1. The Nursing Process and Drug Therapy Barbara A. Kunkel, RN, MSN Office: MS 119 Phone: 609-731-4368 Office Hours: Monday & Thursday 11a-12n; 3:30-5p; 8p-8:30p

2. The Nursing Process (cont'd) Assessment Assessment Nursing diagnosis Nursing diagnosis Planning (with outcome criteria) Planning (with outcome criteria) Implementation Implementation Evaluation Evaluation

3. The “Six Rights” Right drug Right drug Right dose Right dose Right time Right time Right route Right route Right patient Right patient Right documentation Right documentation

4. Another “Right”—Constant System Analysis A “double-check” A “double-check” The entire “system” of medication administration The entire “system” of medication administration Ordering, dispensing, preparing, administering, documenting Ordering, dispensing, preparing, administering, documenting Involves the physician, nurse, nursing unit, pharmacy department, and patient education Involves the physician, nurse, nursing unit, pharmacy department, and patient education

5. Other “Rights” Proper circumstance Proper circumstance Proper drug storage Proper drug storage Accurate dosage calculation Accurate dosage calculation Accurate dosage preparation Accurate dosage preparation Careful checking of transcription of orders Careful checking of transcription of orders Patient safety Patient safety

6. Other “Rights” (cont'd) Close consideration of special situations Close consideration of special situations Prevention and reporting of medication errors Prevention and reporting of medication errors Patient teaching Patient teaching Monitoring for therapeutic effects, side effects, toxic effects Monitoring for therapeutic effects, side effects, toxic effects Refusal of medication Refusal of medication

7. Evaluation Ongoing part of the nursing process Ongoing part of the nursing process Determining the status of the goals and outcomes of care Determining the status of the goals and outcomes of care Monitoring the patient’s response to drug therapy Monitoring the patient’s response to drug therapy – Expected and unexpected responses

8. Pharmacologic Principles

9. Drug Names Chemical name Describes the drug’s chemical composition and molecular structure Describes the drug’s chemical composition and molecular structure Generic name (nonproprietary name) Name given by the United States Adopted Name Council 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) The drug has a registered trademark; use of the name restricted by the drug’s patent owner (usually the manufacturer)

10. Drug Names (cont'd) Chemical name (+/-)-2-(p-isobutylphenyl) propionic acid (+/-)-2-(p-isobutylphenyl) propionic acid Generic name ibuprofen ibuprofen Trade name Motrin®, Advil® Motrin®, Advil®

11. Figure 2-1 The chemical, generic, and trade names for the common analgesic ibuprofen are listed next to the chemical structure of the drug.

12. Pharmacologic Principles Pharmaceutics Pharmaceutics Pharmacokinetics Pharmacokinetics Pharmacodynamics Pharmacodynamics Pharmacotherapeutics Pharmacotherapeutics Pharmacognosy Pharmacognosy

13. Pharmaceutics The study of how various drug forms influence pharmacokinetic and pharmacodynamic activities

14. Pharmacokinetics The study of what the body does to the drug – Absorption – Distribution – Metabolism – Excretion

15. Pharmacodynamics The study of what the drug does to the body The study of what the drug does to the body – The mechanism of drug actions in living tissues

16. Pharmacokinetics: Absorption The rate at which a drug leaves its site of administration, and the extent to which absorption occurs The rate at which a drug leaves its site of administration, and the extent to which absorption occurs – Bioavailability – Bioequivalent

17. Factors That Affect Absorption Administration route of the drug Administration route of the drug Food or fluids administered with the drug Food or fluids administered with the drug Dosage formulation Dosage formulation Status of the absorptive surface Status of the absorptive surface Rate of blood flow to the small intestine Rate of blood flow to the small intestine Acidity of the stomach Acidity of the stomach Status of GI motility Status of GI motility

18. Routes A drug’s route of administration affects the rate and extent of absorption of that drug A drug’s route of administration affects the rate and extent of absorption of that drug – Enteral (GI tract) – Parenteral – Topical

19. First-Pass Effect The metabolism of a drug and its passage from the liver into the circulation 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

20. Figure 2-3 First-pass effect is the metabolism of a drug by the liver before its systemic availability

21. Box 2-1 Drug Routes and First-Pass Effects

22. Metabolism (Also Known As Biotransformation) The biologic transformation of a drug into an inactive metabolite, a more soluble compound, or a more potent metabolite Liver (main organ) Liver (main organ) Kidneys Kidneys Lungs Lungs Plasma Plasma Intestinal mucosa Intestinal mucosa

23. Metabolism/Biotransformation (cont'd) Delayed drug metabolism results in: Accumulation of drugs Accumulation of drugs Prolonged action of the drugs Prolonged action of the drugs Stimulating drug metabolism causes: Diminished pharmacologic effects Diminished pharmacologic effects

24. Excretion The elimination of drugs from the body Kidneys (main organ) Kidneys (main organ) Liver Liver Bowel Bowel – Biliary excretion – Enterohepatic circulation

25. Half-life The time it takes for one half of the original amount of a drug in the body to be removed 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 A measure of the rate at which drugs are removed from the body

26. Onset, Peak, and Duration Onset The time it takes for the drug to elicit a therapeutic response 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 The time it takes for a drug to reach its maximum therapeutic responseDuration The time a drug concentration is sufficient to elicit a therapeutic response The time a drug concentration is sufficient to elicit a therapeutic response

27. The Movement of Drugs Through the Body Drug actions The cellular processes involved in the drug and cell interaction The cellular processes involved in the drug and cell interaction Drug effect The physiologic reaction of the body to the drug The physiologic reaction of the body to the drug

28. 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 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 A drug cannot make a cell or tissue perform a function it was not designed to perform

29. Figure 2-7 A, Drugs act by forming a chemical bond with specific receptor sites, similar to a key and lock. B, The better the “fit,” the better the response. Those with complete attachment and response are called agonists. C, Drugs that attach but do not elicit a response are called antagonists. D, Drugs that attach, elicit a small response, and also block other responses are called partial agonists or agonist-antagonists. ( From Clayton BD, Stock YN : Basic pharmacology for nurses, ed 13, St. Louis, 2004, Mosby.)

30. Pharmacotherapeutics: Types of Therapies Acute therapy Acute therapy Maintenance therapy Maintenance therapy Supplemental therapy Supplemental therapy Palliative therapy Palliative therapy Supportive therapy Supportive therapy Prophylactic therapy Prophylactic therapy Empiric therapy Empiric therapy

31. Monitoring The effectiveness of the drug therapy must be evaluated The effectiveness of the drug therapy must be evaluated One must be familiar with the drug’s: One must be familiar with the drug’s: – Intended therapeutic action (beneficial) – Unintended but potential side effects (predictable, adverse reactions)

32. Other Drug- Related Effects Teratogenic Teratogenic Mutagenic Mutagenic Carcinogenic Carcinogenic

33. Toxicology The study of poisons and unwanted responses to therapeutic agents

34. Table 2-9 Common Poisons and Antidotes

35. Life Span Considerations

36. Pregnancy Pregnancy Breast-feeding Breast-feeding Neonatal Neonatal Pediatric Pediatric Geriatric Geriatric

37. Pregnancy First trimester is the period of greatest danger for drug- induced developmental defects First trimester is the period of greatest danger for drug- induced developmental defects Drugs diffuse across the placenta Drugs diffuse across the placenta FDA pregnancy safety categories FDA pregnancy safety categories

38. Table 3-1 Pregnancy safety categories

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

40. Table 3-2 Classification of young patients

41. Pediatric Considerations: Pharmacokinetics Absorption Absorption – Gastric pH less acidic – Gastric emptying is slowed – Topical absorption faster through the skin – Intramuscular absorption faster and irregular

42. Pediatric Considerations: Pharmacokinetics (cont'd) Distribution Distribution – TBW (total body water) 70% to 80% in full-term infants, 85% in premature newborns, 64% in children 1 to 12 years of age – Greater TBW means fat content is lower – Decreased level of protein binding – immature liver – Immature blood-brain barrier

43. Pediatric Considerations: Pharmacokinetics (cont'd) Metabolism Metabolism – Liver immature, does not produce enough microsomal enzymes – Older children may have increased metabolism, requiring higher doses – Other factors

44. Pediatric Considerations: Pharmacokinetics (cont'd) Excretion Excretion – Kidney immaturity affects glomerular filtration rate and tubular secretion – Decreased perfusion rate of the kidneys

45. Summary of Pediatric Considerations Skin is thin and permeable Skin is thin and permeable Stomach lacks acid to kill bacteria Stomach lacks acid to kill bacteria Lungs lack mucus barriers Lungs lack mucus barriers Body temperatures poorly regulated and dehydration occurs easily Body temperatures poorly regulated and dehydration occurs easily Liver and kidneys are immature, impairing drug metabolism and excretion Liver and kidneys are immature, impairing drug metabolism and excretion

46. Methods of Dosage Calculation for Pediatric Patients Body weight dosage calculations Body weight dosage calculations Body surface area method Body surface area method

47. Geriatric Considerations Geriatric: older than age 65 Geriatric: older than age 65 – Healthy People 2010: older than age 55 Use of OTC medications Use of OTC medications Polypharmacy Polypharmacy

48. Table 3-4 Physiologic changes in the geriatric patient

49. Geriatric Considerations: Pharmacokinetics Absorption 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

50. Geriatric Considerations: Pharmacokinetics (cont'd) Distribution Distribution – TBW percentages lower – Fat content increased – Decreased production of proteins by the liver, resulting in decreased protein binding of drugs

51. Geriatric Considerations: Pharmacokinetics (cont'd) Metabolism Metabolism – Aging liver produces less microsomal enzymes, affecting drug metabolism – Reduced blood flow to the liver

52. Geriatric Considerations: Pharmacokinetics (cont'd) Excretion Excretion – Decreased glomerular filtration rate – Decreased number of intact nephrons

53. Geriatric Considerations: Problematic Medications Analgesics Analgesics Anticoagulants Anticoagulants Anticholinergics Anticholinergics Antihypertensives Antihypertensives Digoxin Digoxin Sedatives and hypnotics Sedatives and hypnotics Thiazide diuretics Thiazide diuretics

54. Legal, Ethical, and Cultural Considerations

55. U.S. Drug Legislation 1906: Federal Food and Drug Act 1906: Federal Food and Drug Act 1912: Sherley Amendment (to the Federal Food and Drug Act of 1906) 1912: Sherley Amendment (to the Federal Food and Drug Act of 1906) 1914: Harrison Narcotic Act 1914: Harrison Narcotic Act 1938: Federal Food, Drug, and Cosmetic Act (revision of 1906 Act) 1938: Federal Food, Drug, and Cosmetic Act (revision of 1906 Act)

56. U.S. Drug Legislation (cont'd) 1951: Durham- Humphrey Amendment (to the 1938 act) 1951: Durham- Humphrey Amendment (to the 1938 act) 1962: Kefauver-Harris Amendment (to the 1938 act) 1962: Kefauver-Harris Amendment (to the 1938 act) 1 970: Controlled Substance Act 1 970: Controlled Substance Act

57. U.S. Drug Legislation (cont'd) 1983: Orphan Drug Act 1983: Orphan Drug Act 1991: Accelerated drug approval 1991: Accelerated drug approval

58. Table 4-1 Controlled substances: schedule categories

59. Table 4-2 Controlled substances: categories, dispensing restrictions, and examples

60. New Drug Development Investigational new drug (IND) application Investigational new drug (IND) application Informed consent Informed consent Investigational drug studies Investigational drug studies Expedited drug approval Expedited drug approval

61. Ethical Nursing Practice American Nurses Association (ANA) Code of Ethics for Nurses American Nurses Association (ANA) Code of Ethics for NursesProvisions: Commitment Commitment Advocacy Advocacy Responsibility/Accountability Responsibility/Accountability Duty to self and others Duty to self and others Integrity Integrity Practice, education, administration & knowledge Practice, education, administration & knowledge Collaboration – professional team Collaboration – professional team Professional Associations – articulate nursing values, maintaining integrity of the profession & practice, shaping social policy Professional Associations – articulate nursing values, maintaining integrity of the profession & practice, shaping social policy

62. Cultural Considerations Assess the influence of a patient’s cultural beliefs, values, and customs Assess the influence of a patient’s cultural beliefs, values, and customs Drug polymorphism – cultural safety Drug polymorphism – cultural safety Compliance level with therapy Compliance level with therapy Environmental considerations Environmental considerations Genetic factors Genetic factors Varying responses to specific agents Varying responses to specific agents

63. Cultural Assessment Health beliefs and practices Health beliefs and practices Past uses of medicine Past uses of medicine Folk remedies Folk remedies Home remedies Home remedies Use of nonprescription drugs and herbal remedies Use of nonprescription drugs and herbal remedies OTC treatments OTC treatments

64. Cultural Assessment (cont'd) Usual response to treatment Usual response to treatment Responsiveness to medical treatment Responsiveness to medical treatment Religious practices and beliefs Religious practices and beliefs Dietary habits Dietary habits

65. Medication Errors: Preventing and Responding

66. Medication Misadventures Medication errors (MEs) Medication errors (MEs) Adverse drug events (ADEs) Adverse drug events (ADEs) Adverse drug reactions (ADRs) Adverse drug reactions (ADRs)

67. Medication Misadventures (cont'd) By definition, all ADRs are also ADEs By definition, all ADRs are also ADEs But all ADEs are not ADRs But all ADEs are not ADRs Two types of ADRs Two types of ADRs – Allergic reactions – Idiosyncratic reactions

68. Medication Errors Preventable Preventable Common cause of adverse health care outcomes Common cause of adverse health care outcomes Effects can range from no significant effect to directly causing disability or death Effects can range from no significant effect to directly causing disability or death

69. Box 5-1 Common classes of medications involved in serious errors

70. Preventing Medication Errors Minimize verbal or telephone orders Minimize verbal or telephone orders – Repeat order to prescriber – Spell drug name aloud – Speak slowly and clearly List indication next to each order List indication next to each order Avoid medical shorthand, including abbreviations and acronyms Avoid medical shorthand, including abbreviations and acronyms

71. Preventing Medication Errors (cont'd) Never assume anything about items not specified in a drug order (i.e., route) Never assume anything about items not specified in a drug order (i.e., route) Do not hesitate to question a medication order for any reason when in doubt Do not hesitate to question a medication order for any reason when in doubt Do not try to decipher illegibly written orders; contact prescriber for clarification Do not try to decipher illegibly written orders; contact prescriber for clarification

72. Preventing Medication Errors (cont'd) NEVER use “trailing zeros” with medication orders NEVER use “trailing zeros” with medication orders Do not use 1.0 mg; use 1 mg Do not use 1.0 mg; use 1 mg 1.0 mg could be misread as 10 mg, resulting in a tenfold dose increase 1.0 mg could be misread as 10 mg, resulting in a tenfold dose increase

73. Preventing Medication Errors (cont'd) ALWAYS use a “leading zero” for decimal dosages ALWAYS use a “leading zero” for decimal dosages Do not use.25 mg; use 0.25 mg Do not use.25 mg; use 0.25 mg.25 mg may be misread as 25 mg.25 mg may be misread as 25 mg “.25” is sometimes called a “naked decimal” “.25” is sometimes called a “naked decimal”

74. Preventing Medication Errors (cont'd) Check medication order and what is available while using the “6 rights” Check medication order and what is available while using the “6 rights” Take time to learn special administration techniques of certain dosage forms Take time to learn special administration techniques of certain dosage forms

75. Preventing Medication Errors (cont'd) Always listen to and honor any concerns expressed by patients regarding medications Always listen to and honor any concerns expressed by patients regarding medications Check patient allergies and identification Check patient allergies and identification

76. Medication Errors Possible consequences to nurses Possible consequences to nurses Reporting and responding to MEs Reporting and responding to MEs – ADE monitoring programs – USPMERP (United States Pharmacopeia Medication Errors Reporting Program) – MedWatch, sponsored by the FDA – Institute for Safe Medication Practices (ISMP) Notification of patient regarding MEs Notification of patient regarding MEs

77. Medication Reconciliation Process to prevent medication errors: Process to prevent medication errors: – 1. Verification – 2. Clarification. – 3. Reconciliation Performed: Performed: – Admission – Status change – Transfer – Discharge Pt Assessment Pt Assessment – Open-ended questions – Avoid medical jargon – Clarify – Current & complete medication list

78. Drug Administration

79. Preparing for Drug Administration Check the “6 rights” Check the “6 rights” Standard Precautions: Wash your hands! Standard Precautions: Wash your hands! Double-check if unsure about anything Double-check if unsure about anything Check for drug allergies Check for drug allergies Prepare drugs for one patient at a time Prepare drugs for one patient at a time Check three times Check three times