The Nursing Process and Drug Therapy by tqo12217

VIEWS: 0 PAGES: 113

									The Nursing Process
and Drug Therapy




Karen Ruffin RN, MSN Ed.
The Nursing   • An organizational
Process         framework for the
                practice of nursing
              • Orderly, systematic
              • Central to all nursing
                care
              • Encompasses all steps
                taken by the nurse in
                caring for a patient
              • Flexibility is important
The Nursing
Process (cont'd)
                   • Assessment
                   • Nursing diagnosis
                   • Planning (with outcome
                     criteria)
                   • Implementation
                   • Evaluation
The Nursing        Assessment
Process (cont'd)
                   • Data collection
                       – Subjective, objective
                       – Data collected on the patient,
                         drug, environment
                   •   Medication history
                   •   Nursing assessment
                   •   Physical assessment
                   •   Data analysis
The Nursing        Nursing diagnosis
Process (cont'd)
                   • Judgment or conclusion
                     about the
                     need/problem (actual
                     or at risk for) of the
                     patient
                   • Based upon an accurate
                     assessment
                   • NANDA format
The Nursing        Planning
Process (cont'd)
                   • Identification of goals
                     and outcome criteria
                   • Prioritization
                   • Time frame
The Nursing        Goals
Process (cont'd)
                   • Objective, measurable,
                    realistic
                   • Time frame specified
                   Outcome criteria
                   • Specific standard(s) of
                    measure
                   • Patient oriented
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
The “Five
Rights”
•   Right drug
•   Right dose
•   Right time
•   Right route
•   Right patient
Another “Right”—Constant
    System Analysis
         • A ―double-check‖
         • The entire ―system‖ of
           medication
           administration
         • Ordering, dispensing,
           preparing, administering,
           documenting
         • Involves the physician,
           nurse, nursing unit,
           pharmacy department,
           and patient education
Other “Rights”   • Proper drug storage
                 • Proper documentation
                 • Accurate dosage
                   calculation
                 • Accurate dosage
                   preparation
                 • Careful checking of
                   transcription of orders
                 • Patient safety
Other “Rights”   • Close consideration of
(cont'd)           special situations
                 • Prevention and
                   reporting of medication
                   errors
                 • Patient teaching
                 • Monitoring for
                   therapeutic effects, side
                   effects, toxic effects
                 • Refusal of medication
Evaluation   • Ongoing part of the
               nursing process
             • Determining the status
               of the goals and
               outcomes of care
             • Monitoring the
               patient’s response to
               drug therapy
               – Expected and
                 unexpected responses
Pharmacologic
  Principles
             Chemical name
Drug Names   • 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)
             Chemical name
Drug Names   • (+/-)-2-(p-isobutylphenyl)
(cont'd)       propionic acid

             Generic name
             • ibuprofen

             Trade name
             • Motrin®, Advil®
Figure 2-1 The chemical,
generic, and trade names
for the common
analgesic ibuprofen are
listed next to the
chemical structure of the
drug.
Pharmacologic   •   Pharmaceutics
Principles      •   Pharmacokinetics
                •   Pharmacodynamics
                •   Pharmacotherapeutics
                •   Pharmacognosy
Pharmaceutics   The study of how various
                drug forms influence
                pharmacokinetic and
                pharmacodynamic activities
Pharmacokinetics   • The study of what the
                    body does to the drug
                     – Absorption
                     – Distribution
                     – Metabolism
                     – Excretion
Pharmacodynamics

                   • The study of what the
                    drug does to the body
                     – The mechanism of drug
                       actions in living tissues
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.)
Pharmacotherapeutics




                       The use of drugs and the
                       clinical indications for
                       drugs to prevent and
                       treat diseases
Pharmacognosy   The study of natural
                (plant and animal) drug
                sources
Pharmacokinetics: Absorption

                   • The rate at which a
                     drug leaves its site of
                     administration, and the
                     extent to which
                     absorption occurs
                     – Bioavailability
                     – Bioequivalent
Factors That
Affect Absorption
                    • Administration route of the
                      drug
                    • Food or fluids
                      administered with the drug
                    • Dosage formulation
                    • Status of the absorptive
                      surface
                    • Rate of blood flow to the
                      small intestine
                    • Acidity of the stomach
                    • Status of GI motility
Routes   • A drug’s route of
           administration affects
           the rate and extent of
           absorption of that drug
           – Enteral (GI tract)
           – Parenteral
           – Topical
Enteral Route   • Drug is absorbed into
                  the systemic circulation
                  through the oral or
                  gastric mucosa, the
                  small intestine, or
                  rectum
                  – Oral
                  – Sublingual
                  – Buccal
                  – Rectal
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
Figure 2-3 First-pass effect is the
metabolism of a drug by the liver before
its systemic availability
Box 2-1 Drug Routes and First-Pass Effects
Parenteral Route   • Intravenous (fastest
                     delivery into the blood
                     circulation)
                   • Intramuscular
                   • Subcutaneous
                   • Intradermal
                   • Intrathecal
                   • Intraarticular
Topical Route   • Skin (including
                  transdermal patches)
                • Eyes
                • Ears
                • Nose
                • Lungs (inhalation)
                • Vagina
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
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)
                •   Kidneys
                •   Lungs
                •   Plasma
                •   Intestinal mucosa
Metabolism/Biotransformation
(cont'd)
                  Delayed drug metabolism
                   results in:
                  • Accumulation of drugs
                  • Prolonged action of the
                    drugs
                  Stimulating drug
                    metabolism causes:
                  • Diminished pharmacologic
                    effects
Excretion   The elimination of drugs
             from the body
            • Kidneys (main organ)
            • Liver
            • Bowel
              – Biliary excretion
              – Enterohepatic circulation
Half-life   • The time it takes for one
              half of the original amount
              of a drug in the body to be
              removed
            • A measure of the rate at
              which drugs are removed
              from the body
Onset, Peak, and
Duration
                   Onset
                   • The time it takes for the drug
                     to elicit a
                     therapeutic response
                   Peak
                   • The time it takes for a drug
                     to reach its maximum
                     therapeutic response
                   Duration
                   • The time a drug
                     concentration is sufficient to
                     elicit a therapeutic response
The Movement of Drugs Through
the Body
              Drug actions
              • The cellular processes
                involved in the drug and
                cell interaction
              Drug effect
              • The physiologic reaction of
                the body to the drug
Ways Drugs Produce Therapeutic
Effects       • Once the drug is at the
                    site of action, it can
                    modify the rate
                    (increase or decrease) at
                    which the cells or
                    tissues function
                  • A drug cannot make a
                    cell or tissue perform a
                    function it was not
                    designed to perform
Figure 2-7 A, Drugs act by forming a chemical bond
with specific receptor sites, similar to a key and lock.
B, The better the ―fit,‖ the better the response. Those
with complete attachment and response are called
agonists. C, Drugs that attach but do not elicit a
response are called antagonists. D, Drugs that attach,
elicit a small response, and also block other
responses are called partial agonists or agonist-
antagonists. (From Clayton BD, Stock YN: Basic
pharmacology for nurses, ed 13, St. Louis, 2004,
Mosby.)
Pharmacotherapeutics: Types of
Therapies
              •   Acute therapy
              •   Maintenance therapy
              •   Supplemental therapy
              •   Palliative therapy
              •   Supportive therapy
              •   Prophylactic therapy
              •   Empiric therapy
Monitoring   • The effectiveness of the
               drug therapy must be
               evaluated
             • One must be familiar
               with the drug’s:
               – Intended therapeutic
                 action (beneficial)
               – Unintended but
                 potential side effects
                 (predictable, adverse
                 reactions)
Monitoring   • Therapeutic index
(cont'd)       – The ratio between a
               drug’s therapeutic
               benefits and its toxic
               effects
Monitoring   • Tolerance
(cont'd)         – A decreasing response
             to repetitive drug doses
Monitoring   • Dependence
(cont'd)      – A physiologic or
                psychological need for a
                drug
Monitoring   Interactions may occur
(cont'd)     with other drugs or food
             • Drug interactions: the
             alteration of action of
               a drug by:
                – Other prescribed drugs
                – Over-the-counter
                  medications
                – Herbal therapies
Monitoring   • Drug interactions
(cont'd)      – Additive effect
              – Synergistic effect
              – Antagonistic effect
              – Incompatibility
Monitoring   • Medication
(cont'd)       misadventures
               – Adverse drug events
               – Adverse drug reactions
               – Medication errors
Monitoring     Some adverse drug
(cont'd)       reactions are classified
               as side effects
             • Expected, well-known
               reactions that result in little
               or no change in patient
               management
             • Predictable frequency
             • The effect’s intensity and
               occurrence are related to
               the size of the dose
Adverse Drug       An adverse outcome of
Reaction           drug therapy in which
                   a patient is harmed in
                   some way
               •   Pharmacologic reactions
               •   Idiosyncratic reactions
               •   Hypersensitivity reactions
               •   Drug interactions
Other Drug-       • Teratogenic
Related Effects   • Mutagenic
                  • Carcinogenic
Toxicology   The study of poisons
             and unwanted
             responses to
             therapeutic agents
Table 2-9 Common
Poisons and Antidotes
Life Span
Considerations
Life Span        •   Pregnancy
Considerations   •   Breast-feeding
                 •   Neonatal
                 •   Pediatric
                 •   Geriatric
Pregnancy   • First trimester is the
              period of greatest
              danger for drug-
              induced developmental
              defects
            • Drugs diffuse across the
              placenta
            • FDA pregnancy safety
              categories
Table 3-1
Pregnancy safety
categories
Breast-feeding   • Breast-fed infants are at
                   risk for exposure to
                   drugs consumed by the
                   mother
                 • Consider risk-to-benefit
                   ratio
Table 3-2 Classification of
young patients
Pediatric Considerations:
Pharmacokinetics
                • Absorption
                  – Gastric pH less acidic
                  – Gastric emptying is
                    slowed
                  – Topical absorption faster
                    through the skin
                  – Intramuscular
                    absorption faster and
                    irregular
Pediatric Considerations:
Pharmacokinetics (cont'd)
              • Distribution
                – TBW 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 blood-brain
                  barrier
Pediatric Considerations:
Pharmacokinetics (cont'd)
               • Metabolism
                 – Liver immature, does
                   not produce enough
                   microsomal enzymes
                 – Older children may have
                   increased metabolism,
                   requiring higher doses
                 – Other factors
Pediatric Considerations:
Pharmacokinetics (cont'd)

                • Excretion
                  – Kidney immaturity
                    affects glomerular
                    filtration rate and
                    tubular secretion
                  – Decreased perfusion rate
                    of the kidneys
Summary of Pediatric
Considerations
                  • Skin is thin and permeable
                  • Stomach lacks acid to kill
                    bacteria
                  • Lungs lack mucus barriers
                  • Body temperatures poorly
                    regulated and dehydration
                    occurs easily
                  • Liver and kidneys are
                    immature, impairing drug
                    metabolism and excretion
Methods of Dosage Calculation
for Pediatric Patients
                   • Body weight dosage
                     calculations

                   • Body surface area
                     method
Geriatric        • Geriatric: older than
Considerations     age 65
                   – Healthy People 2010:
                     older than age 55
                 • Use of OTC
                   medications
                 • Polypharmacy
Table 3-4 Physiologic changes in the geriatric
                   patient
Geriatric Considerations:
Pharmacokinetics
               • Absorption
                 – Gastric pH less acidic
                 – Slowed gastric emptying
                 – Movement through GI
                   tract slower
                 – Reduced blood flow to the
                   GI tract
                 – Reduced absorptive
                   surface area due to
                   flattened intestinal villi
Geriatric Considerations:
Pharmacokinetics (cont'd)

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

               • Metabolism
                 – Aging liver produces
                   less microsomal
                   enzymes, affecting drug
                   metabolism
                 – Reduced blood flow to
                   the liver
Geriatric Considerations:
Pharmacokinetics (cont'd)
               • Excretion
                 – Decreased glomerular
                   filtration rate
                 – Decreased number of
                   intact nephrons
Geriatric Considerations: Problematic
Medications
                  • Analgesics
                  • Anticoagulants
                  • Anticholinergics
                  • Antihypertensives
                  • Digoxin
                  • Sedatives and
                    hypnotics
                  • Thiazide diuretics
Legal, Ethical,
and Cultural
Considerations
U.S. Drug     • 1906: Federal Food and
Legislation     Drug Act
              • 1912: Sherley
                Amendment (to the
                Federal Food and Drug
                Act of 1906)
              • 1914: Harrison Narcotic
                Act
              • 1938: Federal Food,
                Drug, and Cosmetic Act
                (revision of 1906 Act)
U.S. Drug
Legislation (cont'd)
                       • 1951: Durham-
                         Humphrey
                         Amendment (to the
                         1938 act)
                       • 1962: Kefauver-Harris
                         Amendment (to the
                         1938 act)
                       • 1970: Controlled
                         Substance Act
U.S. Drug
Legislation (cont'd)
                       • 1983: Orphan Drug Act

                       • 1991: Accelerated drug
                         approval
Table 4-1 Controlled substances: schedule
               categories
Table 4-2 Controlled substances: categories,
  dispensing restrictions, and examples
New Drug      • Investigational new
Development     drug (IND) application
              • Informed consent
              • 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
Ethical Nursing   • American Nurses
Practice            Association (ANA)
                    Code of Ethics for
                    Nurses
Cultural
Considerations
                 • Assess the influence of a
                   patient’s cultural beliefs,
                   values, and customs
                 • Drug polymorphism
                 • Compliance level with
                   therapy
                 • Environmental
                   considerations
                 • Genetic factors
                 • Varying responses to
                   specific agents
Cultural     • Health beliefs and
Assessment     practices
             • Past uses of medicine
             • Folk remedies
             • Home remedies
             • Use of nonprescription
               drugs and herbal
               remedies
             • OTC treatments
Cultural
Assessment (cont'd)
                      • Usual response to
                        treatment
                      • Responsiveness to
                        medical treatment
                      • Religious practices and
                        beliefs
                      • Dietary habits
Medication
Errors:
Preventing
and
Responding
Medication      • Medication errors
Misadventures     (MEs)
                • Adverse drug events
                  (ADEs)
                • Adverse drug reactions
                  (ADRs)
Medication
Misadventures (cont'd)

                         • By definition, all ADRs
                           are also ADEs
                         • But all ADEs are not
                           ADRs
                         • Two types of ADRs
                           – Allergic reactions
                           – Idiosyncratic reactions
Medication Errors


                    • Preventable
                    • Common cause of
                      adverse health care
                      outcomes
                    • Effects can range from no
                      significant effect to
                      directly causing disability
                      or death
Box 5-1 Common classes of medications
       involved in serious errors
Preventing
Medication Errors

                    • Minimize verbal or
                      telephone orders
                      – Repeat order to prescriber
                      – Spell drug name aloud
                      – Speak slowly and clearly
                    • List indication next to
                      each order
                    • Avoid medical shorthand,
                      including abbreviations
                      and acronyms
Preventing
Medication Errors
(cont'd)
                    • Never assume anything
                      about items not specified in
                      a drug order (i.e., route)
                    • Do not hesitate to question
                      a medication order for any
                      reason when in doubt
                    • Do not try to decipher
                      illegibly written orders;
                      contact prescriber for
                      clarification
Preventing Medication
Errors (cont'd)
                        • NEVER use ―trailing
                          zeros‖ with medication
                          orders
                        • Do not use 1.0 mg; use
                          1 mg
                        • 1.0 mg could be
                          misread as 10 mg,
                          resulting in a tenfold
                          dose increase
Preventing
Medication Errors
(cont'd)            • ALWAYS use a
                      ―leading zero‖ for
                      decimal dosages
                    • Do not use .25 mg; use
                      0.25 mg
                    • .25 mg may be misread
                      as 25 mg
                    • ―.25‖ is sometimes
                      called a ―naked
                      decimal‖
Preventing Medication
Errors (cont'd)
                        • Check medication order
                          and what is available
                          while using the ―5 rights‖

                        • Take time to learn special
                          administration
                          techniques of certain
                          dosage forms
Preventing
Medication Errors
(cont'd)

                    • Always listen to and
                      honor any concerns
                      expressed by patients
                      regarding medications

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


                     • Check the ―5 rights‖
                     • Standard Precautions:
                       Wash your hands!
                     • Double-check if unsure
                       about anything
                     • Check for drug allergies
                     • Prepare drugs for one
                       patient at a time
                     • Check three times
Preparing for Drug
Administration
(cont'd)
                     • Check expiration dates
                     • Check the patient’s
                       identification
                     • Give medications on time
                     • Explain medications to the
                       patient
                     • Open the medications at
                       the bedside
                     • Document the medications
                       given before going to the
                       next patient
Enteral
Drugs     • Giving oral medications
          • Giving sublingual or buccal
            medications
          • Liquid medications
          • Giving oral medications to
            infants
          • Administering drugs
            through a nasogastric or
            gastrostomy tube
          • Rectal administration
Parenteral   • Never recap a used
               needle!
Drugs
             • May recap an unused
               needle with the ―scoop
               method‖

             • Prevention of
               needlesticks

             • Filter needles
Parenteral   • Removing medications
Drugs          from ampules
(cont'd)
             • Removing medications
               from vials

             • Disposal of used
               needles and syringes
             • Needle angles for
Injections     various injections
               – Intramuscular (IM)
               – Subcutaneous (SC or SQ)
               – Intradermal (ID)


             • Z-track method for IM
               injections

             • Air-lock technique
Injection    • Intradermal injections
Techniques
             • Subcutaneous injections
               – Insulin administration
               – Heparin administration
Injection    • Intramuscular
               injections
Techniques     – Ventrogluteal site
(cont'd)         (preferred)
               – Vastus lateralis site
               – Dorsogluteal site
               – Deltoid site
Preparing
Intravenous
Medications   • Needleless systems
              • Compatibility issues
              • Expiration dates
              • Mixing intravenous
                piggyback (IVPB)
                medications
              • Labeling intravenous (IV)
                infusion bags when
                adding medications
Intravenous
Medications   • Adding medications to a
                primary infusion bag

              • IVPB medications
                (secondary line)

              • IV push medications
                (bolus)
                – Through an IV lock
                – Through an existing IV
                  infusion
Intravenous
Medications
(cont'd)      • Volume-controlled
                administration set

              • Using electronic
                infusion pumps

              • Patient-controlled
                analgesia (PCA) pumps
Topical
Drugs
          • Eye medications
            – Drops
            – Ointments


          • Ear drops
            – Adults
            – Infant or child younger
              than 3 years of age
Topical    • Nasal drugs
             – Drops
Drugs
             – Spray
(cont'd)
           • Inhaled drugs
             – Metered-dose inhalers
             – Small-volume nebulizers
Topical    • Administering
             medications to the skin
Drugs        – Lotions, creams,
(cont'd)       ointments, powders
             – Transdermal patches


           • Vaginal medications
             – Creams, foams, gels
             – Suppositories

								
To top