1. CHAPTER 1 The Nursing Process and Drug Therapy

2. Learning Objectives 1. List the five phases of the nursing process.
2. Identify the components of the assessment process for patients receiving medications, including collection and analysis of subjective and objective data.
3. Discuss the process of formulating nursing diagnoses for patients receiving medications.
4. Identify goals and outcome criteria for patients receiving medications.

3. Learning Objectives
5. Discuss the evaluation process as it relates to the administration of medications and as reflected by goals and outcome criteria.
6. Develop a nursing care plan with use of the nursing process as it is related to medication administration.
7. Briefly discuss the Five Rights of drug administration and the related professional responsibility for safe medication practice.
8. Discuss the additional rights of drug administration that are ensured in safe medication practice.

4. The Nursing Process
A research-based organizational framework for professional nursing practice
Central to all nursing care
Encompasses all steps taken by the nurse in caring for a patient
Flexibility is important
Critical thinking
Ongoing and constantly evolving process
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5. The Nursing Process (cont’d)
Assessment
Nursing diagnosis
Planning
Goals
Outcome criteria
Implementation
Evaluation
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6. The Nursing Process (cont’d)
Assessment
Data collection
Subjective, objective
Medication history
Prescriptions
OTCs
Herbals
Responses to medications (therapeutic and adverse responses)
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7. The Nursing Process (cont’d)
Nursing diagnosis
Decision about the need/problem (actual or at risk for) of the patient
Critical thinking, creativity, and accurate data collection
NANDA format
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8. The Nursing Process (cont’d)
Nursing diagnosis
Decision about the need/problem (actual or at risk for) of the patient
Critical thinking, creativity, and accurate data collection
NANDA format
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9. The Nursing Process (cont’d)
Nursing diagnosis
Three steps
Human response to illness (actual or risk)
“related to”
“as evidenced by”
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10. The Nursing Process (cont’d)
Planning
Identification of goals and outcome criteria
Must be specific and measurable
Must be patient-centered
Time frame
Prioritization
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11. The Nursing Process (cont’d)
Goals
Objective, measurable, realistic
Time frame specified
Outcome criteria
Specific standard(s) of measure
Patient oriented
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12. The Nursing Process (cont’d)
Implementation
Initiation and completion of the nursing care plan as defined by the nursing diagnoses and outcome criteria
Follow the “Five Rights” of medication administration
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13. The Five Rights of Medication Administration
Right drug
Right dose
Right time
Right route
Right patient
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14. 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
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15. Other “Rights” Proper drug storage Proper documentation
Accurate dosage calculation
Accurate dosage preparation
Careful checking of transcription of orders
Patient safety
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16. Other “Rights” (cont’d)
Close consideration of special situations
Prevention and reporting of medication errors
Patient teaching
Monitoring for therapeutic effects, adverse effects, toxic effects
Refusal of medication
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17. Six Elements of a Drug Order
1. Patient's name
2. Date order is written
3. Name of medication
4. Dosage (includes size, frequency, and number of doses)
5. Route of delivery
6. Signature of the prescriber
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18. 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
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19. CHAPTER 2 Pharmacologic Principles
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20. Learning Objectives
1. Define the common terms used in pharmacology (see the listing of terms in the Glossary).
2. Understand the role of pharmaceutics, pharmacokinetics, and pharmacodynamics in medication administration and the application of the nursing process.
3. Discuss the application of the four principles of pharmacotherapeutics to everyday nursing practice as they relate to drug therapy for a variety of patients in different health care settings.

21. Learning Objectives
4. Discuss the use of natural drug sources in the development of new drugs.
5. Develop a nursing care plan that considers the phases of pharmacokinetics in carrying out drug therapy and the nursing process.

22. Drug
Any chemical that affects the physiologic processes of a living organism
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23. The study or science of drugs
Pharmacology
The study or science of drugs
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24. Drug Names Chemical name Generic name (nonproprietary 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)
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26. Pharmacologic Principles
Pharmaceutics
Pharmacokinetics
Pharmacodynamics
Pharmacotherapeutics
Pharmacognosy
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27. Pharmaceutics
The study of how various drug forms influence pharmacokinetic and pharmacodynamic activities
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28. Pharmacokinetics The study of what the body does to the drug
Absorption
Distribution
Metabolism
Excretion
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29. Pharmacodynamics The study of what the drug does to the body
The mechanism of drug actions in living tissues
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31. Pharmacotherapeutics
The use of drugs and the clinical indications for drugs to prevent and treat diseases
Empirical therapeutics
Rational therapeutics
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32. Pharmacognosy The study of natural (plant and animal) drug sources
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33. Pharmaceutics Dosage form design affects dissolution
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35. Pharmacokinetics: Absorption
The rate at which a drug leaves its site of administration, and the extent to which absorption occurs
Bioavailability
Bioequivalent
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36. Factors That Affect Absorption
Absorption characteristics vary according to the dosage form and route
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
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37. Routes
A drug’s route of administration affects the rate and extent of absorption of that drug
Enteral (GI tract)
Parenteral
Topical
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38. Enteral Route
Drug is absorbed into the systemic circulation through the oral or gastric mucosa or the small intestine
Oral
Sublingual
Buccal
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39. 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 first-pass effect)
– The same drug—given IV—bypasses the liver, preventing the first-pass effect from taking place, and more drug reaches the circulation
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40. First-Pass Effect and Box 2-1 (Drug Routes and First-Pass Effect)
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41. Parenteral Route
Intravenous (fastest delivery into the blood circulation)
Intramuscular
Subcutaneous
Intradermal
Intrathecal
Intraarticular
Transdermal can be considered parenteral, too
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42. Topical Route Skin (including transdermal patches) Eyes Ears Nose
Lungs (inhalation)
Rectum
Vagina
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43. Distribution
The transport of a drug in the body by the bloodstream to its site of action
Protein-binding
Water soluble vs. fat soluble
Blood-brain barrier
Areas of rapid distribution: heart, liver, kidneys, brain
Areas of slow distribution: muscle, skin, fat
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44. Metabolism (Also Known as Biotransformation)
The biochemical transformation of a drug into an inactive metabolite, a more soluble compound, or a more potent metabolite
Liver (main organ)
Skeletal muscle
Kidneys
Lungs
Plasma
Intestinal mucosa
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46. Metabolism/Biotransformation
Biologic transformation of a drug into:
An inactive metabolite
A more soluble compound
A more potent metabolite
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47. Metabolism/Biotransformation (cont’d)
Organs or body tissues
Liver (main)
Skeletal muscle
Kidneys
Lungs
Plasma
Intestinal mucosa

48. Metabolism/Biotransformation (cont’d)
Factors that decrease metabolism
Cardiovascular dysfunction
Renal insufficiency
Starvation
Obstructive jaundice
Slow acetylator
Erythromycin or ketoconazole drug therapy
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49. Metabolism/Biotransformation (cont’d)
Factors that increase metabolism
Fast acetylator
Barbiturate therapy
Rifampin therapy
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50. Metabolism/Biotransformation (cont’d)
Delayed drug metabolism results in:
Accumulation of drugs
Prolonged action of the drugs
Stimulating drug metabolism causes:
Diminished pharmacologic effects
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51. Metabolism/Biotransformation (cont’d)
Cytochrome P-450 enzymes
Also known as microsomal enzymes
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52. Excretion The elimination of drugs from the body Kidneys (main organ)
Liver
Bowel
Biliary excretion
Enterohepatic recirculation
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54. 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
Most drugs are considered to be effectively removed after about five half-lives
Steady state
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55. 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
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56. Onset, Peak, and Duration
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
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58. Therapeutic Drug Monitoring
Peak Level
Highest blood level
Trough Level
Lowest blood level
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59. 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
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60. Pharmacodynamics: Mechanisms of Action
Receptor interactions
Enzyme interactions
Nonspecific interactions
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63. Pharmacotherapeutics: Types of Therapies
Acute therapy
Maintenance therapy
Supplemental/replacement therapy
Palliative therapy
Supportive therapy
Prophylactic therapy
Empiric therapy
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64. Contraindication
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!
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65. 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 adverse effects (predictable, adverse reactions)
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66. Monitoring (cont’d) Therapeutic index Drug concentration
Patient’s condition
Tolerance and dependence
Interactions
Adverse drug effects
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67. Monitoring (cont’d) Therapeutic index
– The ratio between a drug’s therapeutic
benefits and its toxic effects
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68. Monitoring (cont’d) Tolerance
– A decreasing response to repeated drug doses
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69. Monitoring (cont’d) Dependence
A physiologic or psychological need for a drug
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70. Monitoring (cont’d) Interactions may occur with other drugs or food
Drug interactions: the alteration of action of a drug by:
Other prescribed drugs
Over-the-counter medications
Herbal therapies
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71. Monitoring (cont’d) Drug interactions Additive effect
Synergistic effect
Antagonistic effect
Incompatibility
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72. Monitoring (cont’d) Adverse Drug Events Adverse drug reactions
Medication errors
Adverse drug reactions
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73. Monitoring (cont’d) Adverse Drug Reactions
Pharmacologic reactions, including adverse effects
Hypersensitivity (allergic) reaction
Idiosyncratic reaction
Drug interaction
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74. Monitoring (cont’d) Adverse effects
Predictable, well-known reactions that result in little or no change in patient management
Predictable frequency
Occurrences are related to the size of the dose
Usually resolve when the drug is discontinued
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75. Other Drug-Related Effects
Teratogenic
Mutagenic
Carcinogenic
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76. Pharmacognosy Four main sources for drugs Plants Animals Minerals
Laboratory synthesis
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77. Toxicology
The study of poisons and unwanted responses to drugs and other chemicals
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79. CHAPTER 3 Life Span Considerations

80. Learning Objectives
1. Discuss the influences of the patient’s age on the effects of drugs and drug responses.
2. Identify drug-related concerns during pregnancy and lactation and provide an explanation of the physiologic basis for these concerns.
3. Discuss the process of pharmacokinetics and associated changes in various patient age groups, such as in pediatrics, pregnancy, and the elderly.

81. Learning Objectives
4. Summarize the impact of age-related changes on pharmacokinetics in drug therapy.
5. Calculate a drug dosage for a pediatric patient using a variety of formulas.
6. Identify the importance of a body surface area nomogram for pediatric patients.
7. Develop a nursing care plan for drug therapy and the nursing process for patients across the life span.

82. Life Span Considerations
Pregnancy
Breast-feeding
Neonatal and Pediatric
Elderly

83. Pregnancy
First trimester is the period of greatest danger for drug-induced developmental defects
Drugs cross the placenta by diffusion
During the last trimester the greatest percentage of maternally absorbed drug gets to the fetus
FDA pregnancy safety categories

85. Breast-feeding
Breast-fed infants are at risk for exposure to drugs consumed by the mother
Consider risk-to-benefit ratio

87. Neonatal and Pediatric Considerations: Pharmacokinetics
Absorption
Gastric pH less acidic
Gastric emptying is slowed
Intramuscular absorption faster and irregular

88. Neonatal and Pediatric Considerations: Pharmacokinetics (cont’d)
Distribution
The younger the person, the greater the % of total body water
Greater TBW means fat content is lower
Decreased level of protein binding
Immature blood-brain barrier—more drugs enter the brain

89. Neonatal and Pediatric Considerations: Pharmacokinetics (cont’d)
Metabolism
Liver immature, does not produce enough microsomal enzymes
Older children may have increased metabolism, requiring higher doses than infants
Other factors

90. Neonatal and Pediatric Considerations: Pharmacokinetics (cont’d)
Excretion
Kidney immaturity affects glomerular filtration rate and tubular secretion
Decreased perfusion rate of the kidneys may reduce excretion of drugs

91. 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 excretion

92. Methods of Dosage Calculation for Pediatric Patients
Body surface area method
Using the West nomogram
Body weight dosage calculations
Using mg/kg

94. Pediatric Considerations: Medication Administration
General interventions
Infants
Toddlers
Preschoolers
School-aged children
Adolescents

95. The Elderly Elderly: older than age 65 Use of OTC medications
Healthy People 2010: older than age 55
Use of OTC medications
Increased incidence of chronic illnesses
Polypharmacy

96. Physiologic Changes in the Elderly Patient
Cardiovascular
Gastrointestinal
Hepatic
Renal

98. The Elderly: 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

99. The Elderly: Pharmacokinetics (cont’d)
Distribution
TBW percentages lower
Fat content increased
Decreased production of proteins by the liver, resulting in decreased protein binding of drugs (and increased circulation of free drugs)

100. The Elderly: Pharmacokinetics (cont’d)
Metabolism
Aging liver produces fewer microsomal enzymes, affecting drug metabolism
Reduced blood flow to the liver

101. The Elderly: Pharmacokinetics (cont’d)
Excretion
Decreased glomerular filtration rate
Decreased number of intact nephrons

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