CHAPTER 1 The Nursing Process and Drug Therapy

CHAPTER 1 The Nursing Process and Drug Therapy

Learning Objectives n n 1. List the five phases of the nursing process. 2. Identify the components of the assessment process for patients receiving medications, including collection and analysis of subjective and objective data. 3. Discuss the process of formulating nursing diagnoses for patients receiving medications. 4. Identify goals and outcome criteria for patients receiving medications.

Learning Objectives n n 5. Discuss the evaluation process as it relates to the administration of medications and as reflected by goals and outcome criteria. 6. Develop a nursing care plan with use of the nursing process as it is related to medication administration. 7. Briefly discuss the Five Rights of drug administration and the related professional responsibility for safe medication practice. 8. Discuss the additional rights of drug administration that are ensured in safe medication practice.

The Nursing Process n n n A research-based organizational framework for professional nursing practice Central to all nursing care Encompasses all steps taken by the nurse in caring for a patient Flexibility is important Critical thinking Ongoing and constantly evolving process Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc. , an affiliate of Elsevier Inc.

The Nursing Process (cont’d) n n n Assessment Nursing diagnosis Planning ¡ ¡ n n Goals Outcome criteria Implementation Evaluation Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc. , an affiliate of Elsevier Inc.

The Nursing Process (cont’d) Assessment n Data collection ¡ n Subjective, objective Medication history ¡ ¡ Prescriptions OTCs Herbals Responses to medications (therapeutic and adverse responses) Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc. , an affiliate of Elsevier Inc.

The Nursing Process (cont’d) Nursing diagnosis n Decision about the need/problem (actual or at risk for) of the patient n Critical thinking, creativity, and accurate data collection n NANDA format Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc. , an affiliate of Elsevier Inc.

The Nursing Process (cont’d) Nursing diagnosis n Decision about the need/problem (actual or at risk for) of the patient n Critical thinking, creativity, and accurate data collection n NANDA format Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc. , an affiliate of Elsevier Inc.

The Nursing Process (cont’d) Nursing diagnosis Three steps n n n Human response to illness (actual or risk) “related to” “as evidenced by” Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc. , an affiliate of Elsevier Inc.

The Nursing Process (cont’d) Planning n Identification of goals and outcome criteria ¡ ¡ n n Must be specific and measurable Must be patient-centered Time frame Prioritization Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc. , an affiliate of Elsevier Inc.

The Nursing Process (cont’d) Goals n Objective, measurable, realistic n Time frame specified Outcome criteria n Specific standard(s) of measure n Patient oriented Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc. , an affiliate of Elsevier Inc.

The Nursing Process (cont’d) Implementation n Initiation and completion of the nursing care plan as defined by the nursing diagnoses and outcome criteria n Follow the “Five Rights” of medication administration Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc. , an affiliate of Elsevier Inc.

The Five Rights of Medication Administration n n Right drug Right dose Right time Right route Right patient Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc. , an affiliate of Elsevier Inc.

Another “Right”—Constant System Analysis n n A “double-check” The entire “system” of medication administration Ordering, dispensing, preparing, administering, documenting Involves the physician, nurse, nursing unit, pharmacy department, and patient education Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc. , an affiliate of Elsevier Inc.

Other “Rights” n Proper drug storage n Proper documentation n Accurate dosage calculation n Accurate dosage preparation n Careful checking of transcription of orders n Patient safety Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc. , an affiliate of Elsevier Inc.

Other “Rights” (cont’d) n n n Close consideration of special situations Prevention and reporting of medication errors Patient teaching Monitoring for therapeutic effects, adverse effects, toxic effects Refusal of medication Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc. , an affiliate of Elsevier Inc.

Six Elements of a Drug Order 1. Patient's name 2. Date order is written 3. Name of medication 4. Dosage (includes size, frequency, and number of doses) 5. Route of delivery 6. Signature of the prescriber Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc. , an affiliate of Elsevier Inc.

Evaluation n Ongoing part of the nursing process Determining the status of the goals and outcomes of care Monitoring the patient’s response to drug therapy ¡ Expected and unexpected responses Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc. , an affiliate of Elsevier Inc.

CHAPTER 2 Pharmacologic Principles Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc. , an affiliate of Elsevier Inc.

Learning Objectives n n n 1. Define the common terms used in pharmacology (see the listing of terms in the Glossary). 2. Understand the role of pharmaceutics, pharmacokinetics, and pharmacodynamics in medication administration and the application of the nursing process. 3. Discuss the application of the four principles of pharmacotherapeutics to everyday nursing practice as they relate to drug therapy for a variety of patients in different health care settings.

Learning Objectives n n 4. Discuss the use of natural drug sources in the development of new drugs. 5. Develop a nursing care plan that considers the phases of pharmacokinetics in carrying out drug therapy and the nursing process.

Drug Any chemical that affects the physiologic processes of a living organism Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc. , an affiliate of Elsevier Inc.

Pharmacology The study or science of drugs Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc. , an affiliate of Elsevier Inc.

Drug Names Chemical name n Describes the drug’s chemical composition and molecular structure Generic name (nonproprietary name) n Name given by the United States Adopted Name Council Trade name (proprietary name) n The drug has a registered trademark; use of the name restricted by the drug’s patent owner (usually the manufacturer) Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc. , an affiliate of Elsevier Inc.

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Pharmacologic Principles n n n Pharmaceutics Pharmacokinetics Pharmacodynamics Pharmacotherapeutics Pharmacognosy Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc. , an affiliate of Elsevier Inc.

Pharmaceutics The study of how various drug forms influence pharmacokinetic and pharmacodynamic activities Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc. , an affiliate of Elsevier Inc.

Pharmacokinetics n The study of what the body does to the drug ¡ ¡ Absorption Distribution Metabolism Excretion Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc. , an affiliate of Elsevier Inc.

Pharmacodynamics n The study of what the drug does to the body ¡ The mechanism of drug actions in living tissues Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc. , an affiliate of Elsevier Inc.

Pharmacotherapeutics The use of drugs and the clinical indications for drugs to prevent and treat diseases Empirical therapeutics ¡ Rational therapeutics ¡ Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc. , an affiliate of Elsevier Inc.

Pharmacognosy The study of natural (plant and animal) drug sources Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc. , an affiliate of Elsevier Inc.

Pharmaceutics Dosage form design affects dissolution Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc. , an affiliate of Elsevier Inc.

Pharmacokinetics: Absorption n The rate at which a drug leaves its site of administration, and the extent to which absorption occurs ¡ ¡ Bioavailability Bioequivalent Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc. , an affiliate of Elsevier Inc.

Factors That Affect Absorption characteristics vary according to the dosage form and route Food or fluids administered with the drug n Dosage formulation n Status of the absorptive surface n Rate of blood flow to the small intestine n Acidity of the stomach n Status of GI motility n Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc. , an affiliate of Elsevier Inc.

Routes n A drug’s route of administration affects the rate and extent of absorption of that drug ¡ ¡ ¡ Enteral (GI tract) Parenteral Topical Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc. , an affiliate of Elsevier Inc.

Enteral Route n Drug is absorbed into the systemic circulation through the oral or gastric mucosa or the small intestine ¡ ¡ ¡ Oral Sublingual Buccal Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc. , an affiliate of Elsevier Inc.

First-Pass Effect n The metabolism of a drug and its passage from the liver into the circulation – A drug given via the oral route may be extensively metabolized by the liver before reaching the systemic circulation (high first-pass effect) – The same drug—given IV—bypasses the liver, preventing the first-pass effect from taking place, and more drug reaches the circulation Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc. , an affiliate of Elsevier Inc.

First-Pass Effect and Box 2 -1 (Drug Routes and First-Pass Effect) Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc. , an affiliate of Elsevier Inc.

Parenteral Route n Intravenous (fastest delivery into the blood circulation) n Intramuscular n Subcutaneous n Intradermal n Intrathecal n Intraarticular n Transdermal can be considered parenteral, too Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc. , an affiliate of Elsevier Inc.

Topical Route n n n n Skin (including transdermal patches) Eyes Ears Nose Lungs (inhalation) Rectum Vagina Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc. , an affiliate of Elsevier Inc.

Distribution The transport of a drug in the body by the bloodstream to its site of action n Protein-binding n Water soluble vs. fat soluble n Blood-brain barrier n Areas of rapid distribution: heart, liver, kidneys, brain Areas of slow distribution: muscle, skin, fat n Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc. , an affiliate of Elsevier Inc.

Metabolism (Also Known as Biotransformation) The biochemical transformation of a drug into an inactive metabolite, a more soluble compound, or a more potent metabolite n Liver (main organ) Skeletal muscle n Kidneys n Lungs n Plasma n Intestinal mucosa n Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc. , an affiliate of Elsevier Inc.

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Metabolism/Biotransformation Biologic transformation of a drug into: An inactive metabolite n A more soluble compound n A more potent metabolite n Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc. , an affiliate of Elsevier Inc.

Metabolism/Biotransformation (cont’d) Organs or body tissues Liver (main) ¡ Skeletal muscle ¡ Kidneys ¡ Lungs ¡ Plasma ¡ Intestinal mucosa ¡

Metabolism/Biotransformation (cont’d) Factors that decrease metabolism n n n Cardiovascular dysfunction Renal insufficiency Starvation Obstructive jaundice Slow acetylator Erythromycin or ketoconazole drug therapy Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc. , an affiliate of Elsevier Inc.

Metabolism/Biotransformation (cont’d) Factors that increase metabolism n Fast acetylator n Barbiturate therapy n Rifampin therapy Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc. , an affiliate of Elsevier Inc.

Metabolism/Biotransformation (cont’d) Delayed drug metabolism results in: n Accumulation of drugs n Prolonged action of the drugs Stimulating drug metabolism causes: n Diminished pharmacologic effects Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc. , an affiliate of Elsevier Inc.

Metabolism/Biotransformation (cont’d) Cytochrome P-450 enzymes Also known as microsomal enzymes Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc. , an affiliate of Elsevier Inc.

Excretion The elimination of drugs from the body n n n Kidneys (main organ) Liver Bowel ¡ ¡ Biliary excretion Enterohepatic recirculation Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc. , an affiliate of Elsevier Inc.

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Half-life n n The time it takes for one half of the original amount of a drug in the body to be removed A measure of the rate at which drugs are removed from the body Most drugs are considered to be effectively removed after about five half-lives Steady state Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc. , an affiliate of Elsevier Inc.

The Movement of Drugs Through the Body Drug actions n The cellular processes involved in the drug and cell interaction Drug effect n The physiologic reaction of the body to the drug Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc. , an affiliate of Elsevier Inc.

Onset, Peak, and Duration Onset n The time it takes for the drug to elicit a therapeutic response Peak n The time it takes for a drug to reach its maximum therapeutic response Duration n The time a drug concentration is sufficient to elicit a therapeutic response Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc. , an affiliate of Elsevier Inc.

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Therapeutic Drug Monitoring Peak Level n Highest blood level Trough Level n Lowest blood level Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc. , an affiliate of Elsevier Inc.

Ways Drugs Produce Therapeutic Effects n n Once the drug is at the site of action, it can modify the rate (increase or decrease) at which the cells or tissues function A drug cannot make a cell or tissue perform a function it was not designed to perform Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc. , an affiliate of Elsevier Inc.

Pharmacodynamics: Mechanisms of Action n Receptor interactions Enzyme interactions Nonspecific interactions Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc. , an affiliate of Elsevier Inc.

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Pharmacotherapeutics: Types of Therapies n n n n Acute therapy Maintenance therapy Supplemental/replacement therapy Palliative therapy Supportive therapy Prophylactic therapy Empiric therapy Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc. , an affiliate of Elsevier Inc.

Contraindication n n Any characteristic of the patient, especially a disease state, that makes the use of a given medication dangerous for the patient It is important to assess for contraindications! Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc. , an affiliate of Elsevier Inc.

Monitoring n n The effectiveness of the drug therapy must be evaluated One must be familiar with the drug’s: ¡ ¡ Intended therapeutic action (beneficial) Unintended but potential adverse effects (predictable, adverse reactions) Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc. , an affiliate of Elsevier Inc.

Monitoring (cont’d) n n n Therapeutic index Drug concentration Patient’s condition Tolerance and dependence Interactions Adverse drug effects Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc. , an affiliate of Elsevier Inc.

Monitoring (cont’d) n Therapeutic index – The ratio between a drug’s therapeutic benefits and its toxic effects Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc. , an affiliate of Elsevier Inc.

Monitoring (cont’d) n Tolerance – A decreasing response to repeated drug doses Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc. , an affiliate of Elsevier Inc.

Monitoring (cont’d) n Dependence ¡ A physiologic or psychological need for a drug Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc. , an affiliate of Elsevier Inc.

Monitoring (cont’d) Interactions may occur with other drugs or food n Drug interactions: the alteration of action of a drug by: ¡ Other prescribed drugs ¡ Over-the-counter medications ¡ Herbal therapies Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc. , an affiliate of Elsevier Inc.

Monitoring (cont’d) n Drug interactions ¡ ¡ Additive effect Synergistic effect Antagonistic effect Incompatibility Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc. , an affiliate of Elsevier Inc.

Monitoring (cont’d) Adverse Drug Events Medication errors Ø Adverse drug reactions Ø Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc. , an affiliate of Elsevier Inc.

Monitoring (cont’d) Adverse Drug Reactions n n Pharmacologic reactions, including adverse effects Hypersensitivity (allergic) reaction Idiosyncratic reaction Drug interaction Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc. , an affiliate of Elsevier Inc.

Monitoring (cont’d) Adverse effects n n Predictable, well-known reactions that result in little or no change in patient management Predictable frequency Occurrences are related to the size of the dose Usually resolve when the drug is discontinued Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc. , an affiliate of Elsevier Inc.

Other Drug-Related Effects n n n Teratogenic Mutagenic Carcinogenic Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc. , an affiliate of Elsevier Inc.

Pharmacognosy Four main sources for drugs n Plants n Animals n Minerals n Laboratory synthesis Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc. , an affiliate of Elsevier Inc.

Toxicology The study of poisons and unwanted responses to drugs and other chemicals Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc. , an affiliate of Elsevier Inc.

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CHAPTER 3 Life Span Considerations

Learning Objectives n n n 1. Discuss the influences of the patient’s age on the effects of drugs and drug responses. 2. Identify drug-related concerns during pregnancy and lactation and provide an explanation of the physiologic basis for these concerns. 3. Discuss the process of pharmacokinetics and associated changes in various patient age groups, such as in pediatrics, pregnancy, and the elderly.

Learning Objectives n n 4. Summarize the impact of age-related changes on pharmacokinetics in drug therapy. 5. Calculate a drug dosage for a pediatric patient using a variety of formulas. 6. Identify the importance of a body surface area nomogram for pediatric patients. 7. Develop a nursing care plan for drug therapy and the nursing process for patients across the life span.

Life Span Considerations n n Pregnancy Breast-feeding Neonatal and Pediatric Elderly

Pregnancy n n First trimester is the period of greatest danger for drug-induced developmental defects Drugs cross the placenta by diffusion During the last trimester the greatest percentage of maternally absorbed drug gets to the fetus FDA pregnancy safety categories

Breast-feeding n n Breast-fed infants are at risk for exposure to drugs consumed by the mother Consider risk-to-benefit ratio

Neonatal and Pediatric Considerations: Pharmacokinetics n Absorption ¡ ¡ ¡ Gastric p. H less acidic Gastric emptying is slowed Intramuscular absorption faster and irregular

Neonatal and Pediatric Considerations: Pharmacokinetics (cont’d) n Distribution ¡ ¡ The younger the person, the greater the % of total body water Greater TBW means fat content is lower Decreased level of protein binding Immature blood-brain barrier—more drugs enter the brain

Neonatal and Pediatric Considerations: Pharmacokinetics (cont’d) n Metabolism ¡ ¡ ¡ Liver immature, does not produce enough microsomal enzymes Older children may have increased metabolism, requiring higher doses than infants Other factors

Neonatal and Pediatric Considerations: Pharmacokinetics (cont’d) n Excretion ¡ ¡ Kidney immaturity affects glomerular filtration rate and tubular secretion Decreased perfusion rate of the kidneys may reduce excretion of drugs

Factors Affecting Pediatric Drug Dosages n n n Skin is thin and permeable Stomach lacks acid to kill bacteria Lungs have weaker mucus barriers Body temperatures less well regulated and dehydration occurs easily Liver and kidneys are immature, impairing drug metabolism and excretion

Methods of Dosage Calculation for Pediatric Patients n Body surface area method ¡ n Using the West nomogram Body weight dosage calculations ¡ Using mg/kg

Pediatric Considerations: Medication Administration n n n General interventions Infants Toddlers Preschoolers School-aged children Adolescents

The Elderly n Elderly: older than age 65 ¡ n n n Healthy People 2010: older than age 55 Use of OTC medications Increased incidence of chronic illnesses Polypharmacy

Physiologic Changes in the Elderly Patient n n Cardiovascular Gastrointestinal Hepatic Renal

The Elderly: Pharmacokinetics n Absorption ¡ ¡ ¡ Gastric p. H less acidic Slowed gastric emptying Movement through GI tract slower Reduced blood flow to the GI tract Reduced absorptive surface area due to flattened intestinal villi

The Elderly: Pharmacokinetics (cont’d) n Distribution ¡ ¡ ¡ TBW percentages lower Fat content increased Decreased production of proteins by the liver, resulting in decreased protein binding of drugs (and increased circulation of free drugs)

The Elderly: Pharmacokinetics (cont’d) n Metabolism ¡ ¡ Aging liver produces fewer microsomal enzymes, affecting drug metabolism Reduced blood flow to the liver

The Elderly: Pharmacokinetics (cont’d) n Excretion ¡ ¡ Decreased glomerular filtration rate Decreased number of intact nephrons

The Elderly: Problematic Medications n n n n Analgesics, including NSAIDs Anticoagulants Anticholinergics Antidepressants Antihypertensives Cardiac glycosides (digoxin) Sedatives and hypnotics Thiazide diuretics