NRS 230 Pharmacology Week 1 Students_11!22!11

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The Nursing Process and Drug Therapy

CHAPTER 1

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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

• Requires critical thinking

• Ongoing and constantly evolving process3

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– Over-the-counter medications– Herbal therapies– Responses to medications (therapeutic and adverse)

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The Nursing Process (cont’d)

Nursing diagnosis

• Decision about the need/problem of the patient (actual or at risk)

• Critical thinking, creativity, and accurate data collection

• NANDA-I format

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The Nursing Process (cont’d)

Nursing diagnosis

• Three steps– Human response to illness (actual or at 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 “Six Rights” of medication administration

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The Role of Nurses in Relation to Pharmacology

Nurses share information with other health care professionals to provide the most effective medication regimen for the patient

Nurses have to follow the “Six Rights” of Medication Administration

Nurses play an active role in drug administration

Nurses contribute to the planning and modification of drug therapy from their assessment of patient factors and evaluation of progress or problems occurring during drug therapy

In addition to: the role in patient education and compliance

1. Right drug

2. Right dose

3. Right time

4.Right Route

5. Right Patient

6. Right Documentation

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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

• Clear concise documentation

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Pharmacologic Principles

CHAPTER 2

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Pharmacologic Principles

• Drug– Any chemical that affects the physiologic

processes of a living organism

• Pharmacology– Study or science of drugs

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Drug NamesChemical 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 is 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– Bioequivalency

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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

• The drug is absorbed into the systemic circulation through the oral or gastric mucosa or the small intestine– Oral– Sublingual– Buccal– Rectal (can also be topical)

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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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Parenteral Route• Intravenous (fastest delivery into the blood

circulation)• Intramuscular• Subcutaneous• Intradermal• Intraarterial• Intrathecal• Intraarticular• Transdermal also can be considered parenteral

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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/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

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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)Delaying drug metabolism causes:• Accumulation of drugs

• Prolonged action of the drugs drug toxicity

Stimulating drug metabolism causes:• Diminished pharmacologic effects

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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 to be removed from the body

• A measure of the rate at which a drug is removed from the body

• Most drugs 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 Duration

Onset• The time it takes for the drug to elicit a

therapeutic response

Peak• The time it takes for a drug to reach its

maximum therapeutic response

Duration• The time a drug concentration is

sufficient to elicit a therapeutic response 41

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Therapeutic Drug Monitoring

Peak level• Highest blood level

Trough level• Lowest 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

• Nonselective 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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Contraindications

• 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– Ratio of a drug’s toxic level to the level that

provides therapeutic benefits

• Tolerance– Decreasing response to repeated drug doses

• Dependence– Physiologic or psychological need for a drug

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Monitoring (cont’d)

Interactions may occur with other drugs or food• A drug interaction is the alteration of a drug’s action 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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Life Span Considerations

CHAPTER 3

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Life Span Considerations

• Pregnancy

• Breast-feeding

• Neonatal and pediatric

• Elderly

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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 has implemented pregnancy safety categories

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Breast-feeding

• Breast-fed infants are at risk for exposure to drugs consumed by the mother

• Consider risk-to-benefit ratio

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Neonatal and Pediatric Considerations: Pharmacokinetics• Absorption

– Gastric pH less acidic– Gastric emptying slowed– Intramuscular absorption faster and

irregular

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Neonatal and Pediatric Considerations: Pharmacokinetics (cont’d)• Distribution

– The younger the person, the greater the percentage of total body water

– Greater total body water means lower fat content

– Decreased level of protein binding – Immature blood-brain barrier—more drugs

enter the brain

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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

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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

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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

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Methods of Dosage Calculation for Pediatric Patients

• Body surface area method– Using the West nomogram

• Always use weight in kilograms, not pounds

• Body weight dosage calculations– Using mg/kg (most commonly used)

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The Elderly

• Elderly: older than age 65

• Use of over-the-counter medications

• Increased incidence of chronic illnesses

• Sensory and motor deficits

• Polypharmacy

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Physiologic Changes in the Elderly Patient

• Cardiovascular

• Gastrointestinal

• Hepatic

• Renal

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The Elderly: Pharmacokinetics

• Absorption– Gastric pH less acidic– Gastric emptying slowed– Movement through GI tract slowed– Blood flow to GI tract reduced– Use of laxatives may accelerate GI motility

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The Elderly: Pharmacokinetics (cont’d)

• Distribution– Lower total body water percentages– Increased fat content– Decreased production of proteins by the

liver, resulting in decreased protein binding of drugs (and increased circulation of free drugs)

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The Elderly: Pharmacokinetics (cont’d)

• Metabolism– Aging liver produces fewer microsomal

enzymes, affecting drug metabolism– Reduced blood flow to the liver

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The Elderly: Pharmacokinetics (cont’d)

• Excretion– Decreased glomerular filtration rate– Decreased number of intact nephrons

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The Elderly:Problematic Medications

• Analgesics, including NSAIDs and opioids• Anticoagulants• Anticholinergics• Antidepressants• Antihypertensives• Cardiac glycosides (digoxin)• Sedatives and hypnotics, CNS depressants• Thiazide diuretics

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CHAPTER 4

Cultural, Legal, and Ethical Considerations

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New Drug Development

• Investigational new drug (IND) application– Informed consent

• U.S. FDA drug approval process– Preclinical testing– Clinical studies– Investigational drug studies– Expedited drug approval

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U.S. FDA Drug Approval Process• Preclinical investigational drug studies

• Informed consent

• Clinical phases of investigational drug studies– Phase I– Phase II– Phase III– Phase IV

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Ethical Nursing Practice

• American Nurses Association (ANA) Code of Ethics for Nurses

• International Council of Nurses (ICN) Code of Ethics for Nurses

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Cultural Considerations

• Assess the influence of a patient’s cultural beliefs, values, and customs

• Drug polymorphism

• Compliance level with therapy

• Environmental considerations

• Genetic factors

• Varying responses to specific drugs

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Cultural Considerations (cont’d)

• Changing national demographics• Influence of ethnicity and genetics• Rapid and slow acetylators• Examples of various ethnic groups found

in the U.S.– Asian– African American– Hispanic– Native American

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Cultural Assessment

• Health beliefs and practices

• Past uses of medicine

• Folk remedies

• Home remedies

• Over-the-counter drugs and treatment

• Herbal remedies

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Cultural Assessment (cont’d)

• Usual response to illness

• Responsiveness to medical treatment

• Religious practices and beliefs

• Dietary habits

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Chapter 1

The Nursing Process and Drug Therapy

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1. The day shift charge nurse is making rounds. A patient tells the nurse that the night shift nurse never gave him his medication, which was due at 11 pm. What should the nurse do first to determine whether the medication was given?

1. Call the night nurse at home.

2. Check the Medication Administration Record.

3. Call the pharmacy.

4. Review the nurse’s notes.

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2. The nurse answers a patient’s call light and finds the patient sitting up in bed and requesting pain medication. What should the nurse do first?

1. Check the orders and give the patient the requested pain medication.

2.Provide comfort measures to the patient.

3.Assess the patient’s pain and pain level.

4. Evaluate the effectiveness of previous pain medications.

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3. The patient’s Medication Administration Record lists two antiepileptic medications that are due at 0900, but the patient is NPO for a barium study. The nurse’s coworker suggests giving the medications via IV because the patient is NPO. What should the nurse do?

1.Give the medications PO with a small sip of water.

2.Give the medications via the IV route because the patient is NPO.

3.Hold the medications until after the test is completed.

4.Call the physician to clarify the instructions.

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4. The nurse goes into a patient’s room to give medications. The patient is confused, and the nurse discovers that the patient is not wearing an armband. How should the nurse identify the patient?

1. Ask the patient to state his name.2. Ask the visitor the patient’s name.3. Ask the patient to state his birthday.4. Check with the charge nurse to obtain an

armband.

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Chapter 2

Pharmacologic Principles

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1. The nurse is giving a medication that has a high first-pass effect. The physician has changed the route from IV to PO. The nurse expects the oral dose to be:

1. higher because of the first-pass effect.2. lower because of the first-pass effect.3. the same as the IV dose.4. unchanged.

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2. A patient is complaining of severe pain and has orders for morphine sulfate. The nurse knows that the route that would give the slowest pain relief would be which route?

1. IV

2. IM

3. SC

4. PO

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33. A patient is prescribed ibuprofen 200 mg PO every 4 hours as needed for pain. The pharmacy sends up enteric-coated tablets, but the patient refuses the tablets, stating that she cannot swallow pills. What should the nurse do?

1. Crush the tablets and mix them with applesauce or pudding.2. Call the pharmacy and ask for the liquid form of the medication.3. Call the pharmacy and ask for the IV form of the medication.4. Encourage the patient to try to swallow the tablets.

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4. When giving morning medications, the nurse is preparing to administer a transdermal patch medication and finds that the patient already has a medication patch on his right upper chest. What should the nurse do?

1. Remove the old medication patch and notify the physician.

2. Apply the new patch without removing the old one.3. Remove the old patch and apply the new patch in the

same spot.4. Remove the old patch and apply the new one to a

different, clean area.

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5. Two drugs that are synergistic do not have a drug interaction with each other.

1. True2. False

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Chapter 3

Life Span Considerations

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• Most medications have been extensively studied in a variety of different populations and age groups.

1. True

2. False

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2. A pregnant woman with liver disease is taking a pregnancy category B medication for her illness. Which statement is true in this situation?

1. The mother’s liver disease will expose the fetus to less of the medication.

2. The mother’s liver disease will expose the fetus to more of the medication.

3. Because the medication is pregnancy category B, the medication is generally considered safe for the fetus.

4. The liver of the fetus will protect the fetus from the effects of the medication.

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3. A mother calls the clinic to ask about giving acetaminophen to her infant. She says she has used the liquid form for her 5-year-old child, and she wants to know how much to give to her infant, who has a fever. The nurse should:

1. instruct the mother to give the infant the same dose as the child.

2. instruct the mother to give the infant half the dose that she would normally give the child.

3. assist the mother in calculating the dose for the infant.

4. consult with a physician before instructing the mother on giving the medication.

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4.The elderly patient will experience polypharmacy, but not much can be done about it.

1. True

2. False

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5.What percent of currently approved drugs in the U.S. lack approval for pediatric use?

1. 10%

2. 25%

3. 50%

4. 75%

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Chapter 4

Cultural, Legal, and Ethical

Considerations 105

• A 20-year-old patient is receiving chemotherapy for leukemia. Her parents are very involved in her care. The patient has indicated that she would like to try alternative therapies in addition to the chemotherapy. Her parents disapprove of this and do not want their daughter to take any “wacky treatments.” The nurse’s responsibility is to:

1. research the safety of combining the therapies.

2. agree with the parents as they are being more reasonable.

3. work with the patient and physician to find appropriate alternative therapies.

4. convince the patient that the chemotherapy is most beneficial to her health.

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2. Two 40-year-old patients, one of Asian origin and one of European origin, are taking the same drug. The same drug may result in very different responses in these individuals.

1. True

2. False

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3. A nurse has been asked to participate in an elective procedure that violates the nurse’s personal ethical principles. The nurse should:

1. refuse to participate.2. ask to switch assignments with

another nurse.3. speak to the manager or supervisor.4. perform the procedure.

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4. A research group is conducting an investigational drug study on a promising new drug for osteoporosis. It has been difficult to find research subjects that meet the criteria. Just before the conclusion of the study, four subjects approach the researchers and express their desire to withdraw from the study. The researcher should first:

1. inform them that they waited too long to withdraw from the study.

2. explore with them the reasons for withdrawing from the study.

3. acknowledge that they can withdraw at any time from the study.

4. request that they try to remain with the study until it is completed.

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5. Which racial group is predicted to be nearly one in three U.S. residents in 2050?

1. African American2. Asian3. Hispanic4. White

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