The Nursing The Nursing Process and Drug Process and Drug TherapyTherapy

Barbara A. Kunkel, RN, MSN Office: MS 119 Phone: 609-731-4368 Office Hours: Monday & Thursday 11a-12n; 3:30-5p; 8p-8:30p

The Nursing The Nursing Process (cont'd)Process (cont'd)

• AssessmentAssessment• Nursing diagnosisNursing diagnosis• Planning (with Planning (with

outcome criteria)outcome criteria)• ImplementationImplementation• EvaluationEvaluation

The “Six The “Six Rights”Rights”• Right drugRight drug• Right doseRight dose• Right timeRight time• Right routeRight route• Right patientRight patient• Right Right

documentationdocumentation

Another “Right”—Constant Another “Right”—Constant System AnalysisSystem Analysis

• A “double-check”A “double-check”• The entire “system” of The entire “system” of

medication medication administrationadministration

• Ordering, dispensing, Ordering, dispensing, preparing, preparing, administering, administering, documentingdocumenting

• Involves the physician, Involves the physician, nurse, nursing unit, nurse, nursing unit, pharmacy department, pharmacy department, and patient educationand patient education

Other Other “Rights”“Rights” • Proper circumstanceProper circumstance

• Proper drug storageProper drug storage• Accurate dosage Accurate dosage

calculationcalculation• Accurate dosage Accurate dosage

preparationpreparation• Careful checking of Careful checking of

transcription of transcription of ordersorders

• Patient safetyPatient safety

Other Other “Rights” “Rights” (cont'd)(cont'd)

• Close consideration Close consideration of special situationsof special situations

• Prevention and Prevention and reporting of reporting of medication errorsmedication errors

• Patient teachingPatient teaching• Monitoring for Monitoring for

therapeutic effects, therapeutic effects, side effects, toxic side effects, toxic effectseffects

• Refusal of medicationRefusal of medication

EvaluationEvaluation •• Ongoing part of the Ongoing part of the nursing processnursing process

• Determining the Determining the status of the goals status of the goals and and outcomes of careoutcomes of care

• Monitoring the Monitoring the patient’s response to patient’s response to drug therapydrug therapy– Expected and Expected and

unexpected unexpected responsesresponses

Pharmacologic Pharmacologic PrinciplesPrinciples

Drug NamesDrug Names Chemical nameChemical name• Describes the drug’s Describes the drug’s

chemical composition and chemical composition and molecular structuremolecular structure

Generic nameGeneric name (nonproprietary name)(nonproprietary name)

• Name given by the United Name given by the United States Adopted States Adopted Name CouncilName Council

Trade nameTrade name (proprietary (proprietary name)name)

• The drug has a registered The drug has a registered trademark; use of the name trademark; use of the name restricted by the drug’s restricted by the drug’s patent owner patent owner (usually the manufacturer)(usually the manufacturer)

Drug Names Drug Names (cont'd)(cont'd)

Chemical nameChemical name• (+/-)-2-(p-isobutylphenyl) (+/-)-2-(p-isobutylphenyl)

propionic acidpropionic acid

Generic nameGeneric name• ibuprofenibuprofen

Trade nameTrade name• Motrin®, Advil®Motrin®, Advil®

Figure 2-1 The Figure 2-1 The chemical, generic, and chemical, generic, and trade names for the trade names for the common analgesic common analgesic ibuprofen are listed ibuprofen are listed next to the chemical next to the chemical structure of the drug.structure of the drug.

Pharmacologic Pharmacologic PrinciplesPrinciples

• PharmaceuticsPharmaceutics• PharmacokineticsPharmacokinetics• PharmacodynamicsPharmacodynamics• PharmacotherapeutiPharmacotherapeuti

cscs• PharmacognosyPharmacognosy

PharmaceuticsPharmaceutics

The study of how The study of how various drug forms various drug forms influence influence pharmacokinetic and pharmacokinetic and pharmacodynamic pharmacodynamic activitiesactivities

PharmacokinetiPharmacokineticscs

• •

The study of what the The study of what the body does to the body does to the drugdrug– AbsorptionAbsorption– DistributionDistribution– MetabolismMetabolism– ExcretionExcretion

PharmacodynamiPharmacodynamicscs

• • The study of what the The study of what the drug does to the bodydrug does to the body– The mechanism of drug The mechanism of drug

actions in living tissuesactions in living tissues

Pharmacokinetics: Pharmacokinetics: AbsorptionAbsorption

• The rate at which a The rate at which a drug leaves its site drug leaves its site of administration, of administration, and the extent to and the extent to which absorption which absorption occursoccurs– BioavailabilityBioavailability– BioequivalentBioequivalent

Factors That Factors That Affect Affect AbsorptionAbsorption • Administration route of Administration route of

the drugthe drug• Food or fluids Food or fluids

administered with the administered with the drugdrug

• Dosage formulationDosage formulation• Status of the absorptive Status of the absorptive

surfacesurface• Rate of blood flow to Rate of blood flow to

the small intestinethe small intestine• Acidity of the stomachAcidity of the stomach• Status of GI motilityStatus of GI motility

Routes Routes

• A drug’s route of A drug’s route of administration administration affects the rate and affects the rate and extent of absorption extent of absorption of that drugof that drug– EnteralEnteral (GI tract) (GI tract)– ParenteralParenteral– TopicalTopical

First-Pass EffectFirst-Pass Effect• The metabolism of a drug The metabolism of a drug

and its passage from the and its passage from the liver into the circulationliver into the circulation– A drug given via the oral A drug given via the oral

route may be extensively route may be extensively metabolized by the liver metabolized by the liver before reaching the before reaching the systemic circulation (high systemic circulation (high first-pass effect)first-pass effect)

– The same drug—given IV—The same drug—given IV—bypasses the liver, bypasses the liver, preventing the first-pass preventing the first-pass effect from taking place, effect from taking place, and more drug reaches the and more drug reaches the circulationcirculation

Figure 2-3 First-pass effect is the metabolism of a drug by the liver before its systemic availability

Box 2-1 Drug Routes and First-Pass Effects

MetabolismMetabolism(Also Known As (Also Known As Biotransformation)Biotransformation)

The biologic The biologic transformation of a drug transformation of a drug into into an inactive metabolite, a an inactive metabolite, a more soluble compound, more soluble compound, or a more potent or a more potent metabolitemetabolite• Liver (main organ)Liver (main organ)• KidneysKidneys• LungsLungs• PlasmaPlasma• Intestinal mucosaIntestinal mucosa

Metabolism/Metabolism/Biotransformation (cont'd)Biotransformation (cont'd)

Delayed drug Delayed drug metabolism results metabolism results in:in:

• Accumulation of drugsAccumulation of drugs• Prolonged action of the Prolonged action of the

drugsdrugs

Stimulating drug Stimulating drug metabolism causes:metabolism causes:

• Diminished Diminished pharmacologic effectspharmacologic effects

ExcretionExcretion

The elimination of The elimination of drugs from the bodydrugs from the body

• Kidneys (main organ)Kidneys (main organ)• LiverLiver• BowelBowel– Biliary excretionBiliary excretion– Enterohepatic circulationEnterohepatic circulation

Half-lifeHalf-life

• The time it takes for The time it takes for one half of the original one half of the original amount of a drug in the amount of a drug in the body to be removedbody to be removed

• A measure of the rate A measure of the rate at which drugs are at which drugs are removed from the bodyremoved from the body

Onset, Peak, Onset, Peak, and Durationand Duration

OnsetOnset• The time it takes for the The time it takes for the

drug to elicit a drug to elicit a therapeutic responsetherapeutic response

PeakPeak• The time it takes for a The time it takes for a

drug to reach its drug to reach its maximum therapeutic maximum therapeutic response response

DurationDuration• The time a drug The time a drug

concentration is sufficient concentration is sufficient to elicit a therapeutic to elicit a therapeutic responseresponse

The Movement of Drugs The Movement of Drugs Through the BodyThrough the Body

Drug actionsDrug actions• The cellular processes The cellular processes

involved in the drug involved in the drug and cell interactionand cell interaction

Drug effectDrug effect• The physiologic reaction The physiologic reaction

of the body to the drugof the body to the drug

Ways Drugs Produce Ways Drugs Produce Therapeutic EffectsTherapeutic Effects• Once the drug is at Once the drug is at

the site of action, it the site of action, it can modify the rate can modify the rate (increase or (increase or decrease) at which decrease) at which the cells or tissues the cells or tissues functionfunction

• A drug cannot make a A drug cannot make a cell or tissue perform cell or tissue perform a function it was not a function it was not designed to performdesigned to perform

Figure 2-7 A, Drugs act by forming a chemical bond with specific receptor sites, similar to a key and lock. B, The better the “fit,” the better the response. Those with complete attachment and response are called agonists. C, Drugs that attach but do not elicit a response are called antagonists. D, Drugs that attach, elicit a small response, and also block other responses are called partial agonists or agonist-antagonists. (From Clayton BD, Stock YN: Basic pharmacology for nurses, ed 13, St. Louis, 2004, Mosby.)

Pharmacotherapeutics: Types Pharmacotherapeutics: Types of Therapiesof Therapies

• Acute therapyAcute therapy• Maintenance therapyMaintenance therapy• Supplemental Supplemental

therapytherapy• Palliative therapyPalliative therapy• Supportive therapySupportive therapy• Prophylactic therapyProphylactic therapy• Empiric therapyEmpiric therapy

MonitoringMonitoring• The effectiveness of The effectiveness of

the drug therapy the drug therapy must be evaluatedmust be evaluated

• One must be familiar One must be familiar with the drug’s:with the drug’s:– Intended therapeutic Intended therapeutic

action (beneficial)action (beneficial)– Unintended but Unintended but

potential side effects potential side effects (predictable, adverse (predictable, adverse reactions)reactions)

Other Drug-Other Drug-Related EffectsRelated Effects

• TeratogenicTeratogenic• MutagenicMutagenic• CarcinogenicCarcinogenic

ToxicologyToxicology

The study of The study of poisons and poisons and unwanted unwanted responses to responses to therapeutic agentstherapeutic agents

Table 2-9 Common Poisons and Antidotes

Life Span Life Span ConsiderationConsiderationss

Life Span Life Span ConsiderationsConsiderations

• PregnancyPregnancy• Breast-feedingBreast-feeding• NeonatalNeonatal• PediatricPediatric• GeriatricGeriatric

PregnancyPregnancy

• First trimester is the First trimester is the period of greatest period of greatest danger for drug-danger for drug-induced induced developmental developmental defectsdefects

• Drugs diffuse across Drugs diffuse across the placentathe placenta

• FDA pregnancy FDA pregnancy safety categoriessafety categories

Table 3-1 Pregnancy Table 3-1 Pregnancy safety categoriessafety categories

Breast-feedingBreast-feeding

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

• Consider risk-to-Consider risk-to-benefit ratiobenefit ratio

Table 3-2 Classification Table 3-2 Classification of young patientsof young patients

Pediatric Considerations: Pediatric Considerations: PharmacokineticsPharmacokinetics

• AbsorptionAbsorption– Gastric pH less acidicGastric pH less acidic– Gastric emptying is Gastric emptying is

slowedslowed– Topical absorption Topical absorption

faster through the faster through the skinskin

– Intramuscular Intramuscular absorption faster and absorption faster and irregularirregular

Pediatric Considerations: Pediatric Considerations: Pharmacokinetics (cont'd)Pharmacokinetics (cont'd)

• DistributionDistribution– TBW (total body water) TBW (total body water)

70% to 80% in full-term 70% to 80% in full-term infants, 85% in premature infants, 85% in premature newborns, 64% in newborns, 64% in children 1 to 12 years of children 1 to 12 years of ageage

– Greater TBW means fat Greater TBW means fat content is lowercontent is lower

– Decreased level of protein Decreased level of protein binding – immature liverbinding – immature liver

– Immature blood-brain Immature blood-brain barrierbarrier

Pediatric Considerations: Pediatric Considerations: Pharmacokinetics (cont'd)Pharmacokinetics (cont'd)

• MetabolismMetabolism– Liver immature, does Liver immature, does

not produce enough not produce enough microsomal enzymesmicrosomal enzymes

– Older children may Older children may have increased have increased metabolism, requiring metabolism, requiring higher doseshigher doses

– Other factorsOther factors

Pediatric Pediatric Considerations: Considerations: Pharmacokinetics Pharmacokinetics (cont'd)(cont'd) • ExcretionExcretion

– Kidney immaturity Kidney immaturity affects glomerular affects glomerular filtration rate and filtration rate and tubular secretiontubular secretion

– Decreased perfusion Decreased perfusion rate of the kidneysrate of the kidneys

Summary of Summary of Pediatric Pediatric ConsiderationsConsiderations • Skin is thin and permeableSkin is thin and permeable

• Stomach lacks acid to kill Stomach lacks acid to kill bacteriabacteria

• Lungs lack mucus barriersLungs lack mucus barriers• Body temperatures poorly Body temperatures poorly

regulated and dehydration regulated and dehydration occurs easilyoccurs easily

• Liver and kidneys are Liver and kidneys are immature, impairing drug immature, impairing drug metabolism and excretionmetabolism and excretion

Methods of Dosage Methods of Dosage Calculation for Pediatric Calculation for Pediatric PatientsPatients

• Body weight dosage Body weight dosage calculationscalculations

• Body surface area Body surface area methodmethod

Geriatric Geriatric ConsiderationsConsiderations

• Geriatric: older than Geriatric: older than age 65age 65– Healthy People 2010: Healthy People 2010:

older than age 55older than age 55

• Use of OTC Use of OTC medicationsmedications

• PolypharmacyPolypharmacy

Table 3-4 Physiologic changes in the Table 3-4 Physiologic changes in the geriatric patientgeriatric patient

Geriatric Considerations: Geriatric Considerations: PharmacokineticsPharmacokinetics

• AbsorptionAbsorption– Gastric pH less acidicGastric pH less acidic– Slowed gastric emptyingSlowed gastric emptying– Movement through GI Movement through GI

tract slowertract slower– Reduced blood flow to Reduced blood flow to

the GI tractthe GI tract– Reduced absorptive Reduced absorptive

surface area due to surface area due to flattened intestinal villiflattened intestinal villi

Geriatric Considerations: Geriatric Considerations: Pharmacokinetics (cont'd)Pharmacokinetics (cont'd)

• DistributionDistribution– TBW percentages TBW percentages

lowerlower– Fat content increasedFat content increased– Decreased production Decreased production

of proteins by the of proteins by the liver, resulting in liver, resulting in decreased protein decreased protein binding of drugsbinding of drugs

Geriatric Considerations: Geriatric Considerations: Pharmacokinetics (cont'd)Pharmacokinetics (cont'd)

• MetabolismMetabolism– Aging liver produces Aging liver produces

less microsomal less microsomal enzymes, affecting enzymes, affecting drug metabolismdrug metabolism

– Reduced blood flow Reduced blood flow to the liverto the liver

Geriatric Considerations: Geriatric Considerations: Pharmacokinetics (cont'd)Pharmacokinetics (cont'd)

• ExcretionExcretion– Decreased glomerular Decreased glomerular

filtration ratefiltration rate– Decreased number of Decreased number of

intact nephronsintact nephrons

Geriatric Considerations: Geriatric Considerations: Problematic MedicationsProblematic Medications

• AnalgesicsAnalgesics• AnticoagulantsAnticoagulants• AnticholinergicsAnticholinergics• AntihypertensivesAntihypertensives• DigoxinDigoxin• Sedatives and Sedatives and

hypnoticshypnotics• Thiazide diureticsThiazide diuretics

Legal, Ethical, Legal, Ethical, and Culturaland CulturalConsiderationConsiderationss

U.S. Drug U.S. Drug LegislationLegislation • 1906: Federal Food 1906: Federal Food

and Drug Actand Drug Act• 1912: Sherley 1912: Sherley

Amendment (to the Amendment (to the Federal Food and Federal Food and Drug Act of 1906)Drug Act of 1906)

• 1914: Harrison 1914: Harrison Narcotic ActNarcotic Act

• 1938: Federal 1938: Federal Food, Drug, and Food, Drug, and Cosmetic Act Cosmetic Act (revision of 1906 Act)(revision of 1906 Act)

U.S. Drug U.S. Drug Legislation Legislation (cont'd)(cont'd) • 1951: Durham-1951: Durham-

Humphrey Humphrey Amendment (to the Amendment (to the 1938 act)1938 act)

• 1962: Kefauver-1962: Kefauver-Harris Amendment Harris Amendment (to the 1938 act)(to the 1938 act)

• 11970: Controlled 970: Controlled Substance ActSubstance Act

U.S. Drug U.S. Drug Legislation Legislation (cont'd)(cont'd) • 1983: Orphan Drug 1983: Orphan Drug

ActAct

• 1991: Accelerated 1991: Accelerated drug approvaldrug approval

Table 4-1 Controlled substances: Table 4-1 Controlled substances: schedule categoriesschedule categories

Table 4-2 Controlled substances: categories, Table 4-2 Controlled substances: categories, dispensing restrictions, and examplesdispensing restrictions, and examples

New Drug New Drug DevelopmentDevelopment

• Investigational new Investigational new drug (IND) drug (IND) applicationapplication

• Informed consentInformed consent• Investigational drug Investigational drug

studiesstudies• Expedited drug Expedited drug

approvalapproval

Ethical Nursing Ethical Nursing PracticePractice

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

Provisions:Provisions:• CommitmentCommitment• AdvocacyAdvocacy• Responsibility/AccountabilityResponsibility/Accountability• Duty to self and others Duty to self and others • IntegrityIntegrity• Practice, education, Practice, education,

administration & knowledgeadministration & knowledge• Collaboration – professional teamCollaboration – professional team• Professional Associations – Professional Associations –

articulate nursing values, articulate nursing values, maintaining integrity of the maintaining integrity of the profession & practice, shaping profession & practice, shaping social policysocial policy

Cultural Cultural ConsiderationsConsiderations

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

• Drug polymorphism – Drug polymorphism – cultural safetycultural safety

• Compliance level with Compliance level with therapytherapy

• Environmental Environmental considerationsconsiderations

• Genetic factorsGenetic factors• Varying responses to Varying responses to

specific agentsspecific agents

Cultural Cultural AssessmentAssessment

• Health beliefs and Health beliefs and practicespractices

• Past uses of medicinePast uses of medicine• Folk remediesFolk remedies• Home remediesHome remedies• Use of Use of

nonprescription drugs nonprescription drugs and herbal remediesand herbal remedies

• OTC treatmentsOTC treatments

Cultural Cultural Assessment Assessment (cont'd)(cont'd) • Usual response to Usual response to

treatmenttreatment• Responsiveness to Responsiveness to

medical treatmentmedical treatment• Religious practices Religious practices

and beliefsand beliefs• Dietary habitsDietary habits

Medication Medication Errors:Errors:Preventing Preventing and and RespondingResponding

Medication Medication MisadventuresMisadventures

• Medication errors Medication errors (MEs)(MEs)

• Adverse drug events Adverse drug events (ADEs)(ADEs)

• Adverse drug Adverse drug reactions (ADRs)reactions (ADRs)

Medication Medication Misadventures Misadventures (cont'd)(cont'd)

• By definition, all By definition, all ADRs are also ADEsADRs are also ADEs

• But all ADEs are not But all ADEs are not ADRsADRs

• Two types of ADRsTwo types of ADRs– Allergic reactionsAllergic reactions– Idiosyncratic Idiosyncratic

reactionsreactions

Medication Medication ErrorsErrors

• PreventablePreventable• Common cause of Common cause of

adverse health care adverse health care outcomesoutcomes

• Effects can range from Effects can range from no significant effect to no significant effect to directly causing directly causing disability or deathdisability or death

Box 5-1 Common classes of medications Box 5-1 Common classes of medications involved in serious errorsinvolved in serious errors

Preventing Preventing Medication ErrorsMedication Errors

• Minimize verbal or Minimize verbal or telephone orderstelephone orders– Repeat order to Repeat order to

prescriberprescriber– Spell drug name aloudSpell drug name aloud– Speak slowly and clearlySpeak slowly and clearly

• List indication next to List indication next to each ordereach order

• Avoid medical Avoid medical shorthand, including shorthand, including abbreviations and abbreviations and acronymsacronyms

Preventing Preventing Medication Errors Medication Errors (cont'd)(cont'd) • Never assume anything Never assume anything

about items not about items not specified in a drug order specified in a drug order (i.e., route)(i.e., route)

• Do not hesitate to Do not hesitate to question a medication question a medication order for any reason order for any reason when in doubtwhen in doubt

• Do not try to decipher Do not try to decipher illegibly written orders; illegibly written orders; contact prescriber for contact prescriber for clarificationclarification

Preventing Preventing Medication Errors Medication Errors (cont'd)(cont'd) • NEVER use “trailing NEVER use “trailing

zeros” with zeros” with medication ordersmedication orders

• Do not use 1.0 mg; Do not use 1.0 mg; use 1 mguse 1 mg• 1.0 mg could be 1.0 mg could be

misread as 10 mg, misread as 10 mg, resulting in a tenfold resulting in a tenfold dose increasedose increase

Preventing Preventing Medication Medication Errors (cont'd)Errors (cont'd) • ALWAYS use a ALWAYS use a

“leading zero” for “leading zero” for decimal dosagesdecimal dosages

• Do not use .25 mg; Do not use .25 mg; use 0.25 mguse 0.25 mg

• .25 mg may be .25 mg may be misread as 25 mgmisread as 25 mg

• ““.25” is sometimes .25” is sometimes called a “naked called a “naked decimal”decimal”

Preventing Preventing Medication Errors Medication Errors (cont'd)(cont'd) • Check medication Check medication

order and what is order and what is available while using available while using the “6 rights”the “6 rights”

• Take time to learn Take time to learn special administration special administration techniques of certain techniques of certain dosage formsdosage forms

Preventing Preventing Medication Errors Medication Errors (cont'd)(cont'd)

• Always listen to and Always listen to and honor any concerns honor any concerns expressed by patients expressed by patients regarding regarding medicationsmedications

• Check patient Check patient allergies and allergies and identificationidentification

Medication Medication ErrorsErrors

• Possible consequences to Possible consequences to nursesnurses

• Reporting and responding Reporting and responding to MEsto MEs– ADE monitoring programsADE monitoring programs– USPMERP (United States USPMERP (United States

Pharmacopeia Medication Pharmacopeia Medication Errors Reporting Program)Errors Reporting Program)

– MedWatch, sponsored by MedWatch, sponsored by the FDAthe FDA

– Institute for Safe Medication Institute for Safe Medication Practices (ISMP)Practices (ISMP)

• Notification of patient Notification of patient regarding MEsregarding MEs

Medication Medication ReconciliationReconciliation

• Process to prevent Process to prevent medication errors:medication errors:– 1. Verification1. Verification– 2. Clarification.2. Clarification.– 3. Reconciliation3. Reconciliation

• Performed:Performed:– AdmissionAdmission– Status changeStatus change– TransferTransfer– DischargeDischarge

• Pt AssessmentPt Assessment– Open-ended questionsOpen-ended questions– Avoid medical jargonAvoid medical jargon– ClarifyClarify– Current & complete Current & complete

medication listmedication list

Drug Drug AdministrationAdministration

Preparing for Preparing for Drug Drug AdministrationAdministration • Check the “6 rights”Check the “6 rights”

• Standard Precautions: Standard Precautions: Wash your hands!Wash your hands!

• Double-check if unsure Double-check if unsure about anythingabout anything

• Check for drug Check for drug allergiesallergies

• Prepare drugs for one Prepare drugs for one patient at a timepatient at a time

• Check three timesCheck three times