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Learning Objectives
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
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
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)
Assessment Nursing diagnosis Planning
Goals Outcome criteria
Implementation Evaluation
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The Nursing Process (cont’d)
Assessment Data collection
Subjective, objective Medication history
Prescriptions OTCs Herbals Responses to medications (therapeutic and
adverse responses)
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The Nursing Process (cont’d)
Nursing diagnosis Decision about the need/problem
(actual or at risk for) of the patient Critical thinking, creativity, and
accurate data collection NANDA format
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The Nursing Process (cont’d)
Nursing diagnosis Decision about the need/problem
(actual or at risk for) of the patient Critical thinking, creativity, and
accurate data collection NANDA format
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The Nursing Process (cont’d)
Nursing diagnosis
Three steps Human response to illness (actual or risk) “related to” “as evidenced by”
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The Nursing Process (cont’d)
Planning Identification of goals and outcome
criteria Must be specific and measurable Must be patient-centered
Time frame Prioritization
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The Nursing Process (cont’d)
Goals Objective, measurable, realistic Time frame specified
Outcome criteria Specific standard(s) of measure Patient oriented
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The Nursing Process (cont’d)
Implementation Initiation and completion of the nursing
care plan as defined by the nursing diagnoses and outcome criteria
Follow the “Five Rights” of medication administration
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The Five Rights of Medication Administration
Right drug Right dose Right time Right route Right patient
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Another “Right”—Constant System Analysis
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
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Other “Rights”
Proper drug storage Proper documentation Accurate dosage calculation Accurate dosage preparation Careful checking of transcription of
orders Patient safety
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Other “Rights” (cont’d)
Close consideration of special situations
Prevention and reporting of medication errors
Patient teaching Monitoring for therapeutic effects,
adverse effects, toxic effects Refusal of medication
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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
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Evaluation
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
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CHAPTER 2
Pharmacologic Principles
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Learning Objectives 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
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
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Pharmacology
The study or science of drugs
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Drug Names
Chemical name Describes the drug’s chemical composition and
molecular structure
Generic name (nonproprietary name) Name given by the United States Adopted Name
Council
Trade name (proprietary name) The drug has a registered trademark; use
of the name restricted by the drug’s patent owner (usually the manufacturer)
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Pharmacologic Principles
Pharmaceutics Pharmacokinetics Pharmacodynamics Pharmacotherapeutics Pharmacognosy
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Pharmaceutics
The study of how various drug forms influence pharmacokinetic and pharmacodynamic activities
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Pharmacokinetics
The study of what the body does to the drug Absorption Distribution Metabolism Excretion
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Pharmacodynamics
The study of what the drug does to the body The mechanism of drug actions in living
tissues
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Pharmacotherapeutics
The use of drugs and the clinical indications for drugs to prevent and treat diseases
Empirical therapeutics Rational therapeutics
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Pharmacognosy
The study of natural (plant and animal) drug sources
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Pharmaceutics
Dosage form design affects dissolution
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Pharmacokinetics: Absorption
The rate at which a drug leaves its site of administration, and the extent to which absorption occurs Bioavailability Bioequivalent
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Factors That Affect Absorption
Absorption characteristics vary according to the dosage form and route
Food or fluids administered with the drug Dosage formulation Status of the absorptive surface Rate of blood flow to the small intestine Acidity of the stomach Status of GI motility
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Routes
A drug’s route of administration affects the rate and extent of absorption of that drug Enteral (GI tract) Parenteral Topical
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Enteral Route
Drug is absorbed into the systemic circulation through the oral or gastric mucosa or the small intestine Oral Sublingual Buccal
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First-Pass Effect
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
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First-Pass Effect and Box 2-1 (Drug Routes and First-Pass Effect)
Parenteral Route
Intravenous (fastest delivery into the blood circulation)
IntramuscularSubcutaneous Intradermal Intrathecal IntraarticularTransdermal can be considered parenteral,
too
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Topical Route
Skin (including transdermal patches) Eyes Ears Nose Lungs (inhalation) Rectum Vagina
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Distribution
The transport of a drug in the body by the bloodstream to its site of action Protein-binding
Water soluble vs. fat soluble
Blood-brain barrier
Areas of rapid distribution: heart, liver, kidneys, brain
Areas of slow distribution: muscle, skin, fat
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Metabolism(Also Known as Biotransformation)
The biochemical transformation of a drug into an inactive metabolite, a more soluble compound, or a more potent metabolite Liver (main organ) Skeletal muscle Kidneys Lungs Plasma Intestinal mucosa
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Metabolism/Biotransformation
Biologic transformation of a drug into: An inactive metabolite A more soluble compound A more potent metabolite
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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 Cardiovascular dysfunction Renal insufficiency Starvation Obstructive jaundice Slow acetylator Erythromycin or ketoconazole drug therapy
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Metabolism/Biotransformation (cont’d)
Factors that increase metabolism Fast acetylator Barbiturate therapy Rifampin therapy
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Metabolism/Biotransformation (cont’d)
Delayed drug metabolism results in: Accumulation of drugs
Prolonged action of the drugs
Stimulating drug metabolism causes: Diminished pharmacologic effects
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Metabolism/Biotransformation (cont’d)
Cytochrome P-450 enzymes
Also known as microsomal enzymes
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Excretion
The elimination of drugs from the body Kidneys (main organ) Liver Bowel
Biliary excretion Enterohepatic recirculation
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Half-life
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
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The Movement of DrugsThrough the Body
Drug actions The cellular processes involved in the drug
and cell interaction
Drug effect The physiologic reaction of the body to the
drug
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Onset, Peak, and DurationOnsetThe time it takes for the drug to elicit a
therapeutic response
PeakThe time it takes for a drug to reach its
maximum therapeutic response
DurationThe time a drug concentration is sufficient to
elicit a therapeutic response
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Therapeutic Drug Monitoring
Peak LevelHighest blood level
Trough LevelLowest blood level
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Ways Drugs Produce Therapeutic Effects
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
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Pharmacodynamics: Mechanisms of Action
Receptor interactions Enzyme interactions Nonspecific interactions
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Pharmacotherapeutics: Types of Therapies
Acute therapy Maintenance therapy Supplemental/replacement therapy Palliative therapy Supportive therapy Prophylactic therapy Empiric therapy
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Contraindication
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!
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Monitoring
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)
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Monitoring (cont’d)
Therapeutic index Drug concentration Patient’s condition Tolerance and dependence Interactions Adverse drug effects
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Monitoring (cont’d)
Therapeutic index– The ratio between a drug’s therapeutic
benefits and its toxic effects
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Monitoring (cont’d)
Tolerance – A decreasing response to repeated drug doses
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Monitoring (cont’d)
Dependence A physiologic or psychological need for
a drug
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Monitoring (cont’d)
Interactions may occur with other drugs or food Drug interactions: the alteration of action of a drug by:
Other prescribed drugs Over-the-counter medications Herbal therapies
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Monitoring (cont’d)
Drug interactions Additive effect Synergistic effect Antagonistic effect Incompatibility
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Monitoring (cont’d)
Adverse Drug Events
Medication errors Adverse drug reactions
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Monitoring (cont’d)
Adverse Drug Reactions Pharmacologic reactions, including adverse
effects Hypersensitivity (allergic) reaction Idiosyncratic reaction Drug interaction
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Monitoring (cont’d)
Adverse effects 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
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Other Drug-Related Effects
Teratogenic Mutagenic Carcinogenic
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Pharmacognosy
Four main sources for drugs Plants Animals Minerals Laboratory synthesis
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Toxicology
The study of poisons and unwanted responses to drugs and other chemicals
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Learning Objectives
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
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.
Pregnancy
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
Breast-fed infants are at risk for exposure to drugs consumed by the mother
Consider risk-to-benefit ratio
Neonatal and Pediatric Considerations: Pharmacokinetics
Absorption Gastric pH less acidic Gastric emptying is slowed Intramuscular absorption faster and
irregular
Neonatal and Pediatric Considerations: Pharmacokinetics (cont’d)
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)
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)
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
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
Body surface area method Using the West nomogram
Body weight dosage calculations Using mg/kg
Pediatric Considerations: Medication Administration
General interventions Infants Toddlers Preschoolers School-aged children Adolescents
The Elderly
Elderly: older than age 65 Healthy People 2010: older than age 55
Use of OTC medications Increased incidence of chronic
illnesses Polypharmacy
The Elderly: Pharmacokinetics
Absorption Gastric pH 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)
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)
Metabolism Aging liver produces fewer microsomal
enzymes, affecting drug metabolism Reduced blood flow to the liver
The Elderly: Pharmacokinetics (cont’d)
Excretion Decreased glomerular filtration rate Decreased number of intact nephrons