introduction to pharmacology in nursing
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Introduction to Pharmacology in Nursing. Donna Penn RN MSN CNE . Nurses need to have knowledge about the actions and effects of medications To safely and accurately administer medications nurses need to have an understanding of pharmacologic principles. Pharmacologic Principles. - PowerPoint PPT PresentationTRANSCRIPT
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Introduction to Introduction to Pharmacology in Pharmacology in NursingNursing
Donna Penn RN MSN CNE.
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• Nurses need to have Nurses need to have knowledge about the knowledge about the actions and effects of actions and effects of medicationsmedications
• To safely and To safely and accurately administer accurately administer medications nurses medications nurses need to have an need to have an understanding of understanding of pharmacologic pharmacologic principlesprinciples
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Pharmacologic Pharmacologic PrinciplesPrinciples
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Drug NamesDrug Names Chemical nameChemical name• Describes the drug’s Describes the drug’s
chemical composition and chemical composition and molecular structuremolecular structure
Generic nameGeneric name (nonproprietary name)(nonproprietary name)
• Name given by the United Name given by the United States Adopted States Adopted Name CouncilName Council
Trade nameTrade name (proprietary (proprietary name)name)
• The drug has a registered The drug has a registered trademark; use of the name trademark; use of the name restricted by the drug’s restricted by the drug’s patent owner patent owner (usually the manufacturer)(usually the manufacturer)
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Drug Names Drug Names (cont'd)(cont'd)
Chemical nameChemical name• (+/-)-2-(p-isobutylphenyl) (+/-)-2-(p-isobutylphenyl)
propionic acidpropionic acid
Generic nameGeneric name• ibuprofenibuprofen
Trade nameTrade name• Motrin®, Advil®Motrin®, Advil®
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Figure 2-1 The Figure 2-1 The chemical, generic, and chemical, generic, and trade names for the trade names for the common analgesic common analgesic ibuprofen are listed ibuprofen are listed next to the chemical next to the chemical structure of the drug.structure of the drug.
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Pharmacological Pharmacological Concepts: Concepts: ClassificationClassification
• Classification- Nurses Classification- Nurses learn to categorize learn to categorize meds with similar meds with similar characteristics by their characteristics by their classclass
• Medication Medication classification indicates classification indicates the effect of the med on the effect of the med on the body system, the the body system, the symptom the med symptom the med relieves, or the med’s relieves, or the med’s desired effect (e.g. oral desired effect (e.g. oral hypoglycemics)hypoglycemics)
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Pharmacological Pharmacological Concepts: Concepts: ClassificationClassification
• A medication may A medication may also be part of more also be part of more than one class than one class
• Aspirin is an Aspirin is an analgesic, analgesic, antipyretic, anti-antipyretic, anti-inflammatory, and inflammatory, and anti-plateletanti-platelet
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Pharmacological Pharmacological Concepts: Concepts: Medication Medication FormsForms
• Medications are Medications are available in a variety of available in a variety of forms and preparationsforms and preparations
• The form of the med The form of the med will determine its route will determine its route of administrationof administration
• Composition of med is Composition of med is designed to enhance its designed to enhance its absorption & absorption & metabolismmetabolism
• Many meds are Many meds are available in several available in several formsforms
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Medication Medication FormsForms
• TabletTablet• CapsuleCapsule• ElixirElixir• Enteric-coatedEnteric-coated• SuppositorySuppository• SuspensionSuspension• Transdermal patchTransdermal patch
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Pharmacologic Pharmacologic PrinciplesPrinciples
• PharmaceuticsPharmaceutics• PharmacokineticsPharmacokinetics• PharmacodynamicsPharmacodynamics• PharmacotherapeutiPharmacotherapeuti
cscs• PharmacognosyPharmacognosy
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PharmaceuticsPharmaceutics The study of how various The study of how various drug forms influence drug forms influence pharmacokinetic and pharmacokinetic and pharmacodynamic pharmacodynamic activitiesactivities
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PharmacokinetiPharmacokineticscs
• • The study of what The study of what the body does to the the body does to the drugdrug– AbsorptionAbsorption– DistributionDistribution– MetabolismMetabolism– ExcretionExcretion
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PharmacodynamiPharmacodynamicscs
• • The study of what the The study of what the drug does to the bodydrug does to the body– The mechanism of drug The mechanism of drug
actions in living tissuesactions in living tissues
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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.)
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PharmacotherapeutiPharmacotherapeuticscs
The use of drugs and The use of drugs and the clinical indications the clinical indications for drugs to prevent for drugs to prevent and treat diseasesand treat diseases
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PharmacognosyPharmacognosy The study of natural The study of natural (plant and animal) (plant and animal) drug sourcesdrug sources
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Pharmacokinetics: Pharmacokinetics: AbsorptionAbsorption
• The rate at which a The rate at which a drug leaves its site drug leaves its site of administration, of administration, and the extent to and the extent to which absorption which absorption occursoccurs– BioavailabilityBioavailability– BioequivalentBioequivalent
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Factors That Factors That Affect Affect AbsorptionAbsorption • Administration route of Administration route of
the drugthe drug• Ability of Med to DissolveAbility of Med to Dissolve• Food or fluids Food or fluids
administered with the administered with the drugdrug
• Body Surface AreaBody Surface Area• Status of the absorptive Status of the absorptive
surfacesurface• Rate of blood flow to the Rate of blood flow to the
small intestinesmall intestine• Lipid Solubility of MedLipid Solubility of Med• Status of GI motilityStatus of GI motility
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Routes of Routes of Administration Administration
• A drug’s route of A drug’s route of administration administration affects the rate and affects the rate and extent of absorption extent of absorption of that drugof that drug– EnteralEnteral (GI tract) (GI tract)– ParenteralParenteral– TopicalTopical
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Enteral RouteEnteral Route • Drug is absorbed Drug is absorbed into the systemic into the systemic circulation through circulation through the oral or gastric the oral or gastric mucosa, the small mucosa, the small intestine, or rectumintestine, or rectum– OralOral– SublingualSublingual– BuccalBuccal– RectalRectal
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First-Pass EffectFirst-Pass Effect• The metabolism of a drug The metabolism of a drug
and its passage from the and its passage from the liver into the circulationliver into the circulation– A drug given via the oral A drug given via the oral
route may be extensively route may be extensively metabolized by the liver metabolized by the liver before reaching the systemic before reaching the systemic circulation (high first-pass circulation (high first-pass effect)effect)
– The same drug—given IV—The same drug—given IV—bypasses the liver, bypasses the liver, preventing the first-pass preventing the first-pass effect from taking place, and effect from taking place, and more drug reaches the more drug reaches the circulationcirculation
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Box 2-1 Drug Routes and First-Pass Effects
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Parenteral Parenteral RouteRoute
• Intravenous (fastest Intravenous (fastest delivery into the delivery into the blood circulation)blood circulation)
• IntramuscularIntramuscular• SubcutaneousSubcutaneous• IntradermalIntradermal• IntrathecalIntrathecal• IntraarticularIntraarticular
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Topical RouteTopical Route • Skin (including Skin (including transdermal transdermal patches)patches)
• EyesEyes• EarsEars• NoseNose• Lungs (inhalation)Lungs (inhalation)• VaginaVagina
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DistributionDistribution
The transport of a drug in The transport of a drug in the body by the the body by the bloodstream to its site of bloodstream to its site of actionaction• Protein-bindingProtein-binding• Water soluble vs. fat solubleWater soluble vs. fat soluble• Blood-brain barrierBlood-brain barrier• Areas of rapid distribution: Areas of rapid distribution: heart, liver, heart, liver,
kidneys, brainkidneys, brain• Areas of slow distribution: Areas of slow distribution: muscle, skin, fatmuscle, skin, fat
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MetabolismMetabolism(Also Known As (Also Known As Biotransformation)Biotransformation)
The biologic The biologic transformation of a drug transformation of a drug into into an inactive metabolite, a an inactive metabolite, a more soluble compound, more soluble compound, or a more potent or a more potent metabolitemetabolite• Liver (main organ)Liver (main organ)• KidneysKidneys• LungsLungs• PlasmaPlasma• Intestinal mucosaIntestinal mucosa
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Metabolism/Metabolism/Biotransformation (cont'd)Biotransformation (cont'd)
Delayed drug Delayed drug metabolism results metabolism results in:in:
• Accumulation of drugsAccumulation of drugs• Prolonged action of the Prolonged action of the
drugsdrugsStimulating drug Stimulating drug
metabolism causes:metabolism causes:• Diminished Diminished
pharmacologic effectspharmacologic effects
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ExcretionExcretion The elimination of The elimination of drugs from the bodydrugs from the body
• Kidneys (main organ)Kidneys (main organ)• LiverLiver• BowelBowel
– Biliary excretionBiliary excretion– Enterohepatic circulationEnterohepatic circulation
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• 1.1. You are caring for a client who has diabetes You are caring for a client who has diabetes complicated by kidney disease. You will need to make a complicated by kidney disease. You will need to make a detailed assessment when administering medications detailed assessment when administering medications because this client may experience problems with:because this client may experience problems with:
• A. A. AbsorptionAbsorption• B. B. BiotransformationBiotransformation• C. C. DistributionDistribution• D. D. ExcretionExcretion
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PharmacodynamiPharmacodynamicscs
• Study of the Study of the mechanism of drug mechanism of drug actions in living actions in living tissuetissue
• Drug-induced Drug-induced alterations to normal alterations to normal physiologic functionphysiologic function
• Positive change-Positive change-Therapeutic effect-Therapeutic effect-Goal of therapyGoal of therapy
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Mechanism of Mechanism of ActionAction
• Ways in which a Ways in which a drug can produce a drug can produce a therapeutic effecttherapeutic effect
• The effects that a The effects that a particular drug has particular drug has depends on the cells depends on the cells or organ targeted by or organ targeted by the drugthe drug
• Once the drug hits Once the drug hits its “site of action” it its “site of action” it can modify the rate can modify the rate at which a cell or at which a cell or tissue functionstissue functions
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Mechanism of Mechanism of ActionAction
• Receptor InteractionReceptor Interaction
• Enzyme InteractionEnzyme Interaction • Non-Specific Non-Specific
InteractionInteraction
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Receptor Receptor InteractionInteraction
• Drug structure is essentialDrug structure is essential
• Involves the selective Involves the selective joining of drug molecule joining of drug molecule with a reactive site on the with a reactive site on the cell surface that elicits a cell surface that elicits a biological effectbiological effect
• Receptor is the reactive Receptor is the reactive site on a cell or tissuesite on a cell or tissue
• Once the substance binds Once the substance binds to and interacts with the to and interacts with the receptor, a pharmacologic receptor, a pharmacologic response is producedresponse is produced
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Receptor Receptor InteractionInteraction
• Affinity- degree to Affinity- degree to which a drug binds with which a drug binds with a receptora receptor
• The drug with the best The drug with the best “fit” or affinity will elicit “fit” or affinity will elicit the best responsethe best response
• Drug can mimic body’s Drug can mimic body’s endogenous substances endogenous substances that normally bind to that normally bind to receptor sitereceptor site
• Drugs that bind to Drugs that bind to receptors interact with receptors interact with receptors in different receptors in different ways to either ways to either blockblock or or elicitelicit a response a response
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Receptor Receptor InteractionInteraction
• Agonist-Drug binds Agonist-Drug binds to receptor-there is a to receptor-there is a response response (Adrenergic Agents)(Adrenergic Agents)
• Antagonist-drug Antagonist-drug binds to receptor-no binds to receptor-no response-prevents response-prevents binding of agonists binding of agonists (Alpha & Beta (Alpha & Beta Blockers)Blockers)
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Enzyme Enzyme InteractionInteraction
• Enzymes are substances Enzymes are substances that catalyze nearly that catalyze nearly every biochemical every biochemical reaction in a cellreaction in a cell
• Drugs can interact with Drugs can interact with enzyme systems to alter enzyme systems to alter a responsea response
• Inhibits action of Inhibits action of enzymes-enzyme is enzymes-enzyme is “fooled” into binding to “fooled” into binding to drug instead of target drug instead of target cellcell
• Protects target cell from Protects target cell from enzyme’s action (ACE enzyme’s action (ACE Inhibitors)Inhibitors)
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Non-Specific Non-Specific InteractionInteraction
• Not involving a receptor Not involving a receptor site or alteration in site or alteration in enzyme functionenzyme function
• Main site of action is Main site of action is cell membrane or cell membrane or cellular processcellular process
• Drugs will physically Drugs will physically interfere or chemically interfere or chemically alter cell processalter cell process
• Final product is altered Final product is altered causing defect or cell causing defect or cell deathdeath
• Cancer drugs, Cancer drugs, AntibioticsAntibiotics
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The nurse is giving a medication that has a high first-pass effect. The physician has changed the route from IV to PO. The nurse expects the oral dose to be:
1.Higher because of the first-pass effect.2.Lower because of the first-pass effect.3.The same as the IV dose.4.Unchanged.
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. A patient is complaining of severe pain and has orders for morphine sulfate. The nurse knows that the route that would give the slowest pain relief would be which route?
1. IV2. IM3.SC4.PO
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Type of Type of Medication Medication ActionAction
• Therapeutic EffectTherapeutic Effect• Side EffectsSide Effects• Adverse EffectsAdverse Effects• Toxic EffectToxic Effect• Idiosyncratic ReactionsIdiosyncratic Reactions• Allergic ReactionAllergic Reaction• Medication InteractionsMedication Interactions• Iatrogenic ResponseIatrogenic Response
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Therapeutic Therapeutic EffectEffect
• The expected or The expected or predictable predictable physiological physiological response a response a medication causesmedication causes
• A single med can A single med can have several have several therapeutic effects therapeutic effects (Aspirin)(Aspirin)
• It is important for the It is important for the nurse to know why nurse to know why med is being med is being prescribedprescribed
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Side EffectsSide Effects• Unintended secondary Unintended secondary
effects a medication effects a medication predictably will causepredictably will cause
• May be harmless or May be harmless or seriousserious
• If side effects are serious If side effects are serious enough to negate the enough to negate the beneficial effect of meds beneficial effect of meds therapeutic action, it therapeutic action, it may be D/C’dmay be D/C’d
• People may stop taking People may stop taking medications because of medications because of the side effectsthe side effects
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Adverse EffectsAdverse Effects • Undesirable response of Undesirable response of a medicationa medication
• Unexpected effects of Unexpected effects of drug not related to drug not related to therapeutic effecttherapeutic effect
• Must be reported to Must be reported to FDAFDA
• Can be a side effect or Can be a side effect or a harmful effecta harmful effect
• Can be categorized as Can be categorized as pharmacologic, pharmacologic, idiosyncratic, idiosyncratic, hypersensitivity, or hypersensitivity, or drug interactiondrug interaction
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Adverse EffectsAdverse Effects • Adverse Drug EventsAdverse Drug Events
• Adverse Drug Adverse Drug Reactions (ADR)Reactions (ADR)
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Toxic EffectToxic Effect • May develop after May develop after prolonged intake or prolonged intake or when a med when a med accumulates in the accumulates in the blood because of blood because of impaired metabolism or impaired metabolism or excretion, or excessive excretion, or excessive amount takenamount taken
• Toxic levels of opioids Toxic levels of opioids can cause can cause resp.depressionresp.depression
• Antidotes available to Antidotes available to reverse effectsreverse effects
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Idiosyncratic Idiosyncratic ReactionsReactions
• Unpredictable effects-Unpredictable effects-overreacts or under overreacts or under reacts to a medication or reacts to a medication or has a reaction different has a reaction different from normalfrom normal
• Genetically determined Genetically determined abnormal responseabnormal response
• Idiosyncratic drug Idiosyncratic drug reactions are usually reactions are usually caused by abnormal caused by abnormal levels of drug-levels of drug-metabolizing enzymes metabolizing enzymes (deficiency or (deficiency or overabundance)overabundance)
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Allergic Allergic ReactionReaction
• Unpredictable response Unpredictable response to a medicationto a medication
• Makes up greater than Makes up greater than 10% of all medication 10% of all medication reactionsreactions
• Client may become Client may become sensitized sensitized immunologically to the immunologically to the initial dose, repeated initial dose, repeated administration causes administration causes an allergic response to an allergic response to the med, chemical the med, chemical preservative or a preservative or a metabolitemetabolite
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Allergic ReactionAllergic Reaction • Medication acts as an Medication acts as an antigen triggering the antigen triggering the release of the body’s release of the body’s antibodiesantibodies
• May be mild or severeMay be mild or severe• Among the different Among the different
classes of meds, classes of meds, antibiotics cause the antibiotics cause the highest incidence of highest incidence of allergic reactionallergic reaction
• Severe reaction-Severe reaction-Anaphylactic reactionAnaphylactic reaction
• Mild reaction-hives, Mild reaction-hives, rash, pruritisrash, pruritis
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• 2. 2. A postoperative client is receiving morphine A postoperative client is receiving morphine sulfate via a PCA. The nurse assesses that the client’s sulfate via a PCA. The nurse assesses that the client’s respirations are depressed. The effects of the morphine respirations are depressed. The effects of the morphine sulfate can be classified as: sulfate can be classified as:
• A. A. AllergicAllergic• B. B. IdiosyncraticIdiosyncratic• C. C. TherapeuticTherapeutic• D. D. ToxicToxic
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Other Drug Other Drug ReactionsReactions
• Teratogenic-Teratogenic-Structural effect in Structural effect in unborn fetus unborn fetus (thalidomide)(thalidomide)
• Carcinogenic-Causes Carcinogenic-Causes cancercancer
• Mutagenic- Changes Mutagenic- Changes genetic composition genetic composition (radiation, (radiation, chemicals)chemicals)
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Drug Drug InteractionsInteractions
• Occurs when one med Occurs when one med modifies the action of modifies the action of another another
• Common in people Common in people taking several taking several medications at oncemedications at once
• One med may One med may potentiate or diminish potentiate or diminish the action of another the action of another or alter the way it is or alter the way it is absorbed, absorbed, metabolized or metabolized or eliminatedeliminated
• Warfarin and Warfarin and AmiodaroneAmiodarone
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Iatrogenic Iatrogenic ResponsesResponses
• Unintentional adverse Unintentional adverse effects that occur during effects that occur during therapytherapy
• Treatment-Induced Treatment-Induced Dermatologic-rash, hives, Dermatologic-rash, hives, acneacne
• Renal Damage-Renal Damage-Aminoglycoside Aminoglycoside antibiotics, NSAIDS, antibiotics, NSAIDS, contrast mediumcontrast medium
• Blood Dyscrasias- Blood Dyscrasias- Destruction of blood cells Destruction of blood cells (Chemotherapy)(Chemotherapy)
• Hepatic Toxicity-Elevated Hepatic Toxicity-Elevated liver enzymes (hepatitis-liver enzymes (hepatitis-like symptoms)like symptoms)
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Synergistic Synergistic EffectEffect
• Effect of 2 meds Effect of 2 meds combined is greater combined is greater than the meds given than the meds given separatelyseparately
• Alcohol & Alcohol & Antihistamines, Antihistamines, antidepressants, antidepressants, barbiturates, narcoticsbarbiturates, narcotics
• Not always undesirable, Not always undesirable, physician may combine physician may combine meds to create an meds to create an interaction that will have interaction that will have beneficial effects beneficial effects (Vasodilators & diuretics (Vasodilators & diuretics to control high BP)to control high BP)
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Medication Medication Dose ResponsesDose Responses
• Except when administered Except when administered IV, meds take time to IV, meds take time to enter bloodstreamenter bloodstream
• The quantity & The quantity & distribution of med in distribution of med in different body different body compartments change compartments change constantlyconstantly
• Goal is to keep constant Goal is to keep constant blood level within a safe blood level within a safe therapeutic rangetherapeutic range
• Repeated doses are Repeated doses are required to achieve a required to achieve a constant therapeutic constant therapeutic concentrationconcentration of a med of a med because a portion of med because a portion of med is always being excretedis always being excreted
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Medication Medication Dose ResponsesDose Responses
• Serum Half-Life:Time it Serum Half-Life:Time it takes for excretion takes for excretion processes to lower the processes to lower the serum medication serum medication concentration by ½concentration by ½
• Regular fixed doses must Regular fixed doses must be given to maintain be given to maintain therapeutic therapeutic concentrationconcentration
• Dosage schedules set by Dosage schedules set by institutions (TID, q8h, HS, institutions (TID, q8h, HS, AC, STAT, PRN)AC, STAT, PRN)
• Peak & Trough levelsPeak & Trough levels• Therapeutic drug Therapeutic drug
monitoringmonitoring
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Half-lifeHalf-life • The time it takes for The time it takes for one half of the original one half of the original amount of a drug in the amount of a drug in the body to be removedbody to be removed
• A measure of the rate A measure of the rate at which drugs are at which drugs are removed from the bodyremoved from the body
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Onset, Peak, Onset, Peak, and Durationand Duration
OnsetOnset• The time it takes for the The time it takes for the
drug to elicit a drug to elicit a therapeutic responsetherapeutic response
PeakPeak• The time it takes for a drug The time it takes for a drug
to reach its maximum to reach its maximum therapeutic response therapeutic response
DurationDuration• The time a drug The time a drug
concentration is sufficient concentration is sufficient to elicit a therapeutic to elicit a therapeutic responseresponse
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Pharmacotherapeutics: Types Pharmacotherapeutics: Types of Therapiesof Therapies
• Acute therapyAcute therapy• Maintenance therapyMaintenance therapy• Supplemental Supplemental
therapytherapy• Palliative therapyPalliative therapy• Supportive therapySupportive therapy• Prophylactic therapyProphylactic therapy• Empiric therapyEmpiric therapy
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MonitoringMonitoring • The effectiveness of The effectiveness of the drug therapy the drug therapy must be evaluatedmust be evaluated
• One must be familiar One must be familiar with the drug’s:with the drug’s:– Intended therapeutic Intended therapeutic
action (beneficial)action (beneficial)– Unintended but Unintended but
potential side effects potential side effects (predictable, adverse (predictable, adverse reactions)reactions)
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Monitoring Monitoring (cont'd)(cont'd)
• • Therapeutic indexTherapeutic index– – The ratio between a The ratio between a drug’s therapeutic drug’s therapeutic benefits and its toxic benefits and its toxic effectseffects
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Monitoring Monitoring (cont'd)(cont'd)
• • ToleranceTolerance – – A decreasing A decreasing response to repetitive response to repetitive drug dosesdrug doses
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Monitoring Monitoring (cont'd)(cont'd)
• • DependenceDependence – – A physiologic or A physiologic or
psychological need psychological need for a drugfor a drug
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Monitoring Monitoring (cont'd)(cont'd)
Interactions may occur Interactions may occur with other drugs or with other drugs or foodfood• Drug interactions: the Drug interactions: the alteration of action of alteration of action of a drug by: a drug by:
– Other prescribed Other prescribed drugsdrugs
– Over-the-counter Over-the-counter medicationsmedications
– Herbal therapiesHerbal therapies
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Monitoring Monitoring (cont'd)(cont'd)
• • Drug interactionsDrug interactions– – Additive effectAdditive effect– – Synergistic effectSynergistic effect– – Antagonistic effectAntagonistic effect– – IncompatibilityIncompatibility
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Monitoring Monitoring (cont'd)(cont'd)
• Medication Medication misadventuresmisadventures– Adverse drug eventsAdverse drug events– Adverse drug Adverse drug
reactions reactions – Medication errorsMedication errors
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Monitoring Monitoring (cont'd)(cont'd)
Some adverse drug Some adverse drug reactions are reactions are classified as side classified as side effectseffects
• Expected, well-known Expected, well-known reactions that result in reactions that result in little or no change in little or no change in patient managementpatient management
• Predictable frequencyPredictable frequency• The effect’s intensity and The effect’s intensity and
occurrence are related to occurrence are related to the size of the dosethe size of the dose
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Adverse Drug Adverse Drug ReactionReaction
An adverse outcome An adverse outcome of drug therapy in of drug therapy in which a patient is which a patient is harmed in some wayharmed in some way
• Pharmacologic Pharmacologic reactionsreactions
• Idiosyncratic reactionsIdiosyncratic reactions• Hypersensitivity Hypersensitivity
reactionsreactions• Drug interactionsDrug interactions
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Other Drug-Other Drug-Related EffectsRelated Effects
• TeratogenicTeratogenic• MutagenicMutagenic• CarcinogenicCarcinogenic
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ToxicologyToxicology The study of poisons The study of poisons and unwanted and unwanted responses to responses to therapeutic agentstherapeutic agents
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Table 2-9 Common Poisons and Antidotes
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The Nursing The Nursing Process (cont'd)Process (cont'd) • AssessmentAssessment
• Nursing diagnosisNursing diagnosis• Planning (with Planning (with
outcome criteria)outcome criteria)• ImplementationImplementation• EvaluationEvaluation
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The Nursing The Nursing ProcessProcess
• An organizational An organizational framework for the framework for the practice of nursingpractice of nursing
• Orderly, systematicOrderly, systematic• Central to all nursing Central to all nursing
carecare• Encompasses all Encompasses all
steps taken by the steps taken by the nurse in caring for a nurse in caring for a patientpatient
• Flexibility is importantFlexibility is important
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The Nursing The Nursing Process (cont'd)Process (cont'd) AssessmentAssessment
• Data collection Data collection – Subjective, objectiveSubjective, objective– Data collected on the Data collected on the
patient, drug, patient, drug, environmentenvironment
• Medication historyMedication history• Nursing assessmentNursing assessment• Physical assessmentPhysical assessment• Data analysisData analysis
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The Nursing The Nursing Process (cont'd)Process (cont'd) Nursing diagnosisNursing diagnosis
• Judgment or Judgment or conclusion about the conclusion about the need/problem need/problem (actual or at risk for) (actual or at risk for) of the patientof the patient
• Based upon an Based upon an accurate assessmentaccurate assessment
• NANDA formatNANDA format
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The Nursing The Nursing Process (cont'd)Process (cont'd) PlanningPlanning
• Identification of Identification of goals and outcome goals and outcome criteriacriteria
• PrioritizationPrioritization• Time frameTime frame
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The Nursing The Nursing Process (cont'd)Process (cont'd)
GoalsGoals• Objective, Objective,
measurable, realisticmeasurable, realistic• Time frame Time frame
specifiedspecifiedOutcome criteriaOutcome criteria• Specific standard(s) Specific standard(s)
of measureof measure• Patient orientedPatient oriented
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The Nursing The Nursing Process (cont'd)Process (cont'd) ImplementationImplementation
• Initiation and Initiation and completion of the completion of the nursing care plan nursing care plan as defined by the as defined by the nursing diagnoses and nursing diagnoses and outcome criteriaoutcome criteria
• Follow the “five rights” Follow the “five rights” of medication of medication administrationadministration
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The “Five The “Five Rights”Rights”• Right drugRight drug• Right doseRight dose• Right timeRight time• Right routeRight route• Right patientRight patient
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Another “Right”—Constant Another “Right”—Constant System AnalysisSystem Analysis
• A “double-check”A “double-check”• The entire “system” of The entire “system” of
medication medication administrationadministration
• Ordering, dispensing, Ordering, dispensing, preparing, preparing, administering, administering, documentingdocumenting
• Involves the physician, Involves the physician, nurse, nursing unit, nurse, nursing unit, pharmacy department, pharmacy department, and patient educationand patient education
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Other Other “Rights”“Rights”
• Proper drug storageProper drug storage• Proper Proper
documentationdocumentation• Accurate dosage Accurate dosage
calculationcalculation• Accurate dosage Accurate dosage
preparationpreparation• Careful checking of Careful checking of
transcription of transcription of ordersorders
• Patient safetyPatient safety
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Other Other “Rights” “Rights” (cont'd)(cont'd)
• Close consideration Close consideration of special situationsof special situations
• Prevention and Prevention and reporting of reporting of medication errorsmedication errors
• Patient teachingPatient teaching• Monitoring for Monitoring for
therapeutic effects, therapeutic effects, side effects, toxic side effects, toxic effectseffects
• Refusal of medicationRefusal of medication
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EvaluationEvaluation •• Ongoing part of the Ongoing part of the nursing processnursing process
• Determining the Determining the status of the goals status of the goals and and outcomes of careoutcomes of care
• Monitoring the Monitoring the patient’s response to patient’s response to drug therapydrug therapy– Expected and Expected and
unexpected responsesunexpected responses
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The day shift charge nurse is making rounds. A patient tells the nurse that the night shift nurse never gave him his medication, which was due at 11 PM. What should the nurse do first to determine whether the medication was given?
1. Call the night nurse at home.2. Check the Medication Administration Record.3. Call the pharmacy.4. Review the nurse’s notes.
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The patient’s Medication Administration Record lists two antiepileptic medications that are due at 0900, but the patient is NPO for a barium study. The nurse’s coworker suggests giving the medications via IV because the patient is NPO. What should the nurse do?
1. Give the medications PO with a small sip of water.2. Give the medications via the IV route because the
patient is NPO.3. Hold the medications until after the test is
completed.4. Call the physician to clarify the instructions.
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Life Span Life Span ConsiderationsConsiderations
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Life Span Life Span ConsiderationsConsiderations
• PregnancyPregnancy• Breast-feedingBreast-feeding• NeonatalNeonatal• PediatricPediatric• GeriatricGeriatric
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PregnancyPregnancy • First trimester is the First trimester is the period of greatest period of greatest danger for drug-danger for drug-induced induced developmental developmental defectsdefects
• Drugs diffuse across Drugs diffuse across the placentathe placenta
• FDA pregnancy FDA pregnancy safety categoriessafety categories
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Table 3-1 Table 3-1 Pregnancy safety Pregnancy safety categoriescategories
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Breast-feedingBreast-feeding • Breast-fed infants Breast-fed infants are at risk for are at risk for exposure to drugs exposure to drugs consumed by the consumed by the mothermother
• Consider risk-to-Consider risk-to-benefit ratiobenefit ratio
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Table 3-2 Classification Table 3-2 Classification of young patientsof young patients
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Pediatric Considerations: Pediatric Considerations: PharmacokineticsPharmacokinetics
• AbsorptionAbsorption– Gastric pH less acidicGastric pH less acidic– Gastric emptying is Gastric emptying is
slowedslowed– Topical absorption Topical absorption
faster through the faster through the skinskin
– Intramuscular Intramuscular absorption faster and absorption faster and irregularirregular
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Pediatric Considerations: Pediatric Considerations: Pharmacokinetics (cont'd)Pharmacokinetics (cont'd)
• DistributionDistribution– TBW 70% to 80% in TBW 70% to 80% in
full-term infants, 85% full-term infants, 85% in premature newborns, in premature newborns, 64% in children 1 to 64% in children 1 to 12 years of age12 years of age
– Greater TBW means fat Greater TBW means fat content is lowercontent is lower
– Decreased level of Decreased level of protein binding protein binding
– Immature blood-brain Immature blood-brain barrierbarrier
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Pediatric Considerations: Pediatric Considerations: Pharmacokinetics (cont'd)Pharmacokinetics (cont'd)
• MetabolismMetabolism– Liver immature, does Liver immature, does
not produce enough not produce enough microsomal enzymesmicrosomal enzymes
– Older children may Older children may have increased have increased metabolism, requiring metabolism, requiring higher doseshigher doses
– Other factorsOther factors
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Pediatric Pediatric Considerations: Considerations: Pharmacokinetics Pharmacokinetics (cont'd)(cont'd) • ExcretionExcretion
– Kidney immaturity Kidney immaturity affects glomerular affects glomerular filtration rate and filtration rate and tubular secretiontubular secretion
– Decreased perfusion Decreased perfusion rate of the kidneysrate of the kidneys
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Summary of Summary of Pediatric Pediatric ConsiderationsConsiderations • Skin is thin and permeableSkin is thin and permeable
• Stomach lacks acid to kill Stomach lacks acid to kill bacteriabacteria
• Lungs lack mucus barriersLungs lack mucus barriers• Body temperatures poorly Body temperatures poorly
regulated and dehydration regulated and dehydration occurs easilyoccurs easily
• Liver and kidneys are Liver and kidneys are immature, impairing drug immature, impairing drug metabolism and excretionmetabolism and excretion
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Methods of Dosage Methods of Dosage Calculation for Pediatric Calculation for Pediatric PatientsPatients • Body weight dosage Body weight dosage
calculationscalculations
• Body surface area Body surface area methodmethod
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Geriatric Geriatric ConsiderationsConsiderations
• Geriatric: older than Geriatric: older than age 65age 65– Healthy People 2010: Healthy People 2010:
older than age 55older than age 55• Use of OTC Use of OTC
medicationsmedications• PolypharmacyPolypharmacy
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Table 3-4 Physiologic changes in the Table 3-4 Physiologic changes in the geriatric patientgeriatric patient
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Geriatric Considerations: Geriatric Considerations: PharmacokineticsPharmacokinetics
• AbsorptionAbsorption– Gastric pH less acidicGastric pH less acidic– Slowed gastric emptyingSlowed gastric emptying– Movement through GI Movement through GI
tract slowertract slower– Reduced blood flow to Reduced blood flow to
the GI tractthe GI tract– Reduced absorptive Reduced absorptive
surface area due to surface area due to flattened intestinal villiflattened intestinal villi
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Geriatric Considerations: Geriatric Considerations: Pharmacokinetics (cont'd)Pharmacokinetics (cont'd)
• DistributionDistribution– TBW percentages TBW percentages
lowerlower– Fat content increasedFat content increased– Decreased production Decreased production
of proteins by the of proteins by the liver, resulting in liver, resulting in decreased protein decreased protein binding of drugsbinding of drugs
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Geriatric Considerations: Geriatric Considerations: Pharmacokinetics (cont'd)Pharmacokinetics (cont'd)
• MetabolismMetabolism– Aging liver produces Aging liver produces
less microsomal less microsomal enzymes, affecting enzymes, affecting drug metabolismdrug metabolism
– Reduced blood flow Reduced blood flow to the liverto the liver
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Geriatric Considerations: Geriatric Considerations: Pharmacokinetics (cont'd)Pharmacokinetics (cont'd)
• ExcretionExcretion– Decreased glomerular Decreased glomerular
filtration ratefiltration rate– Decreased number of Decreased number of
intact nephronsintact nephrons
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Geriatric Considerations: Geriatric Considerations: Problematic MedicationsProblematic Medications
• AnalgesicsAnalgesics• AnticoagulantsAnticoagulants• AnticholinergicsAnticholinergics• AntihypertensivesAntihypertensives• DigoxinDigoxin• Sedatives and Sedatives and
hypnoticshypnotics• Thiazide diureticsThiazide diuretics
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Legal, Ethical, Legal, Ethical, and Culturaland CulturalConsiderationConsiderationss
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U.S. Drug U.S. Drug LegislationLegislation
• 1906: Federal Food 1906: Federal Food and Drug Actand Drug Act
• 1912: Sherley 1912: Sherley Amendment (to the Amendment (to the Federal Food and Federal Food and Drug Act of 1906)Drug Act of 1906)
• 1914: Harrison 1914: Harrison Narcotic ActNarcotic Act
• 1938: Federal Food, 1938: Federal Food, Drug, and Cosmetic Drug, and Cosmetic Act (revision of 1906 Act (revision of 1906 Act)Act)
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U.S. Drug U.S. Drug Legislation Legislation (cont'd)(cont'd) • 1951: Durham-1951: Durham-
Humphrey Humphrey Amendment (to the Amendment (to the 1938 act)1938 act)
• 1962: Kefauver-1962: Kefauver-Harris Amendment Harris Amendment (to the 1938 act)(to the 1938 act)
• 1970: Controlled 1970: Controlled Substance ActSubstance Act
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U.S. Drug U.S. Drug Legislation Legislation (cont'd)(cont'd) • 1983: Orphan Drug 1983: Orphan Drug
ActAct
• 1991: Accelerated 1991: Accelerated drug approvaldrug approval
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New Drug New Drug DevelopmentDevelopment
• Investigational new Investigational new drug (IND) drug (IND) applicationapplication
• Informed consentInformed consent• Investigational drug Investigational drug
studiesstudies• Expedited drug Expedited drug
approvalapproval
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U.S. FDA Drug U.S. FDA Drug Approval ProcessApproval Process • Preclinical Preclinical
investigational drug investigational drug studiesstudies
• Clinical phases of Clinical phases of investigational drug investigational drug studiesstudies– Phase IPhase I– Phase IIPhase II– Phase IIIPhase III– Phase IVPhase IV
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Ethical Nursing Ethical Nursing PracticePractice
• American Nurses American Nurses Association (ANA) Association (ANA) Code of Ethics for Code of Ethics for NursesNurses
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Cultural Cultural ConsiderationsConsiderations
• Assess the influence of Assess the influence of a patient’s cultural a patient’s cultural beliefs, values, and beliefs, values, and customscustoms
• Drug polymorphismDrug polymorphism• Compliance level with Compliance level with
therapytherapy• Environmental Environmental
considerationsconsiderations• Genetic factorsGenetic factors• Varying responses to Varying responses to
specific agentsspecific agents
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Cultural Cultural AssessmentAssessment
• Health beliefs and Health beliefs and practicespractices
• Past uses of medicinePast uses of medicine• Folk remediesFolk remedies• Home remediesHome remedies• Use of Use of
nonprescription nonprescription drugs and herbal drugs and herbal remediesremedies
• OTC treatmentsOTC treatments
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Cultural Cultural Assessment Assessment (cont'd)(cont'd) • Usual response to Usual response to
treatmenttreatment• Responsiveness to Responsiveness to
medical treatmentmedical treatment• Religious practices Religious practices
and beliefsand beliefs• Dietary habitsDietary habits
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Medication Medication Errors:Errors:Preventing Preventing and and RespondingResponding
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Medication Medication MisadventuresMisadventures
• Medication errors Medication errors (MEs)(MEs)
• Adverse drug events Adverse drug events (ADEs)(ADEs)
• Adverse drug Adverse drug reactions (ADRs)reactions (ADRs)
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Medication Medication Misadventures Misadventures (cont'd)(cont'd)
• By definition, all By definition, all ADRs are also ADEsADRs are also ADEs
• But all ADEs are not But all ADEs are not ADRsADRs
• Two types of ADRsTwo types of ADRs– Allergic reactionsAllergic reactions– Idiosyncratic Idiosyncratic
reactionsreactions
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Medication Medication ErrorsErrors
• PreventablePreventable• Common cause of Common cause of
adverse health care adverse health care outcomesoutcomes
• Effects can range from Effects can range from no significant effect to no significant effect to directly causing directly causing disability or deathdisability or death
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Box 5-1 Common classes of medications Box 5-1 Common classes of medications involved in serious errorsinvolved in serious errors
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Preventing Preventing Medication ErrorsMedication Errors
• Minimize verbal or Minimize verbal or telephone orderstelephone orders– Repeat order to prescriberRepeat order to prescriber– Spell drug name aloudSpell drug name aloud– Speak slowly and clearlySpeak slowly and clearly
• List indication next to List indication next to each ordereach order
• Avoid medical Avoid medical shorthand, including shorthand, including abbreviations and abbreviations and acronymsacronyms
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Preventing Preventing Medication Errors Medication Errors (cont'd)(cont'd) • Never assume anything Never assume anything
about items not specified about items not specified in a drug order (i.e., in a drug order (i.e., route)route)
• Do not hesitate to Do not hesitate to question a medication question a medication order for any reason order for any reason when in doubtwhen in doubt
• Do not try to decipher Do not try to decipher illegibly written orders; illegibly written orders; contact prescriber for contact prescriber for clarificationclarification
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Preventing Preventing Medication Errors Medication Errors (cont'd)(cont'd) • NEVER use “trailing NEVER use “trailing
zeros” with zeros” with medication ordersmedication orders
• Do not use 1.0 mg; Do not use 1.0 mg; use 1 mguse 1 mg
• 1.0 mg could be 1.0 mg could be misread as 10 mg, misread as 10 mg, resulting in a tenfold resulting in a tenfold dose increasedose increase
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Preventing Preventing Medication Medication Errors (cont'd)Errors (cont'd) • ALWAYS use a ALWAYS use a
“leading zero” for “leading zero” for decimal dosagesdecimal dosages
• Do not use .25 mg; Do not use .25 mg; use 0.25 mguse 0.25 mg
• .25 mg may be .25 mg may be misread as 25 mgmisread as 25 mg
• ““.25” is sometimes .25” is sometimes called a “naked called a “naked decimal”decimal”
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Preventing Preventing Medication Errors Medication Errors (cont'd)(cont'd) • Check medication Check medication
order and what is order and what is available while using available while using the “5 rights”the “5 rights”
• Take time to learn Take time to learn special administration special administration techniques of certain techniques of certain dosage formsdosage forms
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Preventing Preventing Medication Errors Medication Errors (cont'd)(cont'd)
• Always listen to and Always listen to and honor any concerns honor any concerns expressed by patients expressed by patients regarding medicationsregarding medications
• Check patient allergies Check patient allergies and identificationand identification
• Medication Medication ReconciliationReconciliation
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Medication Medication ErrorsErrors • Possible consequences to Possible consequences to
nursesnurses• Reporting and responding Reporting and responding
to MEsto MEs– ADE monitoring programsADE monitoring programs– USPMERP (United States USPMERP (United States
Pharmacopeia Medication Pharmacopeia Medication Errors Reporting Program)Errors Reporting Program)
– MedWatch, sponsored by MedWatch, sponsored by the FDAthe FDA
– Institute for Safe Institute for Safe Medication Practices (ISMP)Medication Practices (ISMP)
• Notification of patient Notification of patient regarding MEsregarding MEs
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• 3. 3. Nurses are legally required to document Nurses are legally required to document medications that are administered to clients. The nurse medications that are administered to clients. The nurse is mandated to document:is mandated to document:
• A. A. Medication before administering itMedication before administering it• B. B. Medication after administering itMedication after administering it• C. C. Rationale for administering the medicationRationale for administering the medication• D. D. Prescriber’s rationale for prescribing the Prescriber’s rationale for prescribing the
medicationmedication
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• 4. 4. If a nurse experiences a problem reading a If a nurse experiences a problem reading a physician’s medication order, the most appropriate physician’s medication order, the most appropriate action will be to:action will be to:
• A. A. Call the physician to verify the order.Call the physician to verify the order.• B. B. Call the pharmacist to verify the order.Call the pharmacist to verify the order.• C. C. Consult with other nursing staff to verify the Consult with other nursing staff to verify the
order.order.• D. D. Withhold the medication until the physician Withhold the medication until the physician
makes rounds.makes rounds.
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Medication Medication AdministrationAdministration
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Preparing for Preparing for Drug Drug AdministrationAdministration
• Check the “5 rights”Check the “5 rights”• Standard Precautions: Standard Precautions:
Wash your hands!Wash your hands!• Double-check if unsure Double-check if unsure
about anythingabout anything• Check for drug allergiesCheck for drug allergies• Prepare drugs for one Prepare drugs for one
patient at a timepatient at a time• Check three timesCheck three times
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Preparing for Drug Preparing for Drug Administration Administration (cont'd)(cont'd)
• Check expiration datesCheck expiration dates• Check the patient’s Check the patient’s
identificationidentification• Give medications on timeGive medications on time• Explain medications to Explain medications to
the patientthe patient• Open the medications at Open the medications at
the bedsidethe bedside• Document the Document the
medications given before medications given before going to the next patientgoing to the next patient
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Drug Routes & Drug Routes & First Pass First Pass EffectsEffects
• First Pass Routes- First Pass Routes- Oral, RectalOral, Rectal
• Non-First Pass Non-First Pass Routes- Aural, Buccal, Routes- Aural, Buccal, Inhaled, Intraarterial, Inhaled, Intraarterial, Intramuscular, Intramuscular, Intranasal, Intranasal, Intraocular, Vaginal, Intraocular, Vaginal, Intravenous, Intravenous, Subcutaneous, Subcutaneous, Sublingual, Sublingual, TransdermalTransdermal
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Oral RouteOral Route• Easiest, most Easiest, most
commonly usedcommonly used• Slower onset of Slower onset of
actionaction• More prolonged More prolonged
effecteffect• Preferred by clientsPreferred by clients• Sublingual Sublingual
AdministrationAdministration• Buccal Buccal
AdministrationAdministration
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Enteral Enteral DrugsDrugs • Giving oral medicationsGiving oral medications
• Giving sublingual or Giving sublingual or buccal medicationsbuccal medications
• Liquid medicationsLiquid medications• Giving oral medications Giving oral medications
to infantsto infants• Administering drugs Administering drugs
through a nasogastric or through a nasogastric or gastrostomy tubegastrostomy tube
• Rectal administrationRectal administration
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Parenteral RouteParenteral Route Injecting a Injecting a medication into body medication into body tissuestissues
• Subcutaneous (SQ)Subcutaneous (SQ)• Intramuscular (IM)Intramuscular (IM)• Intravenous (IV)Intravenous (IV)• Intradermal (ID)Intradermal (ID)• Advanced Advanced
techniques techniques
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Parenteral Parenteral DrugsDrugs
• Never recap a used Never recap a used needle!needle!
• May recap an May recap an unused needle with unused needle with the “scoop method”the “scoop method”
• Prevention of Prevention of needlesticksneedlesticks
• Filter needlesFilter needles
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Parenteral Parenteral Drugs Drugs (cont'd)(cont'd)
• Removing Removing medications from medications from ampulesampules
• Removing Removing medications from medications from vialsvials
• Disposal of used Disposal of used needles and syringesneedles and syringes
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InjectionsInjections • Needle angles for Needle angles for various injectionsvarious injections– Intramuscular (IM)Intramuscular (IM)– Subcutaneous (SC or Subcutaneous (SC or
SQ)SQ)– Intradermal (ID)Intradermal (ID)
• Z-track method for Z-track method for IM injectionsIM injections
• Air-lock techniqueAir-lock technique
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Injection Injection TechniquesTechniques
• Intradermal Intradermal injectionsinjections
• Subcutaneous Subcutaneous injectionsinjections– Insulin administrationInsulin administration– Heparin Heparin
administrationadministration
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Injection Injection Techniques Techniques (cont'd)(cont'd)
• Intramuscular Intramuscular injectionsinjections– Ventrogluteal site Ventrogluteal site
(preferred)(preferred)– Vastus lateralis siteVastus lateralis site– Dorsogluteal siteDorsogluteal site– Deltoid siteDeltoid site
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Preparing Preparing Intravenous Intravenous MedicationsMedications • Needleless systemsNeedleless systems
• Compatibility issuesCompatibility issues• Expiration datesExpiration dates• Mixing intravenous Mixing intravenous
piggyback (IVPB) piggyback (IVPB) medicationsmedications
• Labeling intravenous Labeling intravenous (IV) infusion bags when (IV) infusion bags when adding medicationsadding medications
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IntravenouIntravenous s MedicationMedicationss
• Adding medications to Adding medications to a primary infusion baga primary infusion bag
• IVPB medications IVPB medications (secondary line)(secondary line)
• IV push medications IV push medications (bolus)(bolus)– Through an IV lockThrough an IV lock– Through an existing IV Through an existing IV
infusioninfusion
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Intravenous Intravenous Medications Medications (cont'd)(cont'd) • Volume-controlled Volume-controlled
administration setadministration set
• Using electronic Using electronic infusion pumpsinfusion pumps
• Patient-controlled Patient-controlled analgesia (PCA) analgesia (PCA) pumpspumps
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Topical Topical DrugsDrugs
• Eye medicationsEye medications– DropsDrops– OintmentsOintments
• Ear dropsEar drops– AdultsAdults– Infant or child younger Infant or child younger
than 3 years of agethan 3 years of age
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Topical Topical Drugs Drugs (cont'd)(cont'd)
• Nasal drugsNasal drugs– DropsDrops– SpraySpray
• Inhaled drugsInhaled drugs– Metered-dose Metered-dose
inhalersinhalers– Small-volume Small-volume
nebulizersnebulizers
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Topical Topical Drugs Drugs (cont'd)(cont'd)
• Administering Administering medications to the medications to the skinskin– Lotions, creams, Lotions, creams,
ointments, powdersointments, powders– Transdermal patchesTransdermal patches
• Vaginal medicationsVaginal medications– Creams, foams, gelsCreams, foams, gels– SuppositoriesSuppositories
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