The Nursing Process
and Drug Therapy
Karen Ruffin RN, MSN Ed.
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
The Nursing
Process (cont'd)
• Assessment
• Nursing diagnosis
• Planning (with outcome
criteria)
• Implementation
• Evaluation
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
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
The Nursing
Process (cont'd)
Planning
• Identification of goals
and outcome criteria
• Prioritization
• Time frame
The Nursing
Process (cont'd)
Goals
• Objective, measurable,
realistic
• Time frame specified
Outcome criteria
• Specific standard(s) of
measure
• Patient oriented
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
The “Five
Rights”
•
•
•
•
•
Right drug
Right dose
Right time
Right route
Right patient
Another “Right”—Constant
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
Other “Rights”
• Proper drug storage
• Proper documentation
• Accurate dosage
calculation
• Accurate dosage
preparation
• Careful checking of
transcription of orders
• Patient safety
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
Evaluation
• Ongoing part of the
nursing process
• Determining the status
of the goals and
outcomes of care
• Monitoring the
patient’s response to
drug therapy
– Expected and
unexpected responses
Pharmacologic
Principles
Drug Names
Chemical name
• Describes the drug’s chemical
composition and molecular
structure
Generic name (nonproprietary
name)
• Name given by the United
States Adopted
Name Council
Trade name (proprietary name)
• The drug has a registered
trademark; use of the name
restricted by the drug’s patent
owner
(usually the manufacturer)
Drug Names
(cont'd)
Chemical name
• (+/-)-2-(p-isobutylphenyl)
propionic acid
Generic name
• ibuprofen
Trade name
• Motrin®, Advil®
Figure 2-1 The chemical,
generic, and trade names
for the common
analgesic ibuprofen are
listed next to the
chemical structure of the
drug.
Pharmacologic
Principles
•
•
•
•
•
Pharmaceutics
Pharmacokinetics
Pharmacodynamics
Pharmacotherapeutics
Pharmacognosy
Pharmaceutics
The study of how various
drug forms influence
pharmacokinetic and
pharmacodynamic activities
Pharmacokinetics
• The study of what the
body does to the drug
– Absorption
– Distribution
– Metabolism
– Excretion
Pharmacodynamics
• The study of what the
drug does to the body
– The mechanism of drug
actions in living tissues
Figure 2-2 Phases of Drug Activity. (From
McKenry LM, Salerno E: Mosby’s
pharmacology in nursing—revised and
updated, ed 21, St. Louis, 2003, Mosby.)
Pharmacotherapeutics
The use of drugs and the
clinical indications for
drugs to prevent and
treat diseases
Pharmacognosy
The study of natural
(plant and animal) drug
sources
Pharmacokinetics: Absorption
• The rate at which a
drug leaves its site of
administration, and the
extent to which
absorption occurs
– Bioavailability
– Bioequivalent
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
Routes
• A drug’s route of
administration affects
the rate and extent of
absorption of that drug
– Enteral (GI tract)
– Parenteral
– Topical
Enteral Route
• Drug is absorbed into
the systemic circulation
through the oral or
gastric mucosa, the
small intestine, or
rectum
– Oral
– Sublingual
– Buccal
– Rectal
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 firstpass effect)
– The same drug—given IV—
bypasses the liver, preventing
the first-pass effect from taking
place, and more drug reaches
the circulation
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
Parenteral Route
• Intravenous (fastest
delivery into the blood
circulation)
• Intramuscular
• Subcutaneous
• Intradermal
• Intrathecal
• Intraarticular
Topical Route
• Skin (including
transdermal patches)
• Eyes
• Ears
• Nose
• Lungs (inhalation)
• Vagina
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
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
Metabolism/Biotransformation
(cont'd)
Delayed drug metabolism
results in:
• Accumulation of drugs
• Prolonged action of the
drugs
Stimulating drug
metabolism causes:
• Diminished pharmacologic
effects
Excretion
The elimination of drugs
from the body
• Kidneys (main organ)
• Liver
• Bowel
– Biliary excretion
– Enterohepatic circulation
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
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
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
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
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 agonistantagonists. (From Clayton BD, Stock YN: Basic
pharmacology for nurses, ed 13, St. Louis, 2004,
Mosby.)
Pharmacotherapeutics: Types of
Therapies
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Acute therapy
Maintenance therapy
Supplemental therapy
Palliative therapy
Supportive therapy
Prophylactic therapy
Empiric therapy
Monitoring
• The effectiveness of the
drug therapy must be
evaluated
• One must be familiar
with the drug’s:
– Intended therapeutic
action (beneficial)
– Unintended but
potential side effects
(predictable, adverse
reactions)
Monitoring
(cont'd)
• Therapeutic index
– The ratio between a
drug’s therapeutic
benefits and its toxic
effects
Monitoring
(cont'd)
• Tolerance
– A decreasing response
to repetitive drug doses
Monitoring
(cont'd)
• Dependence
– A physiologic or
psychological need for a
drug
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
Monitoring
(cont'd)
• Drug interactions
– Additive effect
– Synergistic effect
– Antagonistic effect
– Incompatibility
Monitoring
(cont'd)
• Medication
misadventures
– Adverse drug events
– Adverse drug reactions
– Medication errors
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 effect’s intensity and
occurrence are related to
the size of the dose
An adverse outcome of
drug therapy in which
a patient is harmed in
some way
Adverse Drug
Reaction
•
•
•
•
Pharmacologic reactions
Idiosyncratic reactions
Hypersensitivity reactions
Drug interactions
Other DrugRelated Effects
• Teratogenic
• Mutagenic
• Carcinogenic
Toxicology
The study of poisons
and unwanted
responses to
therapeutic agents
Table 2-9 Common
Poisons and Antidotes
Life Span
Considerations
Life Span
Considerations
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•
•
•
•
Pregnancy
Breast-feeding
Neonatal
Pediatric
Geriatric
Pregnancy
• First trimester is the
period of greatest
danger for druginduced developmental
defects
• Drugs diffuse across the
placenta
• FDA pregnancy safety
categories
Table 3-1
Pregnancy safety
categories
Breast-feeding
• Breast-fed infants are at
risk for exposure to
drugs consumed by the
mother
• Consider risk-to-benefit
ratio
Table 3-2 Classification of
young patients
Pediatric Considerations:
Pharmacokinetics
• Absorption
– Gastric pH less acidic
– Gastric emptying is
slowed
– Topical absorption faster
through the skin
– Intramuscular
absorption faster and
irregular
Pediatric Considerations:
Pharmacokinetics (cont'd)
• Distribution
– TBW 70% to 80% in fullterm 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
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
Pediatric Considerations:
Pharmacokinetics (cont'd)
• Excretion
– Kidney immaturity
affects glomerular
filtration rate and
tubular secretion
– Decreased perfusion rate
of the kidneys
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
Methods of Dosage Calculation
for Pediatric Patients
• Body weight dosage
calculations
• Body surface area
method
Geriatric
Considerations
• Geriatric: older than
age 65
– Healthy People 2010:
older than age 55
• Use of OTC
medications
• Polypharmacy
Table 3-4 Physiologic changes in the geriatric
patient
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
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
Geriatric Considerations:
Pharmacokinetics (cont'd)
• Metabolism
– Aging liver produces
less microsomal
enzymes, affecting drug
metabolism
– Reduced blood flow to
the liver
Geriatric Considerations:
Pharmacokinetics (cont'd)
• Excretion
– Decreased glomerular
filtration rate
– Decreased number of
intact nephrons
Geriatric Considerations: Problematic
Medications
• Analgesics
• Anticoagulants
• Anticholinergics
• Antihypertensives
• Digoxin
• Sedatives and
hypnotics
• Thiazide diuretics
Legal, Ethical,
and Cultural
Considerations
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)
U.S. Drug
Legislation (cont'd)
• 1951: DurhamHumphrey
Amendment (to the
1938 act)
• 1962: Kefauver-Harris
Amendment (to the
1938 act)
• 1970: Controlled
Substance Act
U.S. Drug
Legislation (cont'd)
• 1983: Orphan Drug Act
• 1991: Accelerated drug
approval
Table 4-1 Controlled substances: schedule
categories
Table 4-2 Controlled substances: categories,
dispensing restrictions, and examples
New Drug
Development
• Investigational new
drug (IND) application
• Informed consent
• Investigational drug
studies
• Expedited drug
approval
U.S. FDA Drug
Approval Process
• Preclinical
investigational drug
studies
• Clinical phases of
investigational drug
studies
– Phase I
– Phase II
– Phase III
– Phase IV
Ethical Nursing
Practice
• American Nurses
Association (ANA)
Code of Ethics for
Nurses
Cultural
Considerations
• Assess the influence of a
patient’s cultural beliefs,
values, and customs
• Drug polymorphism
• Compliance level with
therapy
• Environmental
considerations
• Genetic factors
• Varying responses to
specific agents
Cultural
Assessment
• Health beliefs and
practices
• Past uses of medicine
• Folk remedies
• Home remedies
• Use of nonprescription
drugs and herbal
remedies
• OTC treatments
Cultural
Assessment (cont'd)
• Usual response to
treatment
• Responsiveness to
medical treatment
• Religious practices and
beliefs
• Dietary habits
Medication
Errors:
Preventing
and
Responding
Medication
Misadventures
• Medication errors
(MEs)
• Adverse drug events
(ADEs)
• Adverse drug reactions
(ADRs)
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
Medication Errors
• Preventable
• Common cause of
adverse health care
outcomes
• Effects can range from no
significant effect to
directly causing disability
or death
Box 5-1 Common classes of medications
involved in serious errors
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
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
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
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”
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
Preventing
Medication Errors
(cont'd)
• Always listen to and
honor any concerns
expressed by patients
regarding medications
• Check patient allergies
and identification
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
Drug
Administration
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
Preparing for Drug
Administration
(cont'd)
• Check expiration dates
• Check the patient’s
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
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
Parenteral
Drugs
• Never recap a used
needle!
• May recap an unused
needle with the “scoop
method”
• Prevention of
needlesticks
• Filter needles
Parenteral
Drugs
(cont'd)
• Removing medications
from ampules
• Removing medications
from vials
• Disposal of used
needles and syringes
Injections
• Needle angles for
various injections
– Intramuscular (IM)
– Subcutaneous (SC or SQ)
– Intradermal (ID)
• Z-track method for IM
injections
• Air-lock technique
Injection
Techniques
• Intradermal injections
• Subcutaneous injections
– Insulin administration
– Heparin administration
Injection
Techniques
(cont'd)
• Intramuscular
injections
– Ventrogluteal site
(preferred)
– Vastus lateralis site
– Dorsogluteal site
– Deltoid site
Preparing
Intravenous
Medications
Needleless systems
Compatibility issues
Expiration dates
Mixing intravenous
piggyback (IVPB)
medications
• Labeling intravenous (IV)
infusion bags when
adding medications
•
•
•
•
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
Intravenous
Medications
(cont'd)
• Volume-controlled
administration set
• Using electronic
infusion pumps
• Patient-controlled
analgesia (PCA) pumps
Topical
Drugs
• Eye medications
– Drops
– Ointments
• Ear drops
– Adults
– Infant or child younger
than 3 years of age
Topical
Drugs
(cont'd)
• Nasal drugs
– Drops
– Spray
• Inhaled drugs
– Metered-dose inhalers
– Small-volume nebulizers
Topical
Drugs
(cont'd)
• Administering
medications to the skin
– Lotions, creams,
ointments, powders
– Transdermal patches
• Vaginal medications
– Creams, foams, gels
– Suppositories