Chapter 1: The Nursing Process and Drug Therapy

The Nursing Process A research-based organizational framework for professional nursing practice Ensures the delivery of thorough, individualized, and quality nursing care to patients Requires critical thinking Ongoing and constantly evolving process

Five Steps of the Nursing Process Assessment Nursing diagnosis Planning Goals Outcome criteria Implementation including patient education Evaluation

Assessment Data collection, review, and analysis Medication profile Any and all drug use Prescriptions Over-the-counter medications Vitamins, herbs, and supplements Compliance and adherence

The nurse answers a patients call light and finds the patient sitting up in bed and requesting pain medication. What will the nurse do first?A. Check the orders and give the patient the requested pain medication.B. Provide comfort measures to the patient.C. Assess the patients pain and pain level.D. Evaluate the effectiveness of previous pain medications.

Nursing Diagnosis Nursing diagnoses are used to communicate and share information about the patient and the patient experience Common nursing diagnoses related to drug therapy include: Deficient knowledge Risk for injury Noncompliance

Nursing Diagnosis Three-step process: Human response to illness, injury, or significant change Factors related to the response (related to) Listing of cues, clues, evidence, or other data that support the nurses claim for the diagnosis (as evidenced by)

Planning Identification of goals and outcome criteria Goals Objective, measurable, and realistic with an established time period for achievement of the outcomes that are specifically stated in the outcome criteria Outcome criteria Concrete descriptions of patient goals

The patients medication administration record lists two antiepileptic medications that are due at 0900, but the patient is NPO for a barium study. The nurses coworker suggests giving the medications via IV because the patient is NPO. What will the nurse do?A. Give the medications PO with a small sip of water.B. Give the medications via the IV route because the patient is NPO.C. Hold the medications until after the test is completed.D. Call the health care provider to clarify the instructions.

Implementation Initiation and completion of specific nursing actions as defined by the nursing diagnoses, goals, and outcome criteria Independent, collaborative, dependent

The Six Rights of Medication Administration Right drug Right dose Right time Right route Right patient Right documentation

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 2100. What will the nurse do first to determine whether the medication was given?A. Call the night nurse at homeB. Check the medication administration recordC. Call the pharmacyD. Review the nurses notes

Evaluation Ongoing part of the nursing process Determining the status of the goals and outcomes of care Monitoring the patients response to drug therapy Expected and unexpected responses Clear concise documentation

A nurse makes an error when administering medications to a patient. Which action by the nurse requires the supervising nurse to intervene? The nurseA. completes an incident report.B. informs the prescriber of the error.C. documents adverse effects to the medication error.D. records completion of an incident report in the medical chart.

Chapter 2: Pharmacologic Principles

Drug: Any chemical that affects the physiologic processes of a living organismPharmacology: Study or science of drugs

Drug NamesChemical name: Describes the drugs chemical composition and molecular structureGeneric name (nonproprietary name): Name given by the United States Adopted Names CouncilTrade name (proprietary name): The drug has a registered trademark; use of the name is restricted by the drugs patent owner (usually the manufacturer)

Pharmacologic Principles Pharmaceutics Pharmacokinetics Pharmacodynamics Pharmacotherapeutics Pharmacognosy Pharmacoeconomics

Pharmaceutics: The study of how various drug forms influence the way in which the drug affects the body

Pharmacokinetics: The study of what the body does to the drug Absorption Distribution Metabolism Excretion

The nurse is giving a medication that has a high first-pass effect. The health care provider has changed the route from IV to PO. The nurse expects the oral dose to beA. higher because of the first-pass effect.B. lower because of the first-pass effect.C. the same as the IV dose.D. unchanged.

Pharmacodynamics: The study of what the drug does to the body The mechanism of drug actions in living tissues Drug-receptor relationships

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?A. IVB. IMC. SubcutD. PO

Pharmacotherapeutics: The clinical use of drugs to prevent and treat diseases Defines principles of drug actionsthe cellular processes that change in response to the presence of drug molecules Drugs are organized into pharmacologic classes

Pharmacognosy: The study of natural (versus synthetic) drug sources (i.e., plant, animals, minerals)

Pharmaceutics: Different drug dosage forms have different pharmaceutical properties. Dosage form determines the rate of drug dissolution (dissolving of solid dosage forms and their absorption from the GI tract). Enteric-coated tablets Extended-release forms

A patient is prescribed ibuprofen 200 mg PO every 4 hours as needed for pain. The pharmacy sends up enteric-coated tablets, but the patient refuses the tablets, stating that she cannot swallow pills. What will the nurse do?A. Crush the tablets and mix them with applesauce or pudding.B. Call the pharmacy and ask for the liquid form of the medication.C. Call the pharmacy and ask for the IV form of the medication.D. Encourage the patient to try to swallow the tablets.

Pharmacokinetics: A drugs time to onset of action, time to peak effect, and duration of action Study of what happens to a drug from the time it is put into the body until the parent drug and all metabolites have left the body

Absorption: Movement of a drug from its site of administration into the bloodstream for distribution to the tissues Bioavailability First-pass effect

Routes A drugs route of administration affects the rate and extent of absorption of that drug Enteral (GI tract) Parenteral Topical

Enteral Route: The drug is absorbed into the systemic circulation through the oral or gastric mucosa or the small intestine Oral, Sublingual, Buccal, Rectal (can also be topical)

Parenteral Route Intravenous (fastest delivery into the blood circulation), Intramuscular, Subcutaneous, Intradermal, Intraarterial, Intrathecal, Intraarticular

Topical Route: Skin (including transdermal patches), Eyes, Ears, Nose, Lungs (inhalation), Rectum, Vagina

The nurse is preparing to administer a transdermal patch to a patient and finds that the patient already has a medication patch on his right upper chest. What will the nurse do?A. Remove the old medication patch and notify the health care providerB. Apply the new patch without removing the old oneC. Remove the old patch and apply the new patch in the same spotD. Remove the old patch and apply the new patch to a different, clean area

Distribution: The transport of a drug 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/Biotransformation: The biochemical alteration of a drug into an inactive metabolite, a more soluble compound, a more potent active metabolite, or a less active metabolite Liver (main organ) Skeletal muscle Kidneys Lungs Plasma Intestinal mucosa

Factors that decrease metabolism Cardiovascular dysfunction, Renal insufficiency, Starvation, Obstructive jaundice, Slow acetylator, Ketoconazole therapy

Factors that increase metabolism Fast acetylator, Barbiturate therapy, Rifampin therapy, Phenytoin therapy

Excretion: The elimination of drugs from the body Kidneys (main organ) Liver Bowel: Biliary excretion; Enterohepatic recirculation

Half-life: The time it takes for one half of the original amount of a drug to be removed from the body A measure of the rate at which a drug is removed from the body Most drugs considered to be effectively removed after about five half-lives Steady state

The Movement of Drugs Through the BodyDrug actions: The cellular processes involved in the drug and cell interactionDrug effect: The physiologic reaction of the body to the drug. Includes onset, peak, and duration of action

Onset, Peak, and DurationOnset: The time it takes for the drug to elicit a therapeutic responsePeak: 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

Therapeutic Drug MonitoringPeak level: Highest blood levelTrough level: Lowest blood level

Pharmacodynamics: Mechanisms of Action Receptor interactions Enzyme interactions Nonselective interactions

Pharmacotherapeutics: Types of Therapies Acute therapy Maintenance therapy Supplemental/replacement therapy Palliative therapy Supportive therapy Prophylactic therapy Empiric therapy

Contraindications: Any characteristic of the patient, especially a disease state, that makes the use of a given medication dangerous for the patient It is important to assess for contraindications!

Monitoring Evaluating the clinical response of the patient to the treatment One must be familiar with the drugs: Intended therapeutic action (beneficial) Unintended but potential adverse effects (predictable, adverse drug reactions) Therapeutic index Drug concentration Patients condition Tolerance and dependence Drug interactions (additive effect, synergistic effect, antagonistic effect, incompatibility) Adverse drug events

Adverse drug reactions Pharmacologic reactions, including adverse effects Hypersensitivity (allergic) reaction Idiosyncratic reaction Drug interaction

Other Drug-Related Effects Teratogenic, Mutagenic, Carcinogenic

PharmacognosyFour main sources for drugs: Plants, Animals, Minerals, Laboratory synthesis

Toxicology: The study of poisons and unwanted responses to drugs and other chemicals. Overlaps with pharmacotherapeutics

Chapter 3: Lifespan Considerations

Drug Therapy During Pregnancy Drugs cross the placenta by diffusion Factors affecting safety: Drug properties; Fetal gestational age; Maternal factors FDA has implemented pregnancy safety categories

When teaching a pregnant woman about the use of drugs during pregnancy, which statement will the nurse include? A. Exposure of the fetus to drugs is most detrimental during the second trimester of pregnancy.B. Pregnant women must never take drugs to control high blood pressure.C. Drug transfer to the fetus is most likely to occur during the last trimester of pregnancy.D. The fetus is at greatest risk for drug-induced developmental defects during the second trimester of pregnancy.

Drug Therapy During Breastfeeding Breastfed infants are at risk for exposure to drugs consumed by the mother Consider risk-to-benefit ratio

Neonatal and Pediatric Considerations: PharmacokineticsAbsorption Gastric pH less acidic Gastric emptying slowed Intramuscular absorption faster and irregular

Distribution Greater total body water means lower fat content Decreased level of protein binding Immature blood-brain barriermore drugs enter the brain

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

Excretion Kidney immaturity affects glomerular filtration rate and tubular secretion Decreased perfusion rate of the kidneys may reduce excretion of drugs

Factors Affecting Pediatric Drug Dosages Skin is thin and permeable Stomach lacks acid to kill bacteria Lungs have weaker mucus barriers Body temperatures less well regulated, and dehydration occurs easily Liver and kidneys are immature, impairing drug metabolism and excretionMethods of Dosage Calculation for Pediatric Patients Body surface area method: Uses the West nomogram Always use weight in kilograms, not pounds Body weight dosage calculations: Uses mg/kg

When administering medications to pediatric patients, the nurse understands that the dosage calculations for pediatric patients are different than for adults because pediatric patientsA. are more likely to develop edema.B. have more stomach acid.C. have skin that is less permeable.D. have immature liver and kidney function, resulting in impaired drug metabolism and excretion.

Considerations for Elderly Patients Elderly: older than age 65 High use of medications Polypharmacy Noncompliance, nonadherence Increased incidence of chronic illnesses Sensory and motor deficits

The Elderly: PharmacokineticsAbsorption Gastric pH less acidic Gastric emptying slowed Movement through GI tract slowed Blood flow to GI tract reduced Use of laxatives may accelerate GI motility

Distribution Lower total body water percentages Increased fat content Decreased production of proteins by the liver, resulting in decreased protein binding of drugs (and increased circulation of free drugs)

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

Excretion Decreased glomerular filtration rate Decreased number of intact nephrons

The Elderly: Problematic Medications Analgesics, including NSAIDs and opioids Anticoagulants Anticholinergics Antidepressants Antihypertensives Cardiac glycosides (digoxin) Sedatives and hypnotics, CNS depressants Thiazide diuretics

Which does the nurse identify as a pharmacokinetic change that occurs in the elderly?A. Gastric pH is more acidicB. Fat content is decreased because of increased lean body massC. Increased production of proteins by the liverD. The number of intact nephrons is decreased

Chapter 4: Cultural, Legal, and Ethical Considerations

Which racial group is predicted to be nearly one in three U.S. residents in 2050?A. African AmericanB. AsianC. HispanicD. White

Cultural Considerations Influence of ethnicity on genetics and drug response Drug polymorphism Compliance level with therapy Environmental and economic considerations Barriers to adequate health care for culturally diverse

Cultural Assessment Languages spoken Health beliefs and practices Past uses of medicine Herbal treatments, folk remedies, home remedies Over-the-counter drugs and treatment Usual response to illness Responsiveness to medical treatment Religious practices and beliefs Support from the patients cultural community Dietary habits

U.S. Drug Legislation 1906: Federal Food and Drugs 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) 1951: Durham-Humphrey Amendment (to the 1938 act) 1962: Kefauver-Harris Amendments (to the 1938 act) 1970: Controlled Substances Act 1983: Orphan Drug Act 1996: Health Insurance Portability and Accountability Act (HIPAA) 2003: Medicare Prescription Drug, Improvement, and Modernization Act

New Drug Development Investigational new drug (IND) application Informed consent U.S. FDA drug approval process Preclinical testing Clinical studies 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

A research group is conducting an investigational drug study on a promising new drug for osteoporosis. It has been difficult to find research subjects who meet the criteria. Just before the conclusion of the study, four subjects approach the researchers and express their desire to withdraw from the study. The researcher should firstA. inform them that they waited too long to withdraw from the study.B. explore with them the reasons for withdrawing from the study.C. acknowledge that they can withdraw at any time from the study.D. request that they try to remain with the study until it is completed.

Legal Nursing Considerations State and federal legislation Nurse practice acts Scope of nursing practice Expanded nursing roles Educational requirements Standards of care Minimally safe nursing practice Differences between nursing and medical practice Guidelines from professional nursing groups Institutional policies and procedures, state and federal hospital licensing Case law or common law HIPAA

Ethical Considerations American Nurses Association (ANA) Code of Ethics for Nurses International Council of Nurses (ICN) Code of Ethics for Nurses

A nurse has been asked to participate in an elective procedure that violates the nurses personal ethical principles. The nurse shouldA. refuse to participate.B. ask to switch assignments with another nurse.C. speak to the manager or supervisor.D. perform the procedure.

Chapter 5: Medication Errors: Preventing and Responding

Adverse Drug Event Medication errors - Institute of Medicine studies (1999, 2006) Adverse drug reactions: Allergic reaction; Idiosyncratic reaction

In the 2006 Institute of Medicine Study, it was estimated that some form of medication error resulted in harm to how many patients?A. 400,000B. 800,000C. 1 millionD. 1.5 million

Medication Errors Preventable Common cause of adverse health care outcomes More potential for harm with high-alert medications

Issues Contributing to Errors Errors can occur during any step of medication process: Procuring; Prescribing; Transcribing; Dispensing; Administering; Monitoring Organizational issues Educational system issues Sociologic factors

Types of Medication Errors No error, although circumstances or events occurred that could have led to an error Medication error that causes no harm Medication error that causes harm Medication error that results in death

Preventing Medication Errors Multiple systems of checks and balances Legible and correct orders Appropriate consultation Check medication order three times Six Rights of medication administration 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 Never assume anything about items not specified in a drug order (e.g., 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 NEVER use a trailing zero with medication orders (Do not use 1.0 mg; use 1 mg) ALWAYS use a leading zero for decimal dosages (Do not use .25 mg; use 0.25 mg) Take time to learn special administration techniques of certain dosage forms Always verify new medication administration records Always listen to and honor any concerns expressed by patients regarding medications Check patient allergies and identification

The nurse is administering a drug that has been ordered as follows: Give 10 mg on odd-numbered days and 5 mg on even-numbered days. When the date changes from May 31 to June 1, what should the nurse do?A. Give 10 mg because June 1 is an odd-numbered dayB. Hold the dose until the next odd-numbered dayC. Change the order to read Give 10 mg on even-numbered days and 5 mg on odd-numbered daysD. Consult the prescriber to verify that the dose should alternate each day, no matter whether the day is odd- or even-numbered

Reporting Medication Errors Report to prescriber and nursing management Document error per policy and procedure Factual documentation only Medication administered Actual dose Observed changes in patient condition Prescriber notified/follow-up orders External reporting of errors USP MERP (United States Pharmacopeia Medication Errors Reporting Program) MedWatch, sponsored by the FDA Institute for Safe Medication Practices (ISMP) The Joint Commission

The nursing student realizes that she has given a patient a double dose of an antihypertensive medication. The tablet was supposed to be cut in half, but the student forgot and administered the entire tablet. The patients blood pressure just before the dose was 146/98 mm Hg. What should the student nurse do first?A. Notify the patients physicianB. Notify the clinical facultyC. Take the patients blood pressureD. Continue to monitor the patient

Medication Reconciliation: Continuous assessment and updating of patient medication information Verification; Clarification; Reconciliation Should be done at each stage of health care delivery: Admission Status change Patient transfer within or between facilities/provider teams Discharge

Ethical Issues Notification of patients Possible consequences for nurses

Chapter 6: Patient Education and Drug Therapy

The Domains of Learning Cognitive domain Affective domain Psychomotor domain

Patient Education: Assessment Adaptation to any illness Age Barriers to learning

Cognitive abilities Coping mechanisms Cultural background

Developmental status Education, including literacy level Emotional status

Information patient understands about past and present medical conditions Folk medicine, home remedies, alternative/complementary therapies Past and present experience with drug regimens and other therapies

Financial status Health literacy Psychosocial growth and development

Health beliefs Environment Language(s) spoken

Level of knowledge about current medications Current medications, including over-the-counter and herbal medications Limitations (physical, psychologic, cognitive, motor)

Nutritional status Mobility Motivation

Misinformation about drug therapy Past and present health behaviors Family relationships

Race and/or ethnicity Readiness to learn Religious beliefs

Self-care ability Sensory status Social support

The nurse is caring for an 85-year-old patient in the hospital and teaching him how to use an inhaler. His 84-year-old wife attends the teaching sessions, and their daughter comes in to visit in the evenings. The patient is having trouble remembering the steps. The nurse shouldA. provide the package insert that comes with the medication for the patient to read.B. focus the teaching sessions on the patients wife.C. provide small amounts of information at a time, repeating information frequently.D. wait until the daughter comes in and teach the daughter instead.

Patient Education: Nursing Diagnoses Deficient knowledge Impaired memory Ineffective self-health management Readiness for enhanced self-health management Noncompliance Risk for falls Risk for injury Sleep deprivation

A patient with newly diagnosed type 1 diabetes mellitus has completed a diabetes education program. One month later, the patient confesses at a follow-up appointment that he just didnt feel like giving himself the insulin injections. Which nursing diagnosis will the nurse assign the patient?A. Deficient knowledgeB. Noncompliance C. Impaired memoryD. Sleep deprivation

Patient Education: Planning Goals and Outcome Criteria Measurable Realistic Based on patient needs Stated in patient terms Time frame

Patient Education: Implementation Teaching-learning sessions Consideration of age-related changes Consideration of language barriers Safe administration of medications at home Return demonstration with equipment For adults, it is recommended that materials be written at an 8th grade level

A nurse is providing patient teaching for a community health center that serves a primarily Portuguese population. The nurse would best serve this patient population byA. learning Portuguese.B. always using interpreter services.C. using the family member interpreter the patient provides.D. finding a job in a different setting.

Patient Education: Evaluation Validate whether learning has occurred Ask questions Have the patient provide a return demonstration Behavior, such as compliance and adherence to a schedule Occurrence of few or no complications Develop and implement new plan of teaching as needed for: Noncompliance Inadequate levels of learning

After providing education regarding medications to a patient who has been newly diagnosed with type 2 diabetes mellitus, the nurse would use which part of the nursing process to assess whether the patient understands these new instructions?A. AssessmentB. DiagnosisC. ImplementationD. Evaluation