The Nursing Process and Drug Therapy Karen Ruffin RN, MSN

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The Nursing Process and Drug Therapy
Karen Ruffin RN, MSN Ed.
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The Nursing Process

• An organizational framework for the practice of
  nursing
• Orderly, systematic
• Central to all nursing care
• Encompasses all steps taken by the nurse in
  caring for a patient
• Flexibility is important

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The Nursing Process (cont'd)

• Assessment
• Nursing diagnosis
• Planning (with outcome criteria)
• Implementation
• Evaluation

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The Nursing Process (cont'd)

• Assessment
• Data collection
• Subjective, objective
• Data collected on the patient, drug, environment
• Medication history
• Nursing assessment
• Physical assessment
• Data analysis

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The Nursing Process (cont'd)

• Nursing diagnosis
• Judgment or conclusion about the need/problem
  (actual or at risk for) of the patient
• Based upon an accurate assessment
• NANDA format

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The Nursing Process (cont'd)

• Planning
• Identification of goals and outcome criteria
• Prioritization
• Time frame

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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

• Right drug
• Right dose
• Right time
• Right route
• Right patient

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Another RightConstant 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, side effects,
  toxic effects
• Refusal of medication

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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

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Pharmacologic Principles
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Drug Names

• Chemical name
• Describes the drugs 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 drugs patent owner
  (usually the manufacturer)

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Drug Names (cont'd)

• Chemical name
• (/-)-2-(p-isobutylphenyl) propionic acid
• Generic name
• ibuprofen
• Trade name
• Motrin, Advil

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Figure 2-1 The chemical, generic, and trade names
for the common analgesic ibuprofen are listed
next to the chemical structure of the drug.
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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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Figure 2-2 Phases of Drug Activity. (From McKenry
LM, Salerno E Mosbys pharmacology in
nursingrevised and updated, ed 21, St. Louis,
2003, Mosby.)
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Pharmacotherapeutics

• The use of drugs and the clinical indications for
  drugs to prevent and treat diseases

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Pharmacognosy

• The study of natural (plant and animal) drug
  sources

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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

• Administration route of the drug
• 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 drugs 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, the small
  intestine, or rectum
• Oral
• Sublingual
• Buccal
• Rectal

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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 druggiven IVbypasses the liver,
  preventing the first-pass effect from taking
  place, and more drug reaches the circulation

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Figure 2-3 First-pass effect is the metabolism of
a drug by the liver before its systemic
availability
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Box 2-1 Drug Routes and First-Pass Effects
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Parenteral Route

• Intravenous (fastest delivery into the blood
  circulation)
• Intramuscular
• Subcutaneous
• Intradermal
• Intrathecal
• Intraarticular

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Topical Route

• Skin (including transdermal patches)
• Eyes
• Ears
• Nose
• Lungs (inhalation)
• 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 biologic transformation of a drug into an
  inactive metabolite, a more soluble compound, or
  a more potent metabolite
• Liver (main organ)
• Kidneys
• Lungs
• Plasma
• Intestinal mucosa

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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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Excretion

• The elimination of drugs from the body
• Kidneys (main organ)
• Liver
• Bowel
• Biliary excretion
• Enterohepatic circulation

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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

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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

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The Movement of Drugs Through 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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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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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.)
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Pharmacotherapeutics Types of Therapies

• Acute therapy
• Maintenance therapy
• Supplemental therapy
• Palliative therapy
• Supportive therapy
• Prophylactic therapy
• Empiric therapy

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Monitoring

• The effectiveness of the drug therapy must be
  evaluated
• One must be familiar with the drugs
• Intended therapeutic action (beneficial)
• Unintended but potential side effects
  (predictable, adverse reactions)

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Monitoring (cont'd)

• Therapeutic index
• The ratio between a drugs therapeutic
  benefits and its toxic effects

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Monitoring (cont'd)

• Tolerance
• A decreasing response to repetitive 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)

• Medication misadventures
• Adverse drug events
• Adverse drug reactions
• Medication errors

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Monitoring (cont'd)

• Some adverse drug reactions are classified as
  side effects
• Expected, well-known reactions that result in
  little or no change in patient management
• Predictable frequency
• The effects intensity and occurrence are related
  to the size of the dose

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Adverse Drug Reaction

• An adverse outcome of drug therapy in which a
  patient is harmed in some way
• Pharmacologic reactions
• Idiosyncratic reactions
• Hypersensitivity reactions
• Drug interactions

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Other Drug-Related Effects

• Teratogenic
• Mutagenic
• Carcinogenic

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Toxicology

• The study of poisons and unwanted responses to
  therapeutic agents

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Table 2-9 Common Poisons and Antidotes
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Life Span Considerations
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Life Span Considerations

• Pregnancy
• Breast-feeding
• Neonatal
• Pediatric
• Geriatric

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Pregnancy

• First trimester is the period of greatest danger
  for drug-induced developmental defects
• Drugs diffuse across the placenta
• FDA pregnancy safety categories

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Table 3-1 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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Table 3-2 Classification of young patients
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Pediatric Considerations Pharmacokinetics

• Absorption
• Gastric pH less acidic
• Gastric emptying is slowed
• Topical absorption faster through the skin
• Intramuscular absorption faster and irregular

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Pediatric Considerations Pharmacokinetics
(cont'd)

• Distribution
• TBW 70 to 80 in full-term infants, 85 in
  premature newborns, 64 in children 1 to 12
  years of age
• Greater TBW means fat content is lower
• Decreased level of protein binding
• Immature blood-brain barrier

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Pediatric Considerations Pharmacokinetics
(cont'd)

• Metabolism
• Liver immature, does not produce enough
  microsomal enzymes
• Older children may have increased metabolism,
  requiring higher doses
• Other factors

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Pediatric Considerations Pharmacokinetics
(cont'd)

• Excretion
• Kidney immaturity affects glomerular filtration
  rate and tubular secretion
• Decreased perfusion rate of the kidneys

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Summary of Pediatric Considerations

• Skin is thin and permeable
• Stomach lacks acid to kill bacteria
• Lungs lack mucus barriers
• Body temperatures poorly 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 weight dosage calculations
• Body surface area method

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Geriatric Considerations

• Geriatric older than age 65
• Healthy People 2010 older than age 55
• Use of OTC medications
• Polypharmacy

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Table 3-4 Physiologic changes in the geriatric
patient
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Geriatric Considerations 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

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Geriatric Considerations Pharmacokinetics
(cont'd)

• Distribution
• TBW percentages lower
• Fat content increased
• Decreased production of proteins by the liver,
  resulting in decreased protein binding of drugs

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Geriatric Considerations Pharmacokinetics
(cont'd)

• Metabolism
• Aging liver produces less microsomal enzymes,
  affecting drug metabolism
• Reduced blood flow to the liver

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Geriatric Considerations Pharmacokinetics
(cont'd)

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

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Geriatric Considerations Problematic Medications

• Analgesics
• Anticoagulants
• Anticholinergics
• Antihypertensives
• Digoxin
• Sedatives and hypnotics
• Thiazide diuretics

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Legal, Ethical, and CulturalConsiderations
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U.S. Drug Legislation

• 1906 Federal Food and Drug 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)

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U.S. Drug Legislation (cont'd)

• 1951 Durham-Humphrey Amendment (to the 1938 act)
• 1962 Kefauver-Harris Amendment (to the 1938 act)
• 1970 Controlled Substance Act

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U.S. Drug Legislation (cont'd)

• 1983 Orphan Drug Act
• 1991 Accelerated drug approval

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Table 4-1 Controlled substances schedule
categories
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Table 4-2 Controlled substances categories,
dispensing restrictions, and examples
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New Drug Development

• Investigational new drug (IND) application
• Informed consent
• Investigational drug studies
• Expedited drug approval

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U.S. FDA Drug Approval Process

• Preclinical investigational drug studies
• 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

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Cultural Considerations

• Assess the influence of a patients cultural
  beliefs, values, and customs
• Drug polymorphism
• Compliance level with therapy
• Environmental considerations
• Genetic factors
• Varying responses to specific agents

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Cultural Assessment

• Health beliefs and practices
• Past uses of medicine
• Folk remedies
• Home remedies
• Use of nonprescription drugs and herbal remedies
• OTC treatments

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Cultural Assessment (cont'd)

• Usual response to treatment
• Responsiveness to medical treatment
• Religious practices and beliefs
• Dietary habits

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Medication ErrorsPreventing and Responding
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Medication Misadventures

• Medication errors (MEs)
• Adverse drug events (ADEs)
• Adverse drug reactions (ADRs)

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Medication Misadventures (cont'd)

• By definition, all ADRs are also ADEs
• But all ADEs are not ADRs
• Two types of ADRs
• Allergic reactions
• Idiosyncratic reactions

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Medication Errors

• Preventable
• Common cause of adverse health care outcomes
• Effects can range from no significant effect to
  directly causing disability or death

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Box 5-1 Common classes of medications involved in
serious errors
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Preventing Medication Errors

• 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

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Preventing Medication Errors (cont'd)

• Never assume anything about items not specified
  in a drug order (i.e., 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

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Preventing Medication Errors (cont'd)

• NEVER use trailing zeros with medication orders
• Do not use 1.0 mg use 1 mg
• 1.0 mg could be misread as 10 mg, resulting in a
  tenfold dose increase

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Preventing Medication Errors (cont'd)

• ALWAYS use a leading zero for decimal dosages
• Do not use .25 mg use 0.25 mg
• .25 mg may be misread as 25 mg
• .25 is sometimes called a naked decimal

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Preventing Medication Errors (cont'd)

• Check medication order and what is available
  while using the 5 rights
• Take time to learn special administration
  techniques of certain dosage forms

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Preventing Medication Errors (cont'd)

• Always listen to and honor any concerns expressed
  by patients regarding medications
• Check patient allergies and identification

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Medication Errors

• Possible consequences to nurses
• Reporting and responding to MEs
• ADE monitoring programs
• USPMERP (United States Pharmacopeia Medication
  Errors Reporting Program)
• MedWatch, sponsored by the FDA
• Institute for Safe Medication Practices (ISMP)
• Notification of patient regarding MEs

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Drug Administration
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Preparing for Drug Administration

• Check the 5 rights
• Standard Precautions Wash your hands!
• Double-check if unsure about anything
• Check for drug allergies
• Prepare drugs for one patient at a time
• Check three times

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Preparing for Drug Administration (cont'd)

• Check expiration dates
• Check the patients identification
• Give medications on time
• Explain medications to the patient
• Open the medications at the bedside
• Document the medications given before going to
  the next patient

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Enteral Drugs

• Giving oral medications
• Giving sublingual or buccal medications
• Liquid medications
• Giving oral medications to infants
• Administering drugs through a nasogastric or
  gastrostomy tube
• Rectal administration

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Parenteral Drugs

• Never recap a used needle!
• May recap an unused needle with the scoop
  method
• Prevention of needlesticks
• Filter needles

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Parenteral Drugs (cont'd)

• Removing medications from ampules
• Removing medications from vials
• Disposal of used needles and syringes

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Injections

• Needle angles for various injections
• Intramuscular (IM)
• Subcutaneous (SC or SQ)
• Intradermal (ID)
• Z-track method for IM injections
• Air-lock technique

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Injection Techniques

• Intradermal injections
• Subcutaneous injections
• Insulin administration
• Heparin administration

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Injection Techniques (cont'd)

• Intramuscular injections
• Ventrogluteal site (preferred)
• Vastus lateralis site
• Dorsogluteal site
• Deltoid site

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Preparing Intravenous Medications

• Needleless systems
• Compatibility issues
• Expiration dates
• Mixing intravenous piggyback (IVPB) medications
• Labeling intravenous (IV) infusion bags when
  adding medications

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Intravenous Medications

• Adding medications to a primary infusion bag
• IVPB medications (secondary line)
• IV push medications (bolus)
• Through an IV lock
• Through an existing IV infusion

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Intravenous Medications (cont'd)

• Volume-controlled administration set
• Using electronic infusion pumps
• Patient-controlled analgesia (PCA) pumps

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Topical Drugs

• Eye medications
• Drops
• Ointments
• Ear drops
• Adults
• Infant or child younger than 3 years of age

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Topical Drugs (cont'd)

• Nasal drugs
• Drops
• Spray
• Inhaled drugs
• Metered-dose inhalers
• Small-volume nebulizers

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Topical Drugs (cont'd)

• Administering medications to the skin
• Lotions, creams, ointments, powders
• Transdermal patches
• Vaginal medications
• Creams, foams, gels
• Suppositories