The Nursing Process
and Drug Therapy
Barbara A. Kunkel, RN, MSN
Office: MS 119
Phone: 609-731-4368
Office Hours:
Monday & Thursday
11a-12n; 3:30-5p; 8p-8:30p
The Nursing
Process (cont'd)
• Assessment
• Nursing diagnosis
• Planning (with outcome
criteria)
• Implementation
• Evaluation
The “Six Rights”
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Right drug
Right dose
Right time
Right route
Right patient
Right documentation
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 circumstance
• Proper drug storage
• 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
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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
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
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
Metabolism
(Also Known As Biotransformation)
The biologic transformation
of a drug into
an inactive metabolite, a
more soluble compound, or a
more potent metabolite
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•
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•
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
agonist-antagonists. (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)
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 (total body water)
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 liver
– 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
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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
Ethical Nursing
Practice
• American Nurses
Association (ANA) Code
of Ethics for Nurses
Provisions:
Commitment
Advocacy
Responsibility/Accountability
Duty to self and others
Integrity
Practice, education, administration &
knowledge
• Collaboration – professional team
• Professional Associations – articulate
nursing values, maintaining integrity
of the profession & practice, shaping
social policy
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Cultural
Considerations
• Assess the influence of a
patient’s cultural beliefs,
values, and customs
• Drug polymorphism –
cultural safety
• 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 “6 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
Medication
Reconciliation
• Process to prevent
medication errors:
– 1. Verification
– 2. Clarification.
– 3. Reconciliation
• Performed:
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Admission
Status change
Transfer
Discharge
• Pt Assessment
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Open-ended questions
Avoid medical jargon
Clarify
Current & complete medication
list
Drug
Administration
Preparing for Drug
Administration
• Check the “6 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