• Glomerular Filtration
• Passive Reabsorption
• Active Secretion
 Nephron Glomerulus Proximal Tubule Bladder
 When there is a decrease in glomerular filtration rate drug excretion are slowed/impaired.
 Can result to drug accumulation
3. Half-life
 Time it takes for one half of drug concentration to be eliminated.
 Short half-life
• 4-8 hrs: given several times a day (ex. penicillin G)
 Long half-life
• More than 12 hrs: given 2x or 1x a day (ex. digoxin)

1. A.      Introduction to Drugs

-          The human body works through a complicated series of chemical reactions and processes.

-          Drugs are chemicals that are introduce into the body to cause some sort of change.

• Drugs will undergo process with in the body which involve breaking and eliminating the drugs, in turn affect the body’s complex series of chemical reactions.

-          Understanding how drugs act on the body to cause changes and applying that knowledge in the clinical setting are important aspects of nursing practice.

-          The nurse is in a unique position regarding drug therapy because nursing responsibilities include the following:

• Administering drugs
• Assessing drug effects
• Intervening to make the drug regimen more tolerable
• Providing patient teaching about drugs and drug regimen.
• Monitoring the overall patient care plan to prevent medication error

-          Knowing how drugs works make these tasks easier to handle, thus enhancing drug therapy.

1. B.      History

• Early drug – plants, animals & minerals
• 2700 BC – 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 (pharmacy) system (Arab doctors)

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 Eward Jenner, British Doctor)

Digitalis from foxglove plant for strengthening & slowing of heartbeat Vitamin C from fruits

• 19^th century – morphine & codeine extract from opium

      Introduction of atropine & iodine

      Amyl nitrite used to relieve anginal pain

      Discovery of anesthetics (ether, nitrous oxide)

• Early 20^th century – aspirin from salicylic acid

                        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

1. C.      Pharmacology

-          Is the study of the biological effects of chemicals.

-          It is the scientific study of the origin, nature, chemistry, effects and uses of drugs.

-          In clinical practice, health care providers focus on how chemicals act on living organisms.

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

• what the body does to the drug
• deals with beneficial effects of the drugs (medicines)
• source of drugs
• ex: penicillin from penicillium (fungi)

3. Pharmacotherapeutics – study of drugs used in the diagnosis, prevention, suppression, & treatment of diseases

4. Pharmacognonsy – study of drugs in their original unaltered state; origin of drugs

5. Toxicology – study of biologic toxins: study of poison & its effects deals with deleterious effects of physical & chemical agents (including drugs) in human

Nurses deal with Pharmacotherapeutics, or Clinical Pharmacology, the branch of pharmacology that uses drugs to treat, prevent, and diagnose diseases.

Clinical Pharmacology

-          Addresses two key concerns

• The drug’s effects on the body
• The body’s response to the drug

-          Because drug can have many effects the nurse must know which ones may occur when a particular drug is administered.

Effects of the Drug

1. 1.       Therapeutic Effect

-          The primary effect intended, that is the reason the drug is prescribed.

-          Also called desired effect.

1. 2.       Side Effect

-          The effect of the drug that is not intended.

-          Also called secondary effect.

1. 3.       Drug Allergy

-          The immunologic reaction to the drug.

1. 4.       Anaphylactic Reaction

-          A severe allergic reaction which usually occurs immediately following administration of the drug.

1. 5.       Drug Tolerance

-          A decreased physiologic response to the repeated administration of a drug or chemically related substance. Excessive increase in the dosage is required in order to maintain the desired therapeutic effect.

1. 6.       Drug Interaction

-          Effects of one drug are modified by the prior or concurrent administration of another drug, thereby increases or decreases the pharmacological action.

1. Drug Antagonism – the conjoint effects of two drugs is less than the drugs acting separately.
2. Summation – The combined effect of two drugs produces a result that equals the sum of the individual effect of each agent.
3. Synergism – The combined effects of drugs is greater than the sum of each individual agent acting independently.
4. Potentiation – The concurrent administration of two drugs in which one increases the effect of the other drug.

Therapeutic Effects of Drugs

1. 1.       Palliative

-          Relieves the symptoms of a disease but not affect the disease itself.

-          Ex. Analgesic for pain

1. 2.       Curative

-          Treats the disease condition

-          Ex. Antibiotic for infection

1. 3.       Supportive

-          Sustains body functions until other treatment of the body’s response can take over.

-          Ex Mannitol to reduce/ICP in a client for surgery due to brain tumor.

1. 4.       Substitutive

-          Replaces body fluids or substances.

-          Ex. insulin injection for diabetes mellitus

1. 5.       Chemotherapeutic

-          Destroys malignant cells

-          Ex. Cyclophophamide for cancer of the prostate gland.

1. 6.       Restorative

-          Returns the body to health.

1. D.      Drug Nomenclature
   1. CHEMICAL NAME – atomic/molecular structure of drug

• Ex. acetylsalicylic acid

1. 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
• ex. aspirin

1. 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
• ex. Aspilet

1. E.       Sources of Drugs

1. Plants – roots, bark, sap, leaves, flowers, seeds of medicinal plants

• digitalis (use as a herat stimulant) from wildflower, purple foxglove, dried leaves of plant
• active principles of plants
  • alkaloids – alkaline in reaction, bitter in taste, powerful in physiologic activity
  • atropine & scopolamine
  • morphine sulfate, cocaine, quinine, nicotine, caffeine
  • procaine
  • glycosides – digitalis
  • resin – soluble in alcohol; example – colonic irritant found in laxative cascara
  • gums – used in bulk-type laxatives: some used in certain skin preparations for their soothing relief
  • oils – castor oil, oil of wintergreen

2. Animal Products – 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

1. Inorganic Compounds – 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
• more potent, more stable, less toxic
• steroids – arthritis & other diseases
• sulfonamides/chemotherapeutic agents – kill microorganism slow their growth
• meperidine HCI (Demerol)

4. Synthetic Sources – many drugs developed synthetically after chemical in plants, animals, or environment have been screened for signs of therapeutic activity

1. Genetic engineering – alter bacteria to produce chemicals that are therapeutic and effective.

• Reordering of genetic information enables scientists to develop bacteria that produce insulin for human.

1. Chemical alterations – Scientists alter chemical with proven therapeutic effectiveness to make it better.

• Sometimes a small change in a chemical’s structure can make that chemical more useful as a drug, more potent, more stable, less toxic.

1. F.       Drug Classification

1. By Action
• Ant- 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; ex. Phenobarbital
• ANS – governs several bodily functions so that drugs that affect ANS will at the same time affect other systems functions; ex. scopolamine
• GIT – acts on muscular & glandular tissues; ex. loperamide
• Respiratory System – act on resp. tract, tissues, cough center, suppress, relax, liquefy & stimulate depth & rate of respiration; salbutamol
• Urinary system – act on kidney & urinary tract; ex. furosomide
• Circulatory system – act on heart, blood vessels, blood;  ex. Metroprolol

1. G.     Kinds of Drugs
2. 1.       Prescription Drugs

-          Also known as legend drugs

-          Can be dispensed if with prescription order; with specific name  of drug & dosage regimen to be used by patient.

1. 2.       Non-Prescription Drugs

-          Also known as Over – the – Counter Drugs

-          can be dispensed 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:

1. Delay in professional diagnosis & treatment of serious/potentially serious condition may occur
2. Symptoms may be masked making the diagnosis more complicated
3. Clients’ health care provider/pharmacist should be consulted before OTC preparations are taken
4. Labels/instructions should be followed carefully
5. Ingredients in OTC drug may interact with prescribed drug
6. Inactive ingredients may result in adverse reactions
7. Potential for overdose
8. Multiple medication users are at risk as more medications are added to therapy regimen
9. Interactions of medications are potentially dangerous

1. 3.       Investigational drug

-          new drugs undergoing clinical trails

1. 4.       Illicit/street drug

-          used/distributed illegally for non-medical purposes to alter mood of feeling

Psychiatric Nursing

• it is a specialized area of nursing practice that uses theories of human behavior as its scientific framework and requires the purposeful use of self as its art of expression.
• involves the diagnosis and treatment of human responses to actual or potential mental health problems.
• it is concerned with promoting optimum health for society – focusing on prevention of mental illness, health maintenance, manangement of or referral of mental and physical health problems, diagnosis and treatment of mental disorders, and rehabilitation

Historical Development of Psychiatric-Mental Health Nursing

Primitive Era           

• people believed spirits possesed the body and had to be driven away to effect a cure.
• sickness indicated displeasure of the gods and was punishment for sins and wrongdoings.

Before Christ (B.C.)

• the Greeks, Romans, and Arabs believed emotional disorders were an organic dysfunction of the brain.
• Hippocrates: proposed that mental illness was a disturbance of the body’s four basic substances, or “humors” – heat, cold, dryness and moisture.
• Aristotle: concluded that the mind was associated with the heart.
• Galen: emotional or mental disorders were associated with the brain.

Middle ages

• mentally ill people were excluded and confined away from society – lunatics, witches, or demons possessed by evil spirits.
• Bethlehem Royal Hospital, England (1403) – 1st mental hospital

Historical Development of  Psychiatric Nursing (Peplau, 1956)

• Phase 1: The Emergence of Psychiatric-Mental Health Nursing (1773-1881)
• Phase 2: Development of the Work Role of the Nurse in Psychiatric-Mental Health Facilities (1882-1914)
• Phase 3: Development of Undergraduate Psychiatric-Mental Health Nursing Education (1915-1935)
• Phase 4: Development of Graduate Psychiatric-Mental health Nursing Education (1936-1945)
• Phase 5: Develpoment of Consultation and Research in Psychaitric-Mental Health Practice (1946-1956)

Phase 1: The Emergence of Psychiatric-Mental Health Nursing (1773-1881)

• identification of special institutions for individuals with psychiatric disorders – Eastern Lunatic Hospital, Williamsburg, Virginia.
• Benjamin Rush: the father of American Psychiatry, wrote the 1st textbook on psychiatry.
• Johann Weyer: first psychiatrist.
• Dorothea Lynde Dix: devoted her life to the cause of building state mental hospitals and helped improved the humane treatment of mentally ill people.
• Emil Kraepelin (1856 to 1929) differentiated manic-depression psychosis from schizophrenia and stated that schizophrenia was incurable.
• Sigmund Freud (1856 to 1939) introduced psychoanalytic theory and therapy.
• Eugene Bleuler (1857 to 1939) described the psychotic disorder of schizophrenia.
• Alfred Adler (1870 to 1937) focused on the area of psychosomatic medicine, referring to organ inferiority as the causative factor.
• Carl Jung (1875 to 1961) described the human psyche as consisting of a social mask (persona), hidden personal characteristics (shadow), feminine identification in men (anima), masculine identification in women (animus), and the innermost center of the personality (self).

Phase 2: Development of the Work Role of the Nurse in Psychiatric-Mental Health Facilities (1882-1914)

• McLean Hospital, Belmont Massachusetts (1882) – established the first training school for nurses in the psychiatric setting.
• (1890) trained nurses were employed on nursing staff of state mental hospitals.
• Annie Payson Call (1891) wrote the first psychiatric literature by a  psychiatric nurse.
• Mary E. May (1899) wrote the first paper about the work of a nurse in a psychiatric facility: The Work of Nursing the Insane.
• Effie Jayne Taylor: first professor of psychiatric nursing and outlined the curriculum of the undergraduate psychiatric nursing program at Johns Hopkin’s Phipps Psychiatric Clinic.

Phase 3: Development of Undergraduate Psychiatric-Mental Health Nursing Education (1915-1935)

• Linda Richards (1915)  first graduate nurse in the US – “first American psychiatric nurse”.
• Journals published and textbooks focusing on psychiatric nursing were written.
• Harriet Bailey (1920) – wrote the first textbook of psychiatric nursing: Nursing Mental Diseases.
• new treatment approaches were introduced: electroconvulsive therapy (ECT).

Phase 4: Development of Graduate Psychiatric-Mental Health Nursing Education (1936-1945)

• (1937) clinical experiences in psychiatric hospitals were standardized:
  • students were given the opportunity to care for patients with varying degrees of mental disorders including organic origin.

• (1939) approximately half of the nursing schools provided psychiatric nursing courses for students.
• (1955) psychiatric nursing became a requirement for licensure.
• National League of Nursing Education developed curriculum guidelines for graduate education:
  • 60 to 80 hours of theoretical instruction, and
  • 12 to 16 weeks of clinical experience.

Phase 5: Development of Consultation and Research in Psychiatric-Mental Health Practice (1946-1956)

• passage of Mental Health Act of 1946.
• Helen Render (1947) wrote Nurse-Patient Relationships in Psychiatry.
• (1956) National League of Nursing Education formed a committee to review and revised a proposed guide for the development of an advanced clinical course in psychiatric nursing.

• Brown Report: stressed that the interest in the field of psychiatry should be stimulated to facilitate research focusing on the prevention and cure of mental illness.

1956 and beyond.

• Phenothiazines and other major tranquilizers were developed and used to treat the major symptoms of pyschoses.
• (1963) the Community Mental Health Act authorized funding for the establishment of community health centers to provide services to the public.
• 20th Century – Psychiatric nursing began to evolve as a clinical specialty. 

Psychiatric-Mental Health Nursing Today

Use of Psychiatric-Mental Health Nursing Skills in Career Opportunities

Obstetric Nursing

• helping the mother in labor and support person cope with anxiety or stress during labor and delivery.
• providing support to bereaved parents in the event of fetal demise, inevitable abortion, or the birth of an infant with congenital anomalies. providing support to a mother considering whether to keep her child or give the child up for adoption.

Forensic Nursing

• providing services to incarcerated clients.
• acting as a consultant to medical and legal agencies.
• serving as an expert witness in court.
• providing support for victims of violent crime.

Oncologic Nursing

• helping cancer patients or other terminally ill individuals on oncology units work through the grieving process.
• providing support groups for families or terminally ill individuals on oncology units through the grieving process.

Industrial (Occupational Health) Nursing

• implementing or participating in industrial substance abuse programs for employees and thier families.
• providing crisis intervention during an industrial accident or the acute onset of a physical or mental illness.
• teaching stress management.

Public Health Nursing

• assessing the person both physically and psychologically.

Office Nursing

• assisting the client by explaining somatic or emotional concerns during assessment.
• providing support with the problem-solving process when people call the office and the physician is unavailable.
• acting as a community resource person.

Emergency Room Nursing

•  providing crisis intervention as the need arises.

Partial pressure of oxygen (PaO2): Greater than 80 mm Hg (greater than 10.6 kPa)
Partial pressure of carbon dioxide (PaCO2): 35-45 mm Hg (4.6-5.9 kPa)
pH: 7.35-7.45
Bicarbonate (HCO3): 23-30 mEq/L (23-30 mmol/L)

Oxygen content (O2CT): 15-22 mL per 100 mL of blood (6.6-9.7 mmol/L)
Oxygen saturation (O2Sat): 95%-100% (0.95-1.00)
The concentration of oxygen being breathed, called the fraction of inhaled oxygen (FiO2), is also usually reported. This is only useful if you are receiving oxygen therapy from a tank or are on a ventilator.
Many conditions can change blood gas levels. Your doctor will talk with you about any abnormal results that may be related to your symptoms and past health.
What Affects the Test
Reasons you may not be able to have the test or why the results may not be helpful include the following:
• You have a fever or an abnormally low body temperature (hypothermia).
• You have a disease that affects how much oxygen is carried in your blood, such as severe anemia or polycythemia.
• You smoke just before the test or breathe secondhand smoke, carbon monoxide, or certain paint or varnish removers in closed or poorly ventilated areas.
What To Think About
• Arterial blood gas (ABG) values alone don’t provide enough information to diagnose a problem. For example, they can’t tell whether low levels are caused by lung or heart problems. Arterial blood gas values are most helpful when they are reviewed with other examinations and tests.
• An ABG test is often done for a person who is in the hospital because of severe injury or illness. The test can measure how well the person’s lungs and kidneys are working and how well the body is using energy.
• An ABG test may be most useful when a person’s breathing rate is increased or decreased or when the person has very high blood sugar (glucose) levels, a severe infection, or heart failure.
• If several blood samples are needed, a thin tube (arterial catheter) may be placed in an artery. Blood can then be collected when needed.