Introduction to Nursing Pharmacology
Week 1
Prepared By: Maria Lorena Araneta RN MAN
Introduction to Drugs
Learning Objectives
Introduction to drugs:
Any chemical that affects the physiologic processes of a living organism can broadly be
defined as a drug. The study or science of drugs is known as pharmacology. In clinical
practice, health care providers focus on how chemicals act on living organisms. Nurses
deal with pharmacotherapeutics, or clinical pharmacology, the branch of pharmacology
that uses drugs to treat, prevent, and diagnose disease.
For many reasons, understanding how drugs act on the body to cause changes and
applying that knowledge in the clinical setting are important aspects of nursing practice.
A drug can have many effects, and the nurse must know which ones may occur when a
particular drug is administered. Some drug effects are therapeutic, or helpful, but others
are undesirable or potentially dangerous. These negative effects are called adverse
effects.
The nurse is in a unique position regarding drug
therapy because nursing responsibilities include the
following:
•
Administering drugs
•
Assessing drug effects
•
Intervening to make the drug regimen more tolerable
•
Providing patient teaching about drugs and the drug regimen
•
Monitoring the overall patient care plan to prevent medication errors
SOURCES OF DRUGS:
➔ Natural sources
• Chemicals that might prove useful as drugs can come from
many natural sources, such as plants, animals, or inorganic
Compounds.
❏ Plants - products used to treat cardiac disorders and various opiates
❏
used for sedation are still derived from plants.
Animal Products - insulin for treating diabetes was obtained
exclusively from the pancreas of cows and pigs.
SOURCES OF DRUGS:
❏ Animal Products - insulin for treating diabetes was obtained
exclusively from the pancreas of cows and pigs.
❏ Inorganic Compounds - Salts of various chemical
elements can have therapeutic effects in the human body.
SOURCES OF DRUGS:
➔ Synthetic Sources - drugs are developed synthetically after chemicals in plants,
animals, or the environment have been
tested and found to have therapeutic activity
DRUG MONOGRAPH
Drugs Derived from Plants
DRUG EVALUATION
After a chemical that might have therapeutic value is
identified, it must undergo a series of scientific tests to
evaluate its actual therapeutic and toxic effects. This process is
tightly controlled by the U.S. Food and Drug Administration
(FDA), an agency of the U.S. Department of Health and
Human Services that regulates the development and sale of
drugs.
Before receiving final FDA approval to be marketed to the public, drugs must pass through
several stages of development. These include preclinical trials and phase I, II, and III studies
LEGAL REGULATION OF DRUGS
Nurses should become familiar with the rules and regulations in the area in which
they practice. These regulations can vary from state to state, and even within a
state.
Safety During Pregnancy
The categories indicate a drug’s
potential or actual teratogenic effects,
thus offering guidelines for use of at
particular drug in pregnancy.
Controlled Substances
The Controlled Substances Act of
1970 established categories for
ranking of the abuse potential of
various drugs.
The FDA studies the drugs and
determines their abuse potential; the
Drug Enforcement Agency (DEA)
enforces their control. Drugs with
abuse potential are called controlled
substances.
Generic Drugs
chemicals that are produced by companies involved solely in the manufacturing of
drugs. Because they do not have the research, the advertising, or, sometimes, the
quality control departments that pharmaceutical companies have, they can produce
the generic drugs more cheaply.
Orphan Drugs
Drugs that have been discovered but are not
financially viable and therefore have not been
“adopted” by any drug company. Orphan drugs
may be useful in treating a rare disease, or
they may have potentially dangerous adverse
effects.
● Orphan drugs are often abandoned after
preclinical trials or phase I studies. The
Orphan Drug Act of 1983 provided
tremendous financial incentives to drug
companies to adopt these drugs and
develop them.
Over-the-Counter Drugs
(OTC) drugs are products that are available without
prescription for self-treatment of a variety of
complaints.
Some were not rigorously screened and tested by the
current drug evaluation protocols because they were
developed and marketed before the current laws were
put into effect. Many of these drugs were
“grandfathered” into use because they had been used
for so long.
Although OTC drugs have been found
to be safe when taken as directed,
nurses should consider several
problems related to OTC drug use:
• Taking these drugs could mask the signs and symptoms
of underlying disease, making diagnosis difficult.
• Taking these drugs with prescription medications could
result in drug interactions and interfere with drug therapy.
• Not taking these drugs as directed could result in serious
overdoses.
SOURCES OF DRUG
INFORMATION
❏ Drug Labels - Specific information
that identifies a specific drug.
❏ Package Inserts - Contains all of the
chemical and study information that
led to the drug’s approval
❏ Reference Books - A wide variety are
available for drug information.
❏ Journals - Various can be used to
obtain drug information.
Drugs and the Body
Learning Objectives
Drugs and the Body
To understand what happens when a drug is administered,
the nurse must understand pharmacodynamics—how the
drug affects the body—and pharmacokinetics—how the
body acts on the drug. Knowing the basic principles of
pharmacodynamics and pharmacokinetics helps the nurse to
anticipate therapeutic and adverse drug effects and to
intervene in ways that ensure the most effective drug
regimen for the patient.
Drugs usually work in one of four ways:
1. To replace or act as substitutes for missing chemicals.
2. To increase or stimulate certain cellular activities.
3. To depress or slow cellular activities.
4. To interfere with the functioning of foreign cells, such as
invading microorganisms or neoplasms. (Drugs that act in
this way are called chemotherapeutic agents.)
❏ Receptor Sites
Many drugs are thought to act at specific areas on cell membranes
called receptor sites. It react with certain chemicals to cause an
effect within the cell. In many situations, nearby enzymes break
down the reacting chemicals and open the receptor site for further
stimulation
Some drugs interact directly with receptor sites to cause the same
activity that natural chemicals would cause at that site. These
drugs are called agonists. For example, insulin reacts with
specific insulin-receptor sites to change cell membrane
permeability, thus promoting the movement of glucose into the
cell.
❏ Drug–Enzyme Interactions
Drugs also can cause their effects by interfering with the enzyme systems that act as
catalysts for various chemical reactions. Enzyme systems work in a cascade fashion,
with one enzyme activating another, and then that enzyme activating
another, until a cellular reaction eventually occurs.
❏ Selective Toxicity
The ability of a drug to attack only those systems found in foreign cells
is known as selective toxicity.
Unfortunately, most other chemotherapeutic agents also destroy normal
human cells, causing many of the adverse effects associated with anti
pathogen and antineoplastic chemotherapy.
PHARMACOKINETICS
Pharmacokinetics involves the study of
absorption, distribution, metabolism
(biotransformation), and excretion of drugs.
In clinical practice, pharmacokinetic
considerations include the onset of drug
action, drug half-life, timing of the peak
effect, duration of drug effects, metabolism or
biotransformation of the drug, and the site of
excretion.
➢ Critical concentration
The amount of a drug that is needed to cause a therapeutic effect
A. Pharmacokinetics:
Pharmacokinetics involves the study of absorption, distribution, metabolism biotransformation), and excretion of
drugs.
❖ Absorption: First, absorption from the site of administration permits entry of the drug (either directly or
indirectly) into plasma
❖ Distribution: Second, the drug may then reversibly leave the bloodstream and distribute into the
interstitial and intracellular fluids.
❖ Metabolism: Third, the drug may be biotransformed by metabolism by the liver or other tissues.
❖ Elimination: Finally, the drug and its metabolites are eliminated from the body in urine, bile, or feces.
➢ Loading Dose
(a higher dose than that usually used for treatment) to reach the
critical concentration. The critical concentration then is
maintained by using the recommended dosing schedule
➢ Dynamic Equilibrium
The actual concentration that a drug reaches in the body results from a dynamic
equilibrium involving several processes:
• Absorption from the site of entry
• Distribution to the active site
• Biotransformation (metabolism) in the liver
• Excretion from the bod
Using knowledge of pharmacokinetic parameters,
clinicians can design optimal drug regimens, including
the route of administration, the dose, the frequency, and
the duration of treatment.
In clinical practice, pharmacokinetic considerations include the:
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Onset of drug action.
Drug half-life.
Timing of the peak effect.
Duration of drug effects.
Metabolism or biotransformation of the drug.
The site of excretion.
1. Absorption
Refers to what happens to a drug from the time it is introduced to the body until it
reaches the circulating fluids and tissues.
To reach reactive tissues, a drug must first make its way into the circulating fluids
of the body.
Drugs can be absorbed from many different areas in the body: through the GI tract
either orally or rectally, through mucous membranes, through the skin, through the
lung, or through muscle or subcutaneous tissues
Factors influencing absorption:
1. PH of the absorption site.
2. Blood flow to the absorption site.
3. Total surface area available for
absorption.
4. Contact time at the absorption
surface.
1.2. Routes of administration
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Drug absorption is influenced by route of administration.
Oral administration is the most common drug administration route due to its affordability and safety.
Pharmaceutical companies take into account the acidic environment of the stomach when preparing
drugs in capsule or tablet form.
Oral drugs should be given 1 hour before or 2 hours after a meal to reduce the effects of stomach
acidity and certain foods.
IV drugs have an immediate onset and are fully absorbed at administration, but are more likely to
cause toxic effects.
Drugs injected intramuscularly (IM) reach a peak level faster than those injected subcutaneously (SU),
depending on the fat content of the injection site and local circulation.
Absorption:
The transfer of a drug from the site of administration to the
bloodstream. It depends on the environment, chemical
characteristics, and route of administration, which affects
bioavailability. Routes other than intravenous may result in
partial absorption and lower bioavailability.
Drugs are absorbed into cells through passive diffusion, active
transport, and filtration, which occurs across a concentration
gradient and does not require cellular energy.
Active transport is a process that uses energy to move molecules
across a cell membrane, which is important for drug excretion in
the kidney.
Active transport uses energy to move molecules across a cell
membrane, which is essential for drug excretion in the kidney.
2. Distribution:
● Drug distribution from the plasma to the interstitium depends on
cardiac output, capillary permeability, binding to plasma and tissue
proteins, and lipophilicity.
● Distribution is the movement of a drug to the body's tissues, and
factors such as lipid solubility, ionization, and perfusion can affect it.
● Tissue perfusion is essential for effective treatment of diabetic
patients with lower-leg infections due to decreased blood flow.
● Vasoconstriction in extremities prevents drug delivery, resulting in
limited therapeutic effect.
● Drugs that are not lipid soluble cannot be distributed to the CNS due
to the blood-brain barrier.
2.1. Protein Binding
Drugs are bound to proteins in the blood, but the drug must be freed from the
protein's binding site at the tissues in order to react.
Drugs that are tightly bound and released slowly have a long duration of action,
while drugs that are loosely bound tend to act quickly and be excreted quickly. When
two drugs are given together, they may compete for protein binding sites, altering
effectiveness or causing toxicity.
2.2. Blood–Brain Barrier
A protective system of cellular activity that keeps foreign invaders and poisons away
from the CNS. Drugs that are lipid soluble are more likely to pass through the
barrier and reach the CNS. Effective antibiotic treatment can occur only when the
infection is severe enough to alter the blood–brain barrier and allow antibiotics to
cross.
Drugs can cause adverse CNS effects due to indirect drug effects, such as alterations
in glucose and electrolyte levels, which can interfere with nerve functioning and
produce CNS effects.
2.3. Placenta and Breast Milk
Drugs can pass through the placenta and affect the developing fetus in pregnant
women. It is best not to administer any drugs to pregnant women due to the
potential risk to the fetus. Drugs should be given only when the benefit outweighs
the risk. Drugs can also be secreted into breast milk and have the potential to affect
the neonate. Nurses must always check the ability of a drug to pass into breast milk
when giving a drug to a breastfeeding mother.
3. Biotransformation (Metabolism)
The body is well prepared to deal with foreign chemicals. Enzymes in the liver, cells,
GI tract, and circulating in the body detoxify foreign chemicals to protect the fragile
homeostasis. Almost all of the chemical reactions that the body uses to convert drugs
and other chemicals into nontoxic substances are based on processes that make the
chemical less active and more easily excreted from the body.
The liver is the most important site of drug metabolism or biotransformation, where
drugs are changed into new, less active chemicals. It detoxifies chemicals and uses
others to produce enzymes and structures.
3.1. First-Pass Effect
Drugs taken orally are absorbed from the small intestine into the portal venous
system, where they are transformed by liver enzymes into active and deactivated
metabolites. This is known as the first-pass effect, and the portion of the drug that
gets through it is delivered to the circulatory system for transport throughout the
body.
Injected drugs and drugs absorbed from sites other than the GI tract undergo a
similar biotransformation when passing through the liver, making injected drugs
more effective at lower doses. Oral drugs can be higher than parenteral drugs due to
the first-pass effect.
3.2. Hepatic Enzyme System
The hepatic microsomal system is lined with enzymes that work to biotransform
orally administered drugs. Phase I biotransformation involves oxidation, reduction,
or hydrolysis of the drug via the cytochrome P450 system. Phase II
biotransformation involves a conjugation reaction to make the drug more polar and
easier to excrete by the kidneys.
Enzyme induction increases the activity of an enzyme system, which speeds up the
metabolism of drugs. This is why some drugs cannot be taken together effectively
and some drugs inhibit an enzyme system, leading to toxic levels. Liver disease is a
contraindication when administering certain drugs.
4. Excretion
The removal of drugs from the body, with the
kidneys playing the most important role.
Drugs that have been made water soluble in the
liver are excreted from the kidney by glomerular
filtration. Other drugs are secreted or
reabsorbed through the renal tubule by active
transport systems. The acidity of urine can play
an important role in drug excretion, so it is
important to consider the patient's kidney
function and urine acidity before administering a
drug.
5. Half-Life
The half-life of a drug is the time it takes for the amount of drug in the body to
decrease to one half of its peak level. This information is important when
determining the appropriate timing for a drug dose or determine when a drug is
administered orally.
Estimating the half-life of a drug for a patient with kidney or liver dysfunction can
help prescribers adjust dosing schedules.
Follow a schedule of drug administration to achieve the most effective drug therapy.
FACTORS INFLUENCING DRUG EFFECTS
Weight - People who are much heavier may require larger doses to get a therapeutic effect from a drug
because they have increased tissues to perfuse and increased receptor sites in some reactive tissue.
Age - Children metabolize drugs differently than adults due to immature systems.
Gender - Men have more vascular muscles, while women have more fat cells, so drugs that deposit in fat
may cause effects for a prolonged period. Women should be questioned about pregnancy before using drugs
in pregnant women.
Physiological Factors - Physiological differences such as diurnal rhythm, acid-base balance, hydration, and
electrolyte balance can affect the way a drug works on the body and how it handles it.
Pathological Factors - Drugs are used to treat disease or pathology, but pathological conditions can affect
the absorption, distribution, and biotransformation of a drug, leading to toxic reactions.
Genetic Factors - Pharmacogenomics is a new area of study that explores the unique differences in
response to drugs based on genetic makeup.
FACTORS INFLUENCING DRUG EFFECTS
Immunological Factors - People can develop an allergy to a drug after exposure to its proteins, which can
range from mild reactions such as a rash to more severe reactions such as anaphylaxis.
Psychological Factors - The patient's attitude about a drug has an effect on how it works, and the
patient's personality also influences compliance with the drug regimen. Knowing a patient's health-seeking
history and feelings about health care is important for planning educational programs and arranging followup procedures. Nurses can influence the patient's attitude about drug effectiveness by providing positive
attitude and comfort measures.
Environmental Factors - The environment can affect the success of drug therapy, with some effects
enhanced by a quiet, cool, non stimulating environment. Other effects may be influenced by temperature.
Tolerance - Tolerance to drugs can arise due to increased biotransformation, resistance to its effects, or
other pharmacokinetic factors, resulting in larger doses needed to achieve therapeutic effects.
Cumulation - Follow the drug regimen precisely to avoid toxic levels and adverse effects. However, many
people manage their therapy at home, making strict compliance difficult. If a drug is causing serious adverse
effects, review the regimen with the patient and educate appropriately.
Interactions - Alternative therapies and foods can interact with drugs, causing unanticipated effects in the
body.
Drug–Drug or Drug–Alternative Therapy Interactions
• At the site of absorption: Drugs can affect the absorption of each other, such as tetracycline not being
absorbed from the GI tract if calcium is present.
• During distribution: Drugs compete for protein-binding sites, resulting in increased release of drugs and
increased toxicity to tissues. For example, aspirin competes with methotrexate, leading to increased release
and increased toxicity.
• During biotransformation: St. John's wort can alter the effectiveness of several drugs, such as digoxin,
theophylline, oral contraceptives, anticancer drugs, HIV drugs, and antidepressants, due to its effects on the
liver. This can lead to increased doses needed to achieve desired effects.
• During excretion: Drugs compete for excretion, leading to accumulation and toxic effects. For example,
digoxin and quinidine are both excreted from the same sites in the kidney, leading to increased serum levels
of digoxin.
• At the site of action: Drugs can interact with each other, leading to no therapeutic effect. This is seen when
an antihypertensive drug is taken with an anti allergy drug that increases blood pressure, resulting in a loss
of antihypertensive effectiveness. Additionally, antidiabetic medication and the herb ginseng can lead to
hypoglycemia and loss of blood glucose control. To avoid these problems, it is important to consult a drug
guide and adjust doses.
Toxic Effects of Drugs
Drugs are potentially dangerous, as
they can cause unexpected or
unacceptable
reactions
when
administered. The human body operates
by a vast series of chemical reactions,
and today's potent drugs can cause a
variety of reactions, many of which are
more severe than those seen before.
Learning Objectives
ADVERSE EFFECTS
Adverse effects are undesired effects that may be unpleasant or even dangerous.
They can occur for many reasons, including the following:
❏ The drug may have other effects on the body besides the therapeutic effect.
❏ The patient may be sensitive to the drug being given.
❏ The drug’s action on the body may cause other responses that are
undesirable or unpleasant.
❏ The patient may be taking too much or too little of the drug, leading to
adverse effects.
The nurse must be alert for signs of
drug reactions and teach patients and
their families what to look for when
taking drugs at home. Adverse effects
can be primary, secondary, or
hypersensitivity
reactions,
and
knowing how to prevent or cope with
them is key to helping the patient
comply with drug therapy.
1. Extension of PRIMARY ACTIONS
Drug therapy can have adverse effects from simple overdose, such as excessive and
spontaneous bleeding. This can be avoided by monitoring the patient carefully and
adjusting the prescribed dose to fit their needs. Additionally, an antihypertensive
drug may become dizzy, weak, or faint when taking the recommended dose. These
effects can be caused by individual response to the drug, high or low body weight,
age, or underlying pathology that alters the effects of the drug.
2. Occurrence of SECONDARY ACTIONS
Drugs can produce a variety of effects in addition to the desired
pharmacological effect. When this is not possible, the patient
needs to be informed and counseled about ways to cope with the
undesired effects. For example, many antihistamines are effective
in drying up secretions and helping breathing, but they also cause
drowsiness. An oral antibiotic can also cause diarrhea, nausea,
and vomiting, and should be avoided when driving or operating
power tools or machinery.
Hypersensitivity
A condition in which a patient is excessively sensitive to either the
primary or secondary effects of a drug. This can be caused by a
pathological or underlying condition, such as kidney problems,
which may not be able to excrete the drug and may accumulate it in
the body. In some cases, individuals exhibit increased therapeutic
and adverse effects with no definite pathological condition. Older
people may react to narcotics with increased stimulation and
hyperactivity, while patients with an enlarged prostate may develop
urinary retention or even bladder paralysis when the drug’s effects
block the urinary sphincters. A reduced dose may also be required
to avoid potentially serious effects on the urinary system.
3. ALLERGIC REACTIONS
Occurs when the body forms antibodies to a particular drug,
causing an immune response when the person is re-exposed
to the drug. Many people state that they have a drug allergy
due to the effects of a drug, such as the diuretic furosemide
(Lasix). The nurse must ask additional questions of patients
who state that they have a drug allergy to ascertain the
exact nature of the response and whether or not it is a true
drug allergy. Drug allergies fall into four main
classifications: anaphylactic reactions, cytotoxic reactions,
serum sickness, and delayed reactions. The nurse must
constantly assess the patient's response to the drug to
determine if it is a true drug allergy.
4. DRUG-INDUCED TISSUE AND ORGAN DAMAGE
Drugs can cause many types of adverse effects in various tissues, structures, and
organs. These effects account for many of the cautions and contraindications for
drug administration. The specific contraindications and cautions for the
administration of a given drug are noted with each drug type discussed in this book
and in the individual monographs found in various drug guides. The nurse should be
knowledgeable about the presentation of the drug-induced damage and about
appropriate interventions to be used should they occur.
Variety of adverse effects and toxicities associated with drug use
A. Dermatological Reactions
Are adverse reactions involving the skin. These can range from a simple rash to
potentially fatal exfoliative dermatitis. Many adverse reactions involve the skin
because many drugs can deposit there or cause direct irritation to the tissue
B. Rashes, Hives
Procainamide (Pronestyl) is a drug used to treat cardiac arrhythmias and causes a characteristic skin rash.
Meprobamate (Miltown) is associated with an itchy, red rash and in some cases has caused Stevens–Johnson
syndrome. It is important to determine if a rash is a commonly associated adverse effect of the drug before taking it.
Assessment:
The most important details are that severe reactions may include exfoliative dermatitis, fever, enlarged lymph nodes,
and erythema multiforme exudativum (Stevens–Johnson syndrome), which is characterized by dark red papules
appearing on the extremities with no pain or itching.
Intervention:
In mild cases, provide frequent skin care, instruct the patient to avoid rubbing, wearing tight or rough clothing, and
using harsh soaps or perfumed lotions, and administer antihistamines. In severe cases, discontinue the drug and
notify the prescriber and/or primary caregiver. In addition, topical corticosteroids, antihistamines, and emollients are
often used.
C. Stomatitis
An inflammation of the mucous membranes caused by a direct toxic
reaction to a drug or deposits in the end capillaries. Antineoplastic drugs
are known to cause stomatitis due to their toxicity to rapidly turningover cells in the GI tract. Patients receiving antineoplastic drugs are
usually given instructions for proper mouth care when the drugs are
started.
Assessment:
Symptoms of gingivitis include swollen gums, inflamed tongue, difficulty
swallowing, bad breath, and pain in the mouth and throat.
Intervention:
Provide frequent mouth care with a non irritating solution, nutrition
evaluation and development of a tolerated diet, and arrange for a dental
consultation with antifungal agents and/or local anesthetics.
D. Superinfections
The body's normal flora protects it from invasion by other bacteria, viruses, and fungi.
Drugs, especially antibiotics, can destroy the normal flora, leading to superinfections
caused by organisms that are usually controlled by the normal flora. This protects the
body from infections caused by organisms that are usually controlled by the normal flora.
Assessment:
Fever, diarrhea, black or hairy tongue, inflamed and swollen tongue, mucous membrane
lesions, and vaginal discharge are symptoms of gonorrhea.
Intervention:
Provide supportive measures, administer antifungal therapy, and discontinue the drug
responsible for the superinfection in severe cases.
E. Blood Dyscrasia
Blood dyscrasia is a form of bone marrow suppression caused by drugs that cause cell death. Bone
marrow cells multiply rapidly and are highly susceptible to any agent that disrupts cell function,
making them highly susceptible to any agent that disrupts cell function.
Assessment
Blood dyscrasia is a form of bone marrow suppression caused by drugs that cause cell death, as bone
marrow cells multiply rapidly and are highly susceptible to any agent that disrupts cell function.
Intervention
Monitor blood counts, provide supportive measures, and discontinue the drug or stop administration
until the bone marrow recovers to a safe level.
5. Toxicity
Chemicals can have toxic effects on the body, which are
not acceptable adverse effects but potentially serious
reactions to a drug. When a drug is known to have toxic
effects, the benefit of the drug must be weighed against
the potential harm.
A. Liver Injury
Oral drugs are absorbed and passed directly into the liver, exposing
the liver cells to the full impact of the drug before it is broken down
for circulation. Metabolites that are irritating or toxic can also affect
liver integrity.
Assessment:
Symptoms of hepatitis C include fever, malaise, nausea, vomiting,
jaundice, abdominal pain, elevated liver enzymes, bilirubin levels,
and changes in clotting factors.
Intervention:
Discontinue the drug and notify the prescriber and/or primary
caregiver. Offer supportive measures such as small, frequent meals,
skin care, a cool environment, and rest periods
B. Renal Injury
The glomerulus in the kidney has a small capillary network that filters
blood into the renal tubule. Drug molecules can get plugged into the
capillary network and cause acute inflammation and severe renal
problems. Gentamicin (Garamycin), a potent antibiotic, is often
associated with renal toxicity.
Assessment:
Elevated BUN, creatinine concentration, decreased hematocrit,
electrolyte imbalances, fatigue, malaise, edema, irritability, and skin
rash may be seen.
Intervention:
Notify the prescriber and/or primary caregiver and discontinue the
drug as needed. Offer supportive measures such as positioning, diet and
fluid restrictions, skin care, electrolyte therapy, rest periods, and a
controlled environment.
C. Poisoning
Poisoning is when an overdose of a drug damages multiple
body systems, leading to fatal reactions. Assessment and
treatment vary depending on the drug, and emergency and life
support measures are often needed in severe cases. Specific
antidotes or treatments are identified.
6. Alterations in Glucose Metabolism
The control of glucose in the body is an integrated
process that involves hormones and enzymes that
use the liver as the place for glucose storage or
release. Drugs can have an impact on glucose levels
due to their effects on the liver or endocrine
system.
A. Hypoglycemia
Glipizide and glyburide are antidiabetic agents that lower blood glucose levels,
but can cause hypoglycemia if they do so too far. These drugs affect
metabolism and the use of glucose.
Assessment:
The most important idea is that seizures and/or coma may occur in severe
cases. Symptoms include fatigue, drowsiness, hunger, anxiety, headache, cold
skin, shaking, increased heart rate, increased blood pressure, numbness,
confusion, rapid and shallow respirations, and seizures.
Intervention:
Restore glucose, provide supportive measures, institute safety measures,
monitor blood glucose levels, and offer reassurance to help the patient cope
with the experience.
B. Hyperglycemia
Drugs can cause high serum glucose levels, or hyperglycemia, by stimulating the
breakdown of glycogen or altering metabolism. Ephedrine, a bronchodilator and
anti asthma drug, can break down stored glycogen and cause an elevation of blood
glucose. Diazoxide, a drug used for treatment of malignant hypertension, causes a
decrease in insulin release, leading to an increase in blood glucose levels.
Assessment:
Polyuria, polydipsia, deep respirations, restlessness, hunger, nausea, hot or
flushed skin, and fruity odor are common symptoms of polyuria.
Intervention:
Administer insulin therapy to decrease blood glucose, monitor glucose levels, and
provide support to help the patient deal with signs and symptoms. Provide access
to bathroom facilities, control temperature, decrease stimulation, offer
reassurance, and provide mouth care to help make acidosis more tolerable.
7. Electrolyte Imbalances
Drugs can have an effect on electrolyte levels in the body, especially potassium,
which can cause serious effects when altered even a little.
A. Hypokalemia
Drugs affecting the kidney can cause low serum potassium levels (hypokalemia) by
altering the renal exchange system, such as loop diuretics. Potassium is essential for
nerve and muscle function.
Assessment:
symptoms may include fatigue, drowsiness, hunger, anxiety, headache, cold skin,
shaking, increased heart rate, increased blood pressure, numbness and tingling,
confusion, rapid and shallow respirations, and seizures and/or coma.
Interventions:
Include restoring glucose, providing supportive measures, instituting safety
measures, monitoring blood glucose levels, and offering reassurance to help the
patient cope with the experience.
B. Hyperglycemia
Drugs can cause high serum glucose levels, or hyperglycemia, by stimulating the breakdown of glycogen or
altering metabolism. Ephedrine, a bronchodilator and anti asthma drug, can break down stored glycogen and
cause an elevation of blood glucose. Diazoxide, a drug used for treatment of malignant hypertension, causes
a decrease in insulin release, leading to an increase in blood glucose levels.
Assessment:
Fatigue, increased urination, thirst, deep respirations, restlessness, hunger, nausea, hot or flushed skin, and
fruity odor may be observed.
Intervention:
administering insulin therapy to decrease blood glucose, monitoring glucose levels, providing support to help
the patient deal with signs and symptoms, and providing mouth care to make acidosis more tolerable. These
interventions include providing access to bathroom facilities, controlling the temperature of the room,
decreasing stimulation, offering reassurance, and providing mouth care.
8. Sensory Effects
Drugs can affect the special senses, including the eyes and ears. Alterations in
seeing and hearing can pose safety problems for patients.
A. Ocular Damage
Chloroquine (Aralen), a drug used to treat rheumatoid diseases, can cause retinal damage
and even blindness if deposited into the tiny end arteries of the retina. This can lead to
inflammation and tissue damage.
Assessment:
Vision can detect blurring, color vision changes, corneal damage, and blindness.
Intervention:
Monitor the patient's vision when receiving known oculotoxic drugs, consult with the
prescriber/primary caregiver, and discontinue the drug as appropriate. Provide
supportive measures if vision loss is not reversible. Monitor lighting and exposure to
sunlight.
B. Auditory Damage
Drugs such as macrolide antibiotics and aspirin can damage the eighth cranial
nerve, leading to auditory ringing and eighth cranial nerve effects. These
drugs are often linked to auditory ringing and eighth cranial nerve damage.
Assessment:
Dizziness, tinnitus, balance, and hearing can be done.
Interventions:
Include monitoring perceptual changes, providing protective measures,
consulting with the prescriber, and providing supportive measures to cope with
drug effects.
9. Neurological Effects
Nerves function by using a constant source of energy to maintain the resting
membrane potential and allow excitation, which requires glucose, oxygen, and a
balance of electrolytes.
A. General Central Nervous System Effects
Beta-blockers, used to treat hypertension, angina, and other conditions, can cause
feelings of anxiety, insomnia, and nightmares due to their direct or altered levels of
electrolyte or glucose.
Assessment: Symptoms may include confusion, delirium, insomnia, hyperreflexia,
hallucinations, numbness, tingling, and paresthesias.
Interventions: Include providing safety measures, cautioning the patient to avoid
dangerous situations, providing support, and consulting with the prescriber to
decrease or discontinue the drug.
B. Atropine-Like (Anticholinergic) Effects
Drugs can block the parasympathetic nervous system by blocking cholinergic receptors,
such as Atropine, which is used preoperatively to dry up secretions. Cold remedies and
antihistamines can also cause anticholinergic effects.
Assessment: The most important idea is that dry mouth, altered taste perception,
dysphagia, heartburn, constipation, bloating, paralytic ileus, urinary hesitancy and
retention, impotence, blurred vision, cycloplegia, photophobia, headache, mental
confusion, nasal congestion, palpitations, decreased sweating, and dry skin may be noted.
Interventions: Include providing sugarless lozenges and mouth care, arranging for a
bowel program, having the patient void before taking the drug, providing safety
measures if vision changes occur, arranging for medication for headache and nasal
congestion, and advising the patient to avoid hot environments and take protective
measures.
C. Parkinson-Like Syndrome
Drugs that affect dopamine levels in the brain can cause a
syndrome similar to Parkinson's disease, which usually goes away
when the drug is withdrawn.
Assessment
The most important idea is that akinesia, muscular tremors,
drooling, changes in gait, rigidity, extreme restlessness, and
spasms may be observed.
Interventions include discontinuing the drug, treating with
anticholinergics or antiparkinson drugs, providing small, frequent
meals, and providing safety measures if swallowing becomes
difficult.
D. Neuroleptic Malignant Syndrome (NMS)
General anesthetics and other drugs can cause neuroleptic malignant syndrome, a
generalized syndrome that includes high fever.
Assessment: Extrapyramidal symptoms such as slowed reflexes, rigidity,
involuntary movements, hyperthermia, and autonomic disturbances may be noted.
Interventions: Include discontinuing the drug, treating with anticholinergics or
antiparkinson drugs, providing supportive care, and instituting safety precaution
10. Teratogenicity
Drugs that reach the developing fetus or embryo can cause death or congenital
defects, which can include skeletal and limb abnormalities, central nervous system
alterations, and heart defects. Before a drug is administered to a pregnant patient,
the actual benefits should be weighed against the potential risks. All pregnant
women should be advised not to self-medicate during the pregnancy and emotional
and physical support is needed to assist the woman in dealing with the possibility of
fetal death or birth defects.
Summary of Adverse Drug Effects
The Nursing Process in
Drug Therapy and
Patient Safety
The Nursing Process in
Drug Therapy and
Patient Safety
The delivery of medical care today is in a constant state of change, often reaching crisis
levels. The population is aging, resulting in an increased incidence and prevalence of
chronic disease and more complex care issues. Health care is undergoing a technological
boom, including greater use of more sophisticated diagnostic methods and treatments,
new, specialized drugs, and so on. Patients are being discharged earlier from acute care
facilities or not being admitted at all for procedures that used to be treated in hospital
with follow-up support and monitoring. Patients are becoming more knowledgeable and
challenging due to the wide use of the Internet and an emphasis in the media on the need
to question all aspects of health care.
Learning Objectives
NURSING: ART AND SCIENCE
❏ Nursing is a complex science and art that has become increasingly technical and
scientific, requiring nurses to assess, diagnose, and intervene with patients to
treat, prevent, and educate them. It has traditionally been seen as ministering to
and soothing the sick.
❏ Nurses are key health care providers who can assess the whole patient,
administer therapy, teach the patient how to cope with the therapy, and
evaluate the effectiveness of the therapy. They do this by integrating knowledge
of the basic sciences, social sciences, education, and other disciplines and
applying the nursing process.
THE NURSING PROCESS
Nurses use the nursing process to provide efficient and effective care, which includes
assessment, diagnosis, implementation, and evaluation. It is used with drug therapy
to ensure the patient receives the best, safest, most efficient, scientifically based
care.
1. Assessment (gathering information)
Assessment is the first step of the nursing process and involves systematic,
organized collection of data about the patient. This information provides the nurse
with the facts needed to plan educational and discharge programs, arrange for
appropriate consultations, and monitor the physical response to treatment or disease.
Drug therapy is a complex part of healthcare and must be incorporated into every
patient assessment plan. Two major aspects associated with assessment are the
patient's history and examination of their physical status.
A. Past History
The patient's history is an important element of assessment related to drug
therapy, as it can influence the drug's effect and prevent adverse effects. Relevant
aspects of the patient's history are discussed next.
❏ Chronic Conditions
Chronic conditions can affect the pharmacokinetics and
pharmacodynamics of a drug. These conditions may require cautious
use or dose adjustment when administering a drug. For example, a
patient with renal disease may require a decreased dose due to the way
the drug is eliminated.
❏ Drug Use
Prescription drugs, over-the-counter (OTC) drugs, street drugs, alcohol, nicotine,
alternative therapies, and caffeine can have an impact on a drug's effect. Ask
patients specifically about OTC drug or alternative therapy use, as well as
prescription drugs that they routinely take, such as oral contraceptives.
❏ Allergies
A patient's history of allergies can affect drug therapy, so it is important
to obtain specific information about the patient's allergic reaction to
determine if it is a true drug allergy or an actual effect.
❏ Level of Education and Understanding
Information about the patient's education level provides a baseline from which the
nurse can determine the appropriate types of teaching information to use with the
patient. It is important not to assume anything about the patient's ability to
understand based on their reported education level, as stress, disease, and
environmental factors can all affect a patient's learning readiness and ability. Direct
assessment of actual learning abilities is critical for good patient education.
❏ Social Supports
Discharge planning involves determining what support is available to the patient at
home, as well as referring to appropriate community resources, to ensure that the
patient receives the best care and treatment.
❏ Financial Supports
The high cost of health care and medications must be considered when initiating
drug therapy and promoting patient compliance. Financial constraints may cause a
patient not to follow through with a prescribed drug regimen, so the nurse may need
to refer the patient to resources that may offer financial assistance
❏ Pattern of Health Care
Knowing how a patient seeks health care provides valuable information to include in
a patient's teaching plan, such as whether they routinely seek follow up care or wait
for emergency situations. Additionally, information about patterns of health care
provides insight into conditions the patient may have but has not reported.
B. Physical Examination
It is important to assess the patient's physical status before beginning drug therapy
to determine if any conditions are contraindications or cautions, and to develop a
baseline for evaluating the effectiveness of the drug and any adverse effects.
❏ Weight -Patients' weight can affect the recommended drug dose, as the recommended dose is based
on a 150-pound adult man. Dose adjustments are needed for patients of different weights.
❏ Age - Patients at the extremes of the age spectrum require dose adjustments based on the functional
level of the liver and kidneys and the responsiveness of other organs. As patients age, the body
undergoes changes that can affect drug therapy, such as decreased blood volume, decreased GI
absorption, reduced blood flow, and changes in receptor-site responsiveness. This book provides
information related to the drug class as it pertains specifically to children, adults, and the older
population.
❏ Physical Parameters Related to Disease or Drug Effects - Assessing parameters
before drug therapy provides a baseline level to compare to future assessments to determine the effects
of drug therapy. Nurses are the best position to detect minute changes that determine the course of
drug therapy.
2. Nursing Diagnosis
A nursing diagnosis is a statement of the patient’s status from a nursing
perspective. It shows actual or potential alterations in patient function based on
the assessment of the clinical situation.
Drug therapy is only a small part of the overall patient situation, so nursing
diagnoses related to drug therapy must be incorporated into a total picture of the
patient.
These diagnoses, culled from the North American Nursing Diagnosis Association
(NANDA) list of accepted nursing diagnoses, are only a part of the overall
nursing diagnoses related to the patient’s situation.
4. Implementation
Implementation involves taking the information gathered and synthesizing it
into nursing diagnoses to plan patient care. This process includes setting goals
and desired outcomes to ensure safe and effective drug therapy.
Three types of nursing interventions are often involved in drug therapy:
1. Drug administration
2. Comfort measures
3. Patient/family education.
❏ Proper Drug Administration
The nurse must consider seven points to ensure safe and effective drug
administration.
These rights should be reviewed before administering a drug to prevent medication
errors and improve patient outcomes.
❏ Comfort Measures
Nurses are able to help patients cope with the effects of drug therapy, making them
more compliant if the effects are not too uncomfortable or overwhelming.
Placebo Effect - The placebo effect has been linked to the success of drug therapy, so the
nurse's attitude and support is essential for successful drug therapy. A back rub, kind word, and positive
approach can be as beneficial as the drug itself.
Managing Adverse Effects - Interventions can be used to promote patient safety
and reduce the impact of adverse effects of a drug, such as environmental control, safety measures, and
physical comfort measures.
Lifestyle Adjustment - For example, patients taking diuretics may have to rearrange
their day to be near toilet facilities when the drug action peaks. In some cases, the change in lifestyle needed
can have a tremendous impact on the patient and can affect their ability to cope and comply with any medical
regimen.
❏ Patient and Family Education
Patients must have all the information necessary to ensure safe and effective drug
therapy at home, and many states now require written information.
Evaluation
Part of the ongoing process of patient care that leads to changes in assessment,
diagnosis, and intervention. The patient is evaluated for therapeutic response,
adverse drug effects, and drug–drug, drug–food, drug–alternative therapy, or drug–
laboratory test interactions. The efficacy of nursing interventions and the education
program are also evaluated. In some cases, the nurse evaluates the patient by
reapplying the beginning steps of the nursing process and then analyzing for
changes. This process may lead to changes in the nursing interventions being used
to provide better and safer patient care.
PREVENTION OF MEDICATION ERRORS
The Institute of Medicine published a large-scale study of medication errors in the
United States in 2000, To Err Is Human: Building a Safer Health System. It
reported that 44,000 reported deaths in hospitals each year occurred from
medication errors, and that the number could be closer to 98,000.
The drug regimen process, which includes prescribing, dispensing, and
administering a drug to a patient, has a series of checks to catch errors before they
occur. These checks include the physician or nurse practitioner who prescribes the
drug, the pharmacist who dispenses the drug, and the nurse who administers the
drug. The nurse is often the final check in the process as they are responsible for
patient education before the patient is discharged to home.
Nurse’s Role - consistently using the “rights” of medication administration
The Patient’s Role
Patient and family education plays a vital role in the prevention of medication errors.
Encourage patients to be their own advocates and to speak up and ask questions to
help prevent medication errors. The following teaching points help to reduce the risk
of medication errors in the home setting.
❏ Keep a written and/or electronic list of all medications you are taking,
including prescription, OTC, and herbal medications.
❏ Know what each of your drugs is being used to treat.
❏ Read the labels, and follow the directions.
❏ Store drugs in a dry place, away from children and pets.
❏ Speak up.
When teaching parents about their children’s drug regimens,
be sure to include the following instructions:
❏ Keep a list of all medications you are giving your child, including
prescription, OTC, and herbal medications.
❏ Never use adult medications to treat a child.
❏ Read all labels before giving your child a drug.
❏ Measure liquid medications using appropriate measuring devices.
❏ Call your health care provider immediately if your child seems to get worse
or seems to be having trouble with a drug.
❏ When in doubt, do not hesitate to ask questions.
Reporting of Medication Errors
Medication errors must be reported on a national and institutional level to prevent their recurrence.
National reporting programs are coordinated by the U.S. Pharmacopeia (USP) and help to gather
information about errors to prevent their recurrence. In 2007, the name of the drug Omacor was
changed to Lovaza due to reports of confusion between Omacor and Amicar. Other reports have led
to public warnings about look-alike or sound-alike drug names, common dosing errors, and
transcribing issues.
Institutions have policies for reporting medication errors that protect patients and staff and identify
areas in which education or system changes may be needed. If you see or participate in a medication
error, report it to your institution and then to the national reporting program. Your report will be
shared with all of the appropriate agencies, including the FDA, drug manufacturer, and Institute for
Safe Medication Practices. Health care providers working together and sharing information can make
a big impact in decreasing the occurrence of medication errors.
Dosage Calculations
Learning Objectives
To determine the correct dose of a particular drug for a patient, it is necessary to
consider the patient’s sex, weight, age, and physical condition, as well as other drugs
that the patient is taking. This is the responsibility of the prescriber, pharmacist, and
nurse who administer the drug.
In many institutions, drugs arrive in unit-dose form, prepackaged for each individual
patient. However, mistakes still happen, and the nurse is legally and professionally
responsible for any error that might occur. Practicing nurses must know how to
convert drug dosing orders into appropriate doses of available forms of a drug to
ensure that the right patient is getting the right dose of a drug.
MEASURING SYSTEMS
In 1995, the U.S. Pharmacopeia Convention established standards requiring all
prescriptions to include the metric measure for the quantity and strength of drug.
However, prescribers are not completely converted to this new standard, so the
nurse must be able to convert the dose ordered into the available dose form to ensure
patient safety. It is important to be able to perform conversions between two types
of measure, within each system of measure, and between systems of measure.
Used in drug preparation and delivery:
❏
❏
❏
❏
The metric system
The apothecary system
The household system
The avoirdupois system
❏ Metric System
The metric system is the most widely used system of measure, based on the decimal
system, and is used worldwide to share knowledge and research information.
Solid Measure
Liquid Measure
❏ Apothecary system
The apothecary system is an old system of measurement developed for use by
apothecaries or pharmacists. It uses the minim as the basic unit of liquid measure
and the grain as the basic unit of solid measure. It is harder to use than the metric
system and is rarely seen in most clinical settings. An interesting feature of this
system is that it uses Roman numerals placed after the unit of measure to denote
amount. For example, 15 grains would be written "gr xv."on.
Solid Measure
Liquid Measure
❏ Household System
The household system is the measuring system used in recipe books. It uses the
teaspoon as the basic unit of fluid measure and the pound as the basic unit of solid
measure. However, there have been wide variations in the capacity of some of these
measuring devices. Patients should be aware that flatware teaspoons and drinking
cups vary greatly in the volume they contain, and a flatware teaspoon could hold up
to two measuring teaspoons of quantity. It is important to clarify that the measures
indicated in the instructions refer to a standardized measuring device when using a
liquid medication at home.
Solid Measure
Liquid Measure
❏ Avoirdupois System
The avoirdupois system is an older system used by pharmacists to compound
medications. It uses ounces and grains, but measures differently than the apothecary
and household systems. It is seldom used by prescribers, but may be used for bulk
medications from the manufacturer.
❏ Other Systems
Drugs are measured in units other than those already discussed, such as the unit,
which reflects the biological activity of the drug in 1 mL of solution. Milliequivalents
(mEq) are used to measure electrolytes, while International units (IU) are used to
measure certain vitamins or enzymes. These units are unique to each drug and
cannot be converted to another measuring form.
CONVERSION BETWEEN SYSTEMS
The simplest way to convert measurements from one system to another is to set up a
ratio and proportion equation. To do this, a table of conversions must be checked to
determine the equivalent measure in the two systems. It is a good idea to post a
conversion guide in the medication room or on the medication cart for easy access.
Commonly Accepted Conversions
Challenges to Effective
Drug Therapy
Learning Objectives
The 21st century has brought new considerations and pressures in the healthcare
industry, such as access to medical and pharmacological information, demand for
specific treatments, financial pressures, increased risk of exposure to biological or
chemical weapons, illicit drug use, and environmental contamination. The nurse is in
the best position to listen, teach, and explain this confusing information to the
patient and facilitate their care.
CONSUMER AWARENESS
Access to information has become increasingly wide over the last decade, making
consumers overwhelmed with details, facts, and choices that affect their health care.
Patients now come into the health care system with requests and demands, and a
complex array of OTC and alternative medicines that further complicate the safety
and efficacy of standard drug therapy.
❏ Media Influence
Drug advertising in the mass media has increased significantly in the last 20 years, with it now
illegal to advertise prescription drugs directly to the public.
Ads for drugs often contain misleading information, such as contraindications, adverse effects, and
precautions, which can be confusing to consumers. Ads can also feature smiling, healthy-looking
people and encourage viewers to ask their health care providers about the drug.
Ads in parenting magazines encourage readers to check with their pediatricians about the use of
antibiotics and asthma medications. The FDA-approved drug insert is often printed out in tiny print
and medical lingo, making it difficult for readers to understand. It is a challenge to stay up-to-date
and knowledgeable about drug therapy.
The media can influence a patient's response to suggested therapy or provide a new set of demands
or requests for the health care provider. Television talk shows often present medical information out
of context, leading to a lack of credibility with the patient.
❏ The Internet
Tips to determine the usefulness or accuracy of
information found on the Internet
The Internet and World Wide Web are
readily accessible to most consumers, but
the information available is overwhelming
and difficult to evaluate. Patients often come
into the health care system with pages of
information that they think pertains to their
situation.
OVER-THE-COUNTER DRUGS
➢ OTC medications are safe when used as directed, but many were "grandfathered in"
and have not been tested or evaluated. Ipecac, a former standard OTC drug, was not
found to be effective for its intended use. Other approved OTC drugs include
cimetidine, vaginal antifungal medications, and omeprazole and famotidine.
➢ The FDA reviews prescription drugs for OTC status based on the patient's ability of
the patient for self-care, act of self-diagnose and determine treatment needs.
Lovastatin, an antihyperlipidemic drug, was not approved due to lack of signs and
symptoms. OTC drugs can mask signs and symptoms of an underlying problem,
making it difficult to accurately diagnose if the condition persists.
➢ The health care provider should ask the patient if they are taking any OTC drugs or
other medications when taking a drug history.
Ingredients Found in Some Common Cold and Flu OTC Preparations
ALTERNATIVE THERAPIES AND
HERBAL MEDICINE
● Alternative therapies and herbal medicines are becoming increasingly popular, with
the placebo effect being beneficial in relieving pain and suffering. The challenge for
health care providers is to balance therapies with prescribed medications.
● The Dietary Supplement Health and Education Act of 1994 classifies herbal
products, vitamins and minerals, and amino acids as "dietary supplements" that are
not required to go through premarketing testing. Advertising does not allow direct
claims to cure, treat, diagnose, or prevent a specific disease, but does allow for non
disease claims such as muscle enhancement, hot flashes, or memory loss.
● The health care provider must be aware of the risks associated with self-treating
with alternative therapies, such as the unknown active ingredients, the unknown
incidental ingredients, and the wide range of variability in the active ingredients. It
is difficult to guide patients to the correct product with such a wide range of
variability.
ALTERNATIVE THERAPIES AND
HERBAL MEDICINE
● Patients often do not mention the use of alternative therapies to their health
care provider, but this can lead to serious complications for patients taking
prescription medication. If not reported, medical tests and dose adjustments
may be unsuccessful.
● St. John's wort can interact with oral contraceptives, digoxin, selective
serotonin reuptake inhibitors, theophylline, antineoplastic drugs, and antivirals,
making treatment difficult.
● Ask patients about their use of herbal or alternative therapies, and look up
remedies on the Internet.
OFF-LABEL USES
● Refers to uses of a drug that are not part of the stated therapeutic indications
for which the drug was approved by the FDA. It is commonly done for pediatric
and geriatric groups, where there is little premarketing testing. Drugs used for
off-label indications include drugs used to treat various psychiatric problems.
Polypharmacy has led to a polypharmacy approach in psychiatry, where drugs
are mixed and juggling to achieve desired effects.
● Nurse must be aware of off-label uses and be aware of potential risks before
administering drugs.
COSTS OF HEALTHCARE AND THE
IMPORTANCE OF PATIENT TEACHING
The health care crisis in the US has caused the cost of medical care and drugs to
skyrocket. HMOs have surged in popularity, treating the medical care system like a
business. Patients are being discharged earlier, leading to less monitoring and more
responsibility for care. Nurses are responsible for teaching patients about self-care
and drug therapies.
➢ Health Maintenance Organizations and Regulations
HMOs maintain a centralized control system to provide patient medical care within a
budget, but the tradeoff is often a loss of choice. They may regulate access to
emergency facilities, types and timing of tests, procedures, and prescription drugs.
Decisions are often made by nonmedical personnel, and the regulatory power of
HMOs is being challenged in court and legislation.
➢ Home Care
The home care industry is responding to changes in costs and medical care delivery,
with patients being discharged from hospitals and taking over some of the
responsibilities previously handled in the hospital.
The nurse is responsible for teaching patients about medications, doses, adverse
effects, OTC drugs, alternative therapies, and what to watch for. This information
should be provided in writing, in language that is clear and understandable. The cost
of dealing with toxic or adverse effects is often higher than the time spent teaching.
Nurses are essential in home health care, providing education, assessment,
diagnosis, and advocacy.
➢ Cost Considerations
Patients must be reminded to take the full course of antibiotics in order to prevent
the spread of resistant bacteria, which is becoming more dangerous.
Patients should be advised not to split tablets in half unless specifically advised to do
so, as splitting drugs can cause them to become toxic or ineffective. The cost of
treating toxic reactions may exceed the cost of the original drug.
➢ Cost Considerations
Generic drugs can reduce the cost of a drug, as they are off patent and tested for
bioequivalence. When a drug has a small margin of safety, a prescriber may order it
by brand name. However, in some cases, the generic drug is not less expensive than
the brand-name drug, and the nurse must explain the reason for the drug choice or
request an alternative treatment.
The FDA has found discrepancies between what was ordered and what is in the
product, as well as problems in the storage of these products. Consumers are not
protected by U.S. laws when they purchase drugs from other countries, and the
FDA Web site provides important information and guidelines.
EMERGENCY PREPAREDNESS
The events of 9/11 have changed the sense of security and safety in the US. The
CDC and Office of Homeland Security are working to address the risk of exposure to
biological and chemical weapons.
The threat of exposure to biological weapons, so-called germ warfare, is somewhat
theoretical but very real, as seen in the anthrax mail scares in Washington, D.C.,
Pennsylvania, and New York.
Education of health care providers and the public is key to coping effectively with
any biological assault. Nurses are often called upon to answer questions, reassure
the public, offer educational programs, and serve on emergency preparedness
committees.
➢ Drug Abuse and the Opioid Crisis
Illicit drug use in the US is a growing problem, with professional athletes and
Hollywood stars often using street drugs to enhance their moods and increase
pleasure. Parents are often concerned that their children will use street drugs. Drugseeking behavior is a major factor, and trying to reverse these changes is a
physiological and psychological challenge. The use of these drugs can have severe
consequences on health.
Education provides a crucial defense against drug abuse and helps the public and
health care professionals recognize the problem and deal with it. Visit the National
Institute on Drug Abuse for information and resources.
PROTECTING THE ENVIRONMENT
The Office of National Drug Control Policy has released guidelines for the proper
disposal of prescription drugs to protect the environment. This includes teaching
patients how to dispose of drugs properly, encouraging them to clean out their
medicine cabinet at least yearly, and encouraging them to dispose of the drugs they
are no longer using. These guidelines are important to protect the environment and
the people, animals, and crops affected by the presence of these drugs.
The End
Thank you!