Materia medica for nurses

Front matter

Class JRi^lLS.

Book _b±

OoipghtN .

Preface

The modern nurse is no longer merely the gentle attendant at the sick bed, able to perform only a few practical duties, but she is now also a watchful trained observer; of symptoms of disease, of the development of complications, and of the effects of drugs and their poisonous symptoms. In this capacity, and because of her constant presence at the bedside, she is of inestimable value to the physician in the management of the complex and often treacherous phenomena of disease.

The object of this text book is to develop intelligent, trained observers of the effects of drugs and to enable the nurse to administer medicines accurately. The majority of text books for nurses are entirely too technical, with the result that the nurse learns a great many technical terms without gaining a clear idea of the changes that drugs produce in the functions of the human body. An attempt is therefore made to present the subject in a strictly pedagogic manner, to teach facts, not words, and always to proceed from the known to the unknown. The new matter presented is based throughout upon facts previously explained. The pharmacological action is arranged in a simple, concise manner to facilitate the remembrance of the text. The numerous tables scattered throughout the book are intended to correlate the facts already learned; for example, a table of Cardiac Stimulants follows the discussion of the drugs in this group; a table of comparative actions follows that of the Atropine group, etc.

It is also essential that, before taking up the changes which drugs produce in the action of the body, the nurse have some idea of the normal action of the body. For this reason there have been scattered through the text numerous notes on Normal Physiology wherever it was felt to be necessary to a clear understanding of the drugs presented, since the arrangement of the curriculum in most training schools is such that Physiology is often studied at a later time than Materia Medica.

The nurse has ample opportunity, in the wards, to observe the effects of drugs on actual patients; but she does not benefit from this opportunity because her observation is untrained. It is to viii PREFACE

assist and train her observation that the descriptions of the "Appearance of the Patient" are inserted in the text. This enables the nurse to compare the effects of a particular drug, given to an individual patient, with the standard description of that drug as given in the text.

Little attention is given to therapeutics; as the nurse should never treat, but administer and observe. It is occasionally important, however, that in administering certain potent drugs she should have some idea of the reason for such administration, to aid her in the observation of their effects. Short notes on the use of some of the important drugs are therefore inserted.

The chapter on " Solutions" deals with this very important subject at great length, because the proper and accurate administration of drugs, and the preparation of accurate solutions, is of prime importance to the nurse. Most of the rules for the calculation of solutions given in the text are entirely original and have been found in actual practice to be the easiest and simplest. This chapter also contains many helpful tables, such as " Saturation Points," "Usual Strengths of Standard Solutions," etc.

This book is perhaps larger than many texts on this subject but this is due to the inclusion in the text of the following features usually not dealt with: the chapter on "Solutions"; the chapter on "Prescription Reading," a subject required by most State Boards; and particularly by the inclusion, among the preparations, of most of the "New and Non-Official Remedies" in common use. Many of these substances are extensively used, and it is the nurse who has to administer them. Where is she to find the action and preparations of these drugs if not in her text book?

The classification of the drugs is based upon their therapeutic use since the nurse learns their action in this way. They are arranged in two distinct groups: "Stimulants" and "Depressants," and then according to the particular organs of the body they principally affect.

I desire to express my sincere thanks to Dr. Richard Stein and Dr. Norbert Stadtmueller for their careful examination of the proofs; and to Miss Anna L. Schulze, R. N., former Superintendent, and Miss Elizabeth P. Lindheimer, R. N., the present Superintendent of the German Hospital Training School for Nurses, New York, for valuable suggestions.

I avail myself of the opportunity to acknowledge the use, as references, of the following works: "Pharmacology and Therapeutics," by A. R. Cushny; "Therapeutics, Its Principles and

PREFACE ix

Practice/' by H. C. Wood; " Essentials of Materia Medica and Therapeutics/ ' by Henry Morris; "New and Non-Official Remedies/' 1913 edition, of the American Medical Association; and to notes on the Lectures on Pharmacology delivered by Dr. W. A. Bastedo at the College of Physicians and Surgeons (Columbia University), New York.

A. S. Blumgarten. 1114 Madison Ave., New York.

Introduction

Materia Medica is the study of the substances used in treating the sick. Most of these substances are drugs, while many of them are serums, solutions of bacteria, or extracts of organs.

The subject is divided into three distinct branches.

Materia Medica proper, or pharmacognosy, which deals with the botanical, chemical and physical properties of drugs.

Pharmacology or pharmacodynamics, which is the study of the action, or the effects of drugs; that is, the study of the changes which drugs produce in the activities of the body, or of its organs.

Therapeutics, which deals with the treatment of disease by drugs.

For the nurse, only the first two branches of Materia Medica are of importance, as she is never called upon to treat patients, nor should she ever do so without orders from a physician. She should know, however, the properties and effects of drugs, for the physician relies upon her to see that their proper effects are obtained, and that no unusual or poisonous symptoms occur. When these do occur, she should be able to recognize them at the earliest possible moment.

Drugs are obtained from the mineral, vegetable, or animal kingdoms. Those that are obtained from the vegetable kingdom, are made from various parts of plants, such as the roots, the bark, the flowers or the fruit. In some instances the sap, or even the entire plant is used.

l

From the crude plant, various preparations are made, so as to be able to regulate the strength, or measure the dose of the drug more accurately; in some instances to make the drug more palatable, or to disguise its unpleasant taste.

The following is a list of the more commonly used preparations.

Common name

Latin name

Common name

Latin name

Powder

Pulvis

Cerate

Ceratum

Pill

Pilula

Confection

Confectio

Capsule

Capsula

Ointment

Unguentum

Tablet

Tabella

Plaster

Emplastrum

Cachet

Cachet

Sterule

Sterula

Lozenge

Trochiscus

Lamella

Lamella

Vescette

Vescette

Suppository

Suppositorium

Extract

Extractum

Paper

Charta

Resin

Resina

Common name

Latin name

Common name

Latin name

Infusion

Infusum

Spirit

Spiritus

Fluidextract

Fluidextractum Wine

Vinum

Tincture

Tinctura

Mixture

Mistura

Solution

Liquor

Vinegar

Acetum

Aqua

Mucilage

Mucilago

Emulsion

Emulsum

Oleate

Oleatum

Syrup

Syrupus

Oleoresin

Oleoresina

Glycerite

Glyceritum

Liniment

Linimentum

Decoction

Decoctum

DEFINITIONS OF PREPARATIONS

Powder: A crude drug ground up in the form of a powder and used in this form.

Pill: A pill is a drug moulded in the form of a very small sphere. Pills should always be fresh, for when they are exposed to the air, they may become so hard, that they cannot be dissolved by the juices of the stomach or intestine, and they then produce no effects.

Capsule: A drug made up in a small cylindrical gelatin container which disguises the taste of the contained substance.

Tablets are dried powdered drugs which have been compressed into small discs. They are usually prepared in an aseptic manner so that they can be given hypodermically. They are very easily dissolved.

Cachets are small disc-like pieces of rice paper which are stuck together, enclosing between them the drug to be administered.

Lozenges are flat discs consisting of a drug made up with sugar or tragacanth.

Vescettes are effervescent salts compressed into a tablet.

Extract: An extract is a solid preparation obtained by dissolving the drug in alcohol or water, and then evaporating the solution. The resulting sediment is the extract, and is usually about four or five times as strong as the crude drug itself.

Resins are gummy substances which can be dissolved in alcohol, but not in water.

Cerates are preparations of drugs made up with white wax.

Confections are preparations of drugs made up to disguise the taste of unpleasant tasting substances. They are usually made up with honey and sugar.

Ointments are preparations which are applied to the skin and are melted by the heat of the body. The drugs which they contain are then absorbed by the skin. They are usually made up with lard, vaseline, or oils.

Plasters are preparations which are made up with resins, wax or lead plaster, and are then spread upon coarse muslin or white leather. They are applied to the skin, the mixture of the drugs which they contain is dissolved by the heat of the body, and the drugs are then absorbed by the skin.

Sterules are glass capsules containing a sterile solution of a drug. They are used for hypodermic administration.

Lamellae are small gelatin discs containing medicinal substances, which are inserted between the lower eyelid and the eyeball.

Papers are small pieces of paper impregnated with medicinal substances.

Suppositories are cone-shaped preparations of a drug made up with cocoa butter.

LIQUID PREPARATIONS

Infusions are preparations of plant drugs made by pouring hot or cold water over them, and then letting the drug steep for some time. The strength of an infusion depends on how much of the drug is used to a definite quantity of water.

Fluidextracts : Fluidextracts are preparations of plant drugs made by first making an extract of a drug and then dissolving this extract in alcohol or water in such quantities, that the resulting fluid contains 100% of the drug. It is therefore just as strong as the crude drug itself, but is in fluid form.

Tinctures are preparations of plant drugs, or other substances which do not evaporate easily, dissolved in a fluid other than water or glycerin. They are usually dissolved in alcohol and are now mostly 10% in strength. By a tincture, we usually mean an alcoholic solution unless the fluid in which the drug is dissolved is specially mentioned. For example, ammoniated tincture means a solution of a drug in ammonia water; while an ordinary tincture means a weak alcoholic solution.

Solutions are drugs dissolved in water. Solutions usually contain substances which do not evaporate easily.

Waters are solutions of substances which evaporate very easily.

Emulsions are solutions of oily substances which contain the oil divided up into fine globules. They are usually of a milky color and consistency.

Elixirs are palatable preparations of drugs. They are made up with alcohol, sugar and some aromatic substance. They usually contain very smali quantities of the drug.

Syrups are preparations of drugs made with sugar and water.

Glycerites are preparations of drugs dissolved in glycerin.

Decoctions are preparations of plant drugs made by boiling them in water and then straining the fluid.

Spirits are preparations of volatile substances in alcohol.

Wines are preparations of drugs dissolved in wine.

Mixtures are preparations consisting either of several drugs mixed together, or a fluid containing a substance which does not dissolve.

Vinegars are medicinal substances dissolved in a weak solution of acetic acid, or vinegar.

Mucilages are gummy drugs dissolved in water.

Oleates are medicinal substances dissolved in oleic acid, which is an ingredient of many oils and fats. Oleates are more easily absorbed than ointments.

Oleoresins are extracts of plant drugs obtained by dissolving them in ether. They usually consist of a mixture of a resin, and an oil which evaporates easily (volatile oil). They are very concentrated preparations.

Liniments are liquid or soft preparations of drugs which are applied by rubbing on the skin. The drug is usually dissolved in alcohol or in an oily substance.

OFFICIAL AND UNOFFICIAL PREPARATIONS

In order that all drugs should be uniformly prepared, and a standard set for the strengths of the different preparations, a committee of physicians and pharmacists is appointed in every country to regulate the strengths and preparations of all the drugs used in medical practice. This committee publishes a book known as the Pharmacopoeia, which contains a list of all the preparations of drugs whose ingredients, strengths and methods of preparations are up to a certain standard. Such preparations are called official preparations, and often have the letters, U. S. P. (United States Pharmacopoeia), B. P. (British Pharmacopoeia), etc., written after them. Some preparations may be official in one country and not in another, though they may be used in both countries.

UNOFFICIAL PREPARATIONS

Since the Pharmacopoeia committee revises the Pharmacopoeia only once in ten years, and since many drugs and preparations are discovered in the meantime, many of which may be extensively used during that time, though they are not described in the Pharmacopoeia, these drugs are called unofficial preparations. Many of the unofficial preparations are accepted by the Pharmacopoeia committee as being up to a certain standard in strength, ingredients and action, at their next revision, and these drugs then become official preparations.

Other unofficial preparations may not be accepted by the Pharmacopoeia committee, though they may be extensively used.

The National Formulary and United States Dispensatory, are private unofficial books containing a list of both official and unofficial preparations, their ingredients, preparations, and their methods of preparation.

ACTIVE PRINCIPLES

It was formerly thought that certain plants cured disease because of magic or supernatural powers which these plants possessed; and unless certain formalities were complied with, in obtaining these drugs, they were not supposed to have any curative effect.

For example, in obtaining the drug hyoscyamus (henbane) it was necessary that the drug be dug up with certain precautions, and addressed as follows:

" Sacred herb, I summon thee to the house (of my patient) to stop the Rheum of his feet, etc. I conjure thee by the great name Jaoth Sabaoth." We now know that this drug has certain active principles (the alkaloids, atropine, hyoscyamine, hyoscine) which cause its effects.

In gathering other drugs it was necessary to " Delve round the root and take it up with thy two hands turned upward;

and sing over it nine paternosters, and in the ninth, at the words l Deliver us from evil' snap it up," etc., or it was necessary to mention the name of the sick man and his father, etc., etc.

We now know, however, that all drugs (particularly, the plant drugs) cause changes in the activity of the body by virtue of certain chemical substances which they contain. These principles contained in the plant, and which if extracted from the plant, produce the same effects as the crude drug itself, are called active principles.

The most important active principles are of two kinds, alkaloids and glucosides.

Alkaloids

An alkaloid is an active principle, found in plant drugs or made chemically, which acts like an alkali. (An alkali is a chemical substance which combines with acids to form salts. It turns red litmus paper blue). Alkaloids also combine with acids to form salts, and their salts have the same effects as the alkaloids themselves.

For example, when sodium, an alkali, is added to sulphuric acid, a salt, sodium sulphate, is formed.

When morphine, an alkaloid, is added to sulphuric acid, a salt, morphine sulphate, is formed.

The alkaloids have a definite chemical composition, but they do not dissolve readily in water. The salts which they form, however, dissolve very easily in water, and are principally used to produce the effects of the alkaloids.

Glucosides

A glucoside is the active principle of a plant drug, which, when it is decomposed into simpler substances, for example by the action of an acid, one of the simple substances thus formed is always glucose (grape sugar), or another sugar. The other substance formed is usually an aromatic substance.

Chemical Action

Drugs belonging to the mineral kingdom usually act by combining chemically with some of the body secretions, or if they are salts, they are absorbed as such, and then they may act like an alkaloid, or physically, according to the laws of physical chemistry.

Drugs produce two kinds of effects; local or general effects. They may produce changes in an organ or tissue of the body if applied directly to that organ or tissue. The effect which is then produced is called a local effect.

They may enter the blood stream, and then affect one or a number of organs in their travels through the circulation of the blood. The effect then produced is called a general effect.

A drug may enter the blood stream through the skin, through the mucous membranes of various organs, such as the lungs, the stomach, the intestines or the rectum. It may be injected directly into a vein, into a muscle, or under the skin, and the drug then finds its way into the blood from these tissues.

LOCAL ADMINISTRATION

To obtain a local effect, drugs are applied in the following

forms :

Liniments

Oleates

Cerates

Powders

Lozenges

Bougies

Suppositories

Plasters

Ointments

Solutions, Oleates and Liniments are applied to various regions of the body, in the form of wet dressings. In the mouth or mucous membrane lined cavities, solutions are applied as mouth washes or irrigations.

Powders are applied directly to the surface of the body, as a spray.

Lozenges are kept in the mouth, they are dissolved by the saliva, and the medicinal substances which they contain then produce their effect.

Bougies are long thin medicated tubes, made with wax. They dissolve in mucous membrane lined cavities, and then produce either local or general effects.

Suppositories are cone-shaped preparations of drugs made with cocoa butter, and are applied in the same manner as bougies.

Plasters are usually applied on the surface of the body which is to be affected, and they are then left on for about fifteen minutes to a half hour.

Ointments are rubbed on the skin and produce either a general or local effect* For local effect they may be spread on a piece of gauze or lint and applied directly to the surface.

GENERAL EFFECTS

To produce general effects, a drug must enter the blood stream.

The most rapid way that a drug can enter the blood stream, is by being injected directly into a vein.

METHOD OF GIVING AN INTRAVENOUS INJECTION

The median basilic, or median cephalic vein of the front of the elbow is used, as the most suitable vein for injection. A rubber or gauze bandage is tightly wound around the middle of the arm, the hand is gripped firmly, and the forearm is extended. This makes the vein stand out prominently. The surface of the skin over the vein is sterilized with green soap, 50% alcohol and 1-2000 bichloride of mercury, or the site may be painted with tincture of iodine.

A hypodermic syringe (sterilized) is then filled with a sterile solution of the drug to be injected, the air is expelled from the syringe and the needle is then inserted into the vein, pointing it towards the heart, and the blood slightly aspirated from the vein. If blood is aspirated from the vein and enters the syringe you are sure the needle is in the vein.

The bandage at the arm is then loosened, and the solution of the drug is injected very slowly. It is very important to inject drugs into the vein slowly, the slower it is injected, the safer is the injection. Serious effects, at times fatal, have resulted from too rapid injections.

The effect of a drug after an intravenous injection appears immediately.

Another method of injecting a drug into the blood, is by dissolving it in normal saline solution and giving it by means of an intravenous infusion.

METHOD OF GIVING AN INTRAVENOUS INFUSION

The arm is prepared as for an intravenous injection, the fluid is prepared in a special glass jar, which is placed on a stand above the level of the patient. The fluid is then allowed to run through a rubber tube attached to either a special cannula to fit into the vein, or to a specially constructed needle. If the needle is used, it is inserted directly into the vein. If the cannula is used, the vein must be exposed, opened, and the cannula inserted into it in a direction towards the heart.

Recently a method has been devised for administering a specific drug for syphilis, Salvarsan, in this manner.

A new method of anaesthetizing patients has been recently devised, where the anaesthetic is dissolved in the saline solution and administered as an intravenous infusion.

METHOD OF GIVING AN INTRAMUSCULAR INJECTION

This is another method to cause rapid absorption and therefore rapid effects.

The sites for such injection, are usually in the buttocks, and the front of the thighs.

The skin is sterilized by washing it with green soap, alcohol and bichloride of mercury 1-2000, or it is painted with tincture of iodine. A large syringe is used with a firm needle. This is inserted perpendicularly into the skin, the syringe is then removed, or the site for injection is aspirated, to see if the needle has been stuck into a large vessel. If blood oozes from the needle, another site must be chosen. If there is no blood oozing through the needle, the solution may be injected, but very slowly, and the site of injection should be thoroughly massaged afterwards. The site of injection is then covered over with collodion or some other dressing.

METHOD OF GIVING A HYPODERMIC INJECTION

The skin at the site of injection is usually sterilized with alcohol. The syringe is filled with a sterile solution of the drug to be administered, the skin is then taken up between the thumb and index finger of the left hand, and the needle is inserted under the skin at an angle of about forty-five degrees, and the solution slowly injected. The skin at the site of the injection is^then thoroughly massaged.

Care must be taken to insert the needle under the skin, not into the skin, in which case the skin looks like goose skin, and the needle should be withdrawn.

The best sites for injections, are the front of the thighs, the arms and forearms.

The effects appear in about ten minutes to a half hour after injection, depending on how good the patient's circulation is.

METHODS OF GIVING DRUGS FOR ABSORPTION FROM

THE SKIN

To administer drugs for absorption from the skin, it is necessary to rub the drug thoroughly on the skin in such a manner that it will not evaporate very easily. For this purpose ointments are used. These must be rubbed thoroughly over a large surface, to get the greatest amount of absorption. As the pores of the skin become clogged up with the ointment after continued use, the ointment is usually rubbed in a different region of the body every day. For example, on one thigh one day, on the other, the next day; then it is rubbed on the arms, then on the chest, finally on the back.

This is called a course of rubbings, or inunctions. In applying potent drugs in the form of rubbings, the nurse should protect her hands from absorbing the drug by using old kid gloves, or by rubbing the ointment with a piece of chamois.

Another method of applying drugs to the skin for absorption is by means of vapor. The patient sits in a closed cabinet, the head protruding from the top, while underneath the chair the drug to be given is burnt, the fumes being absorbed by the skin.

INTERNAL ADMINISTRATION

The most common way of administering drugs, however, is to let the patient drink or swallow them. The drug is dissolved in the stomach or intestines, if it is not already in a fluid form. It is then absorbed by the mucous membrane of the stomach or intestine, and enters the blood stream in this manner.

Many drugs are given by the rectum, in cases where it may not be possible, or when it is harmful to give them by the stomach. In such cases they are given in the form of suppositories, which are inserted into the rectum, the cocoa butter dissolves, and the contained drug goes through the mucous lining of the rectum into the blood stream.

Drugs may also be given by a rectal enema, or even better, by allowing it to run in drop by drop in saline solution through a catheter attached to an apparatus arranged at the side of the bed, the pressure of which can be easily regulated (Murphy Method).

TIME OF ADMINISTRATION

With some exceptions, it is not of very great importance whether a drug is given before or after meals.

As a rule, drugs which increase the appetite or which increase the secretion of the stomach or intestines should be given before meals.

Those that are given to neutralize excessive secretions in the stomach, or those that are harmful (irritating) to the stomach should be given after meals.

DOSAGE

All drugs are poisons — they are harmful to the individual; in fact they may even cause death if given in sufficiently large quantities.

The harm to the individual is done by causing an overactivity of some, or of all the organs of the body (over stimulation, irritation), or by lessening the activity of an organ or several organs to a very marked degree (depression). It is by taking advantage of these activities of drugs, that they can be used in the treatment of disease. The difference, however, between beneficial and poisonous or dangerous effects, is simply due to the difference in the amount of drug that is used.

By experiments on animals, it can be determined how little of a drug can be given in order to produce any change in the activity of an organ, or the activity of the body: — such an amount is called the minimum or smallest dose. By similar experiments we can find out how large an amount of a drug can be given without producing any dangerous effects. This amount is called the maximum dose. If larger quantities than the maximum dose are given, we get poisonous or dangerous symptoms — such a dose is called an overdose, or poisonous dose.

The doses of different drugs are different ; some drugs may be found to have accidentally the same dose.

Conditions Influencing the Dose of a Drug

There are certain conditions which influence the dose of a drug.

(1) Age : An older person usually needs a larger dose than a younger one.

(2) Sex: Males usually require larger doses than females.

(3) Weight: Heavier, stouter individuals, usually require larger doses than lighter individuals.

(4) Temporary Conditions: After a meal there is usually less absorption than before, the effects are therefore not as marked.

(5) Time of Administration: For example, some drugs, such as those which produce sleep, may produce little effect in the morning, and more marked effect in the evening.

(6) Pregnancy, Lactation, and Menstruation are factors which occasionally cause changes in the activity of certain drugs.

Young's Rule for Dosage

To determine the dose of a drug to be administered to a child, we fill in the known amounts in the following formula, and then calculate it. The result is the fraction of the adult dose to administer.

Young's Rule: Age of the child, divided by (age + 12) = the fraction of the adult dose, or age

of adult dose.

age + 12

For potent drugs, a slightly smaller quantity should be administered, and for some drugs a slightly larger dose should be administered.

Example: How much Aspirin should be given to a child of 3 years old. Adult dose of Aspirin = grs. 5

Age of child = 3

3 3 1

3+12 15 5

We therefore give the child £ of (grs. 5) or gr. 1 of Aspirin.

IDIOSYNCRASY

There are some individuals who get unusual or opposite effects, others who get even poisonous effects, from ordinary doses of some drugs. There are others, upon whom even larger doses of some drugs produce no effect at all. Such people are said to have an idiosyncrasy against a particular drug.

There are two kinds of idiosyncrasies.

(a) Idiosyncrasy of Effect: Those that get opposite, unusual or poisonous effects from small or ordinary doses of drugs.

(b) Idiosyncrasy of Dose: Individuals who get no effect at all from ordinary, or even large doses of certain drugs.

For example, morphine is a drug which usually produces sleep and quiets the patient. There are some people in whom it may cause excitement and keep them awake.

Another example, is one in whom even larger doses of morphine produce no effect at all.

Chapter II

There are two systems of measuring drugs. One is the French or Metric System, the other is the English or Apothecaries' System.

The Metric System is the one which is used in all European countries, and has the advantage, that the units are divided into tenths, that the units of length, volume and weight are similar, and that the units of volume are equal to the units of weight.

In this country, the Apothecaries' System is still used, but it is gradually being superseded by the Metric System, and it is simply a question of time when the Apothecaries' System will be abandoned entirely.

THE METRIC SYSTEM

The elementary unit of measurement in the Metric System is the one for length. This is the meter, which is about one ten-millionth part of the distance from the equator to the north pole. It is equal to about 39.37 inches and is written as 1.0