Chapter 1: The Nursing Process and Drug Therapy
The Nursing Process A research-based organizational framework
for professional nursing practice Ensures the delivery of thorough,
individualized, and quality nursing care to patients Requires
critical thinking Ongoing and constantly evolving process
Five Steps of the Nursing Process Assessment Nursing diagnosis
Planning Goals Outcome criteria Implementation including patient
education Evaluation
Assessment Data collection, review, and analysis Medication
profile Any and all drug use Prescriptions Over-the-counter
medications Vitamins, herbs, and supplements Compliance and
adherence
The nurse answers a patients call light and finds the patient
sitting up in bed and requesting pain medication. What will the
nurse do first?A. Check the orders and give the patient the
requested pain medication.B. Provide comfort measures to the
patient.C. Assess the patients pain and pain level.D. Evaluate the
effectiveness of previous pain medications.
Nursing Diagnosis Nursing diagnoses are used to communicate and
share information about the patient and the patient experience
Common nursing diagnoses related to drug therapy include: Deficient
knowledge Risk for injury Noncompliance
Nursing Diagnosis Three-step process: Human response to illness,
injury, or significant change Factors related to the response
(related to) Listing of cues, clues, evidence, or other data that
support the nurses claim for the diagnosis (as evidenced by)
Planning Identification of goals and outcome criteria Goals
Objective, measurable, and realistic with an established time
period for achievement of the outcomes that are specifically stated
in the outcome criteria Outcome criteria Concrete descriptions of
patient goals
The patients medication administration record lists two
antiepileptic medications that are due at 0900, but the patient is
NPO for a barium study. The nurses coworker suggests giving the
medications via IV because the patient is NPO. What will the nurse
do?A. Give the medications PO with a small sip of water.B. Give the
medications via the IV route because the patient is NPO.C. Hold the
medications until after the test is completed.D. Call the health
care provider to clarify the instructions.
Implementation Initiation and completion of specific nursing
actions as defined by the nursing diagnoses, goals, and outcome
criteria Independent, collaborative, dependent
The Six Rights of Medication Administration Right drug Right
dose Right time Right route Right patient Right documentation
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 2100. What will the nurse do first to determine
whether the medication was given?A. Call the night nurse at homeB.
Check the medication administration recordC. Call the pharmacyD.
Review the nurses notes
Evaluation Ongoing part of the nursing process Determining the
status of the goals and outcomes of care Monitoring the patients
response to drug therapy Expected and unexpected responses Clear
concise documentation
A nurse makes an error when administering medications to a
patient. Which action by the nurse requires the supervising nurse
to intervene? The nurseA. completes an incident report.B. informs
the prescriber of the error.C. documents adverse effects to the
medication error.D. records completion of an incident report in the
medical chart.
Chapter 2: Pharmacologic Principles
Drug: Any chemical that affects the physiologic processes of a
living organismPharmacology: Study or science of drugs
Drug NamesChemical name: Describes the drugs chemical
composition and molecular structureGeneric name (nonproprietary
name): Name given by the United States Adopted Names CouncilTrade
name (proprietary name): The drug has a registered trademark; use
of the name is restricted by the drugs patent owner (usually the
manufacturer)
Pharmacologic Principles Pharmaceutics Pharmacokinetics
Pharmacodynamics Pharmacotherapeutics Pharmacognosy
Pharmacoeconomics
Pharmaceutics: The study of how various drug forms influence the
way in which the drug affects the body
Pharmacokinetics: The study of what the body does to the drug
Absorption Distribution Metabolism Excretion
The nurse is giving a medication that has a high first-pass
effect. The health care provider has changed the route from IV to
PO. The nurse expects the oral dose to beA. higher because of the
first-pass effect.B. lower because of the first-pass effect.C. the
same as the IV dose.D. unchanged.
Pharmacodynamics: The study of what the drug does to the body
The mechanism of drug actions in living tissues Drug-receptor
relationships
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?A. IVB. IMC. SubcutD.
PO
Pharmacotherapeutics: The clinical use of drugs to prevent and
treat diseases Defines principles of drug actionsthe cellular
processes that change in response to the presence of drug molecules
Drugs are organized into pharmacologic classes
Pharmacognosy: The study of natural (versus synthetic) drug
sources (i.e., plant, animals, minerals)
Pharmaceutics: Different drug dosage forms have different
pharmaceutical properties. Dosage form determines the rate of drug
dissolution (dissolving of solid dosage forms and their absorption
from the GI tract). Enteric-coated tablets Extended-release
forms
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 will the nurse do?A. Crush the tablets and mix them
with applesauce or pudding.B. Call the pharmacy and ask for the
liquid form of the medication.C. Call the pharmacy and ask for the
IV form of the medication.D. Encourage the patient to try to
swallow the tablets.
Pharmacokinetics: A drugs time to onset of action, time to peak
effect, and duration of action Study of what happens to a drug from
the time it is put into the body until the parent drug and all
metabolites have left the body
Absorption: Movement of a drug from its site of administration
into the bloodstream for distribution to the tissues
Bioavailability First-pass effect
Routes A drugs route of administration affects the rate and
extent of absorption of that drug Enteral (GI tract) Parenteral
Topical
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)
Parenteral Route Intravenous (fastest delivery into the blood
circulation), Intramuscular, Subcutaneous, Intradermal,
Intraarterial, Intrathecal, Intraarticular
Topical Route: Skin (including transdermal patches), Eyes, Ears,
Nose, Lungs (inhalation), Rectum, Vagina
The nurse is preparing to administer a transdermal patch to a
patient and finds that the patient already has a medication patch
on his right upper chest. What will the nurse do?A. Remove the old
medication patch and notify the health care providerB. Apply the
new patch without removing the old oneC. Remove the old patch and
apply the new patch in the same spotD. Remove the old patch and
apply the new patch to a different, clean area
Distribution: The transport of a drug 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
Metabolism/Biotransformation: The biochemical alteration of a
drug into an inactive metabolite, a more soluble compound, a more
potent active metabolite, or a less active metabolite Liver (main
organ) Skeletal muscle Kidneys Lungs Plasma Intestinal mucosa
Factors that decrease metabolism Cardiovascular dysfunction,
Renal insufficiency, Starvation, Obstructive jaundice, Slow
acetylator, Ketoconazole therapy
Factors that increase metabolism Fast acetylator, Barbiturate
therapy, Rifampin therapy, Phenytoin therapy
Excretion: The elimination of drugs from the body Kidneys (main
organ) Liver Bowel: Biliary excretion; Enterohepatic
recirculation
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
The Movement of Drugs Through the BodyDrug actions: The cellular
processes involved in the drug and cell interactionDrug effect: The
physiologic reaction of the body to the drug. Includes onset, peak,
and duration of action
Onset, Peak, and DurationOnset: The time it takes for the drug
to elicit a therapeutic responsePeak: 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
Therapeutic Drug MonitoringPeak level: Highest blood levelTrough
level: Lowest blood level
Pharmacodynamics: Mechanisms of Action Receptor interactions
Enzyme interactions Nonselective interactions
Pharmacotherapeutics: Types of Therapies Acute therapy
Maintenance therapy Supplemental/replacement therapy Palliative
therapy Supportive therapy Prophylactic therapy Empiric therapy
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!
Monitoring Evaluating the clinical response of the patient to
the treatment One must be familiar with the drugs: Intended
therapeutic action (beneficial) Unintended but potential adverse
effects (predictable, adverse drug reactions) Therapeutic index
Drug concentration Patients condition Tolerance and dependence Drug
interactions (additive effect, synergistic effect, antagonistic
effect, incompatibility) Adverse drug events
Adverse drug reactions Pharmacologic reactions, including
adverse effects Hypersensitivity (allergic) reaction Idiosyncratic
reaction Drug interaction
Other Drug-Related Effects Teratogenic, Mutagenic,
Carcinogenic
PharmacognosyFour main sources for drugs: Plants, Animals,
Minerals, Laboratory synthesis
Toxicology: The study of poisons and unwanted responses to drugs
and other chemicals. Overlaps with pharmacotherapeutics
Chapter 3: Lifespan Considerations
Drug Therapy During Pregnancy Drugs cross the placenta by
diffusion Factors affecting safety: Drug properties; Fetal
gestational age; Maternal factors FDA has implemented pregnancy
safety categories
When teaching a pregnant woman about the use of drugs during
pregnancy, which statement will the nurse include? A. Exposure of
the fetus to drugs is most detrimental during the second trimester
of pregnancy.B. Pregnant women must never take drugs to control
high blood pressure.C. Drug transfer to the fetus is most likely to
occur during the last trimester of pregnancy.D. The fetus is at
greatest risk for drug-induced developmental defects during the
second trimester of pregnancy.
Drug Therapy During Breastfeeding Breastfed infants are at risk
for exposure to drugs consumed by the mother Consider
risk-to-benefit ratio
Neonatal and Pediatric Considerations:
PharmacokineticsAbsorption Gastric pH less acidic Gastric emptying
slowed Intramuscular absorption faster and irregular
Distribution Greater total body water means lower fat content
Decreased level of protein binding Immature blood-brain barriermore
drugs enter the brain
Metabolism Liver immature, does not produce enough microsomal
enzymes Older children may have increased metabolism, requiring
higher doses than infants Other factors
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 excretionMethods of Dosage Calculation for
Pediatric Patients Body surface area method: Uses the West nomogram
Always use weight in kilograms, not pounds Body weight dosage
calculations: Uses mg/kg
When administering medications to pediatric patients, the nurse
understands that the dosage calculations for pediatric patients are
different than for adults because pediatric patientsA. are more
likely to develop edema.B. have more stomach acid.C. have skin that
is less permeable.D. have immature liver and kidney function,
resulting in impaired drug metabolism and excretion.
Considerations for Elderly Patients Elderly: older than age 65
High use of medications Polypharmacy Noncompliance, nonadherence
Increased incidence of chronic illnesses Sensory and motor
deficits
The Elderly: PharmacokineticsAbsorption 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
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)
Metabolism Aging liver produces fewer microsomal enzymes,
affecting drug metabolism Reduced blood flow to the liver
Excretion Decreased glomerular filtration rate Decreased number
of intact nephrons
The Elderly: Problematic Medications Analgesics, including
NSAIDs and opioids Anticoagulants Anticholinergics Antidepressants
Antihypertensives Cardiac glycosides (digoxin) Sedatives and
hypnotics, CNS depressants Thiazide diuretics
Which does the nurse identify as a pharmacokinetic change that
occurs in the elderly?A. Gastric pH is more acidicB. Fat content is
decreased because of increased lean body massC. Increased
production of proteins by the liverD. The number of intact nephrons
is decreased
Chapter 4: Cultural, Legal, and Ethical Considerations
Which racial group is predicted to be nearly one in three U.S.
residents in 2050?A. African AmericanB. AsianC. HispanicD.
White
Cultural Considerations Influence of ethnicity on genetics and
drug response Drug polymorphism Compliance level with therapy
Environmental and economic considerations Barriers to adequate
health care for culturally diverse
Cultural Assessment Languages spoken Health beliefs and
practices Past uses of medicine Herbal treatments, folk remedies,
home remedies Over-the-counter drugs and treatment Usual response
to illness Responsiveness to medical treatment Religious practices
and beliefs Support from the patients cultural community Dietary
habits
U.S. Drug Legislation 1906: Federal Food and Drugs Act 1912:
Sherley Amendment (to the Federal Food and Drug Act of 1906) 1914:
Harrison Narcotic Act 1938: Federal Food, Drug, and Cosmetic Act
(revision of 1906 act) 1951: Durham-Humphrey Amendment (to the 1938
act) 1962: Kefauver-Harris Amendments (to the 1938 act) 1970:
Controlled Substances Act 1983: Orphan Drug Act 1996: Health
Insurance Portability and Accountability Act (HIPAA) 2003: Medicare
Prescription Drug, Improvement, and Modernization Act
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
U.S. FDA Drug Approval Process Preclinical investigational drug
studies Clinical phases of investigational drug studies Phase I
Phase II Phase III Phase IV
A research group is conducting an investigational drug study on
a promising new drug for osteoporosis. It has been difficult to
find research subjects who 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 firstA. inform them that they waited too long to withdraw
from the study.B. explore with them the reasons for withdrawing
from the study.C. acknowledge that they can withdraw at any time
from the study.D. request that they try to remain with the study
until it is completed.
Legal Nursing Considerations State and federal legislation Nurse
practice acts Scope of nursing practice Expanded nursing roles
Educational requirements Standards of care Minimally safe nursing
practice Differences between nursing and medical practice
Guidelines from professional nursing groups Institutional policies
and procedures, state and federal hospital licensing Case law or
common law HIPAA
Ethical Considerations American Nurses Association (ANA) Code of
Ethics for Nurses International Council of Nurses (ICN) Code of
Ethics for Nurses
A nurse has been asked to participate in an elective procedure
that violates the nurses personal ethical principles. The nurse
shouldA. refuse to participate.B. ask to switch assignments with
another nurse.C. speak to the manager or supervisor.D. perform the
procedure.
Chapter 5: Medication Errors: Preventing and Responding
Adverse Drug Event Medication errors - Institute of Medicine
studies (1999, 2006) Adverse drug reactions: Allergic reaction;
Idiosyncratic reaction
In the 2006 Institute of Medicine Study, it was estimated that
some form of medication error resulted in harm to how many
patients?A. 400,000B. 800,000C. 1 millionD. 1.5 million
Medication Errors Preventable Common cause of adverse health
care outcomes More potential for harm with high-alert
medications
Issues Contributing to Errors Errors can occur during any step
of medication process: Procuring; Prescribing; Transcribing;
Dispensing; Administering; Monitoring Organizational issues
Educational system issues Sociologic factors
Types of Medication Errors No error, although circumstances or
events occurred that could have led to an error Medication error
that causes no harm Medication error that causes harm Medication
error that results in death
Preventing Medication Errors Multiple systems of checks and
balances Legible and correct orders Appropriate consultation Check
medication order three times Six Rights of medication
administration Minimize verbal or telephone orders Repeat order to
prescriber Spell drug name aloud Speak slowly and clearly List
indication next to each order Avoid medical shorthand, including
abbreviations and acronyms Never assume anything about items not
specified in a drug order (e.g., route) Do not hesitate to question
a medication order for any reason when in doubt Do not try to
decipher illegibly written orders; contact prescriber for
clarification NEVER use a trailing zero with medication orders (Do
not use 1.0 mg; use 1 mg) ALWAYS use a leading zero for decimal
dosages (Do not use .25 mg; use 0.25 mg) Take time to learn special
administration techniques of certain dosage forms Always verify new
medication administration records Always listen to and honor any
concerns expressed by patients regarding medications Check patient
allergies and identification
The nurse is administering a drug that has been ordered as
follows: Give 10 mg on odd-numbered days and 5 mg on even-numbered
days. When the date changes from May 31 to June 1, what should the
nurse do?A. Give 10 mg because June 1 is an odd-numbered dayB. Hold
the dose until the next odd-numbered dayC. Change the order to read
Give 10 mg on even-numbered days and 5 mg on odd-numbered daysD.
Consult the prescriber to verify that the dose should alternate
each day, no matter whether the day is odd- or even-numbered
Reporting Medication Errors Report to prescriber and nursing
management Document error per policy and procedure Factual
documentation only Medication administered Actual dose Observed
changes in patient condition Prescriber notified/follow-up orders
External reporting of errors USP MERP (United States Pharmacopeia
Medication Errors Reporting Program) MedWatch, sponsored by the FDA
Institute for Safe Medication Practices (ISMP) The Joint
Commission
The nursing student realizes that she has given a patient a
double dose of an antihypertensive medication. The tablet was
supposed to be cut in half, but the student forgot and administered
the entire tablet. The patients blood pressure just before the dose
was 146/98 mm Hg. What should the student nurse do first?A. Notify
the patients physicianB. Notify the clinical facultyC. Take the
patients blood pressureD. Continue to monitor the patient
Medication Reconciliation: Continuous assessment and updating of
patient medication information Verification; Clarification;
Reconciliation Should be done at each stage of health care
delivery: Admission Status change Patient transfer within or
between facilities/provider teams Discharge
Ethical Issues Notification of patients Possible consequences
for nurses
Chapter 6: Patient Education and Drug Therapy
The Domains of Learning Cognitive domain Affective domain
Psychomotor domain
Patient Education: Assessment Adaptation to any illness Age
Barriers to learning
Cognitive abilities Coping mechanisms Cultural background
Developmental status Education, including literacy level
Emotional status
Information patient understands about past and present medical
conditions Folk medicine, home remedies, alternative/complementary
therapies Past and present experience with drug regimens and other
therapies
Financial status Health literacy Psychosocial growth and
development
Health beliefs Environment Language(s) spoken
Level of knowledge about current medications Current
medications, including over-the-counter and herbal medications
Limitations (physical, psychologic, cognitive, motor)
Nutritional status Mobility Motivation
Misinformation about drug therapy Past and present health
behaviors Family relationships
Race and/or ethnicity Readiness to learn Religious beliefs
Self-care ability Sensory status Social support
The nurse is caring for an 85-year-old patient in the hospital
and teaching him how to use an inhaler. His 84-year-old wife
attends the teaching sessions, and their daughter comes in to visit
in the evenings. The patient is having trouble remembering the
steps. The nurse shouldA. provide the package insert that comes
with the medication for the patient to read.B. focus the teaching
sessions on the patients wife.C. provide small amounts of
information at a time, repeating information frequently.D. wait
until the daughter comes in and teach the daughter instead.
Patient Education: Nursing Diagnoses Deficient knowledge
Impaired memory Ineffective self-health management Readiness for
enhanced self-health management Noncompliance Risk for falls Risk
for injury Sleep deprivation
A patient with newly diagnosed type 1 diabetes mellitus has
completed a diabetes education program. One month later, the
patient confesses at a follow-up appointment that he just didnt
feel like giving himself the insulin injections. Which nursing
diagnosis will the nurse assign the patient?A. Deficient
knowledgeB. Noncompliance C. Impaired memoryD. Sleep
deprivation
Patient Education: Planning Goals and Outcome Criteria
Measurable Realistic Based on patient needs Stated in patient terms
Time frame
Patient Education: Implementation Teaching-learning sessions
Consideration of age-related changes Consideration of language
barriers Safe administration of medications at home Return
demonstration with equipment For adults, it is recommended that
materials be written at an 8th grade level
A nurse is providing patient teaching for a community health
center that serves a primarily Portuguese population. The nurse
would best serve this patient population byA. learning
Portuguese.B. always using interpreter services.C. using the family
member interpreter the patient provides.D. finding a job in a
different setting.
Patient Education: Evaluation Validate whether learning has
occurred Ask questions Have the patient provide a return
demonstration Behavior, such as compliance and adherence to a
schedule Occurrence of few or no complications Develop and
implement new plan of teaching as needed for: Noncompliance
Inadequate levels of learning
After providing education regarding medications to a patient who
has been newly diagnosed with type 2 diabetes mellitus, the nurse
would use which part of the nursing process to assess whether the
patient understands these new instructions?A. AssessmentB.
DiagnosisC. ImplementationD. Evaluation