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Lilley, L. L., Collins, S. R., Harrington, S., & Snyder, J. S. (2014). Pharmacology & the Nursing Process, 7th ed. Elsevier

CHAPTER 1 THE NURSING PROCESS AND DRUG THERAPY


FIVE STEPS OF THE NURSING PROCESS • Assessment • Nursing diagnosis • Planning • Goals • Outcome criteria

• Implementation including patient education • Evaluation 2


ASSESSMENT (PP. 7) • Data collected, reviewed, and analyzed • Information come from patient; patient’s family, caregiver and patient’s chart • Medication profile Any and all drug use Prescriptions Over-the-counter medications Vitamins, herbs, and supplements Alcohol, street drugs, caffeine and tobacco use • Compliance and adherence • • • • •

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ASSESSMENT (PP. 7) • Additional data includes: • Patient’s oral intake • Fluids tolerance • Swallowing ability for pills, tablets, capsules and liquids • Current Vital Signs • Lab results on WBC, Hgb/Hct, liver and kidney function 4


QUESTION- NCLEX STYLE The nurse answers a patient’s 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 patient’s pain and pain level. D.Evaluate the effectiveness of previous pain medications. 5


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

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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

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QUESTION- NCLEX STYLE The patient’s medication administration record lists two antiepileptic medications that are due at 0900, but the patient is NPO for a barium study. The nurse’s coworker suggests giving the medications via IV because the patient is NPO. What 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.

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

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THE “SIX RIGHTS” OF MEDICATION ADMINISTRATION • Right drug • Right dose • Right time • Right route • Right patient • Right documentation

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RIGHT DOSE? • The nurse is reviewing the orders for a newly admitted patient. One order reads: “Tylenol, 2 tablets PO, every 4 hours as needed for pain or fever.” The pharmacists call to clarify this order, saying “The dose is not clear.” • What dos the pharmacist means by this? • The order says “2 tablets”. • Isn’t that the dose? 11


QUESTION- NCLEX STYLE 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 home B.Check the medication administration record C.Call the pharmacy D.Review the nurse’s notes 12


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

• Clear concise documentation: • If a drug is not administer the reason and actions taken needs to be documented • If patient refuse medication, respect the patient’s right, determine the reason, notify prescriber.

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QUESTION- NCLEX STYLE A nurse makes an error when administering medications to a patient. Which action by the nurse requires the supervising nurse to intervene? The nurse A.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.

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CHAPTER 2 PHARMACOLOGIC PRINCIPLES


LEARNING OBJECTIVES: Define the common terms used in pharmacology Understand pharmaceutics, pharmacokinetics and pharmacodynamics Understand absorption, distribution, metabolism and excretion 16


PHARMACOLOGIC PRINCIPLES • What is a drug? (pp. 19) • Any chemical that affects the physiologic processes of a living organism

• Pharmacology • Study or science of drugs

• Knowledge of pharmacology enables the nurse to better understand how drugs affect humans.

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DRUG NAMES Chemical name • Describes the drug’s chemical composition and molecular structure Generic name (nonproprietary name) • Name given by the United States Adopted Names Council Trade name (proprietary name) • The drug has a registered trademark; use of the name is restricted by the drug’s patent owner (usually the manufacturer) 18


CHEMICAL, GENERIC, AND TRADE NAMES AND CHEMICAL STRUCTURE OF IBUPROFEN

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DRUG NAMES


PHARMACOLOGIC PRINCIPLES • DRUG CLASSIFICATION: • Drugs are grouped together based on their similar properties • Drugs can be classified • By their structure (e.g., beta-adrenergic blockers) • By their therapeutic use (e.g., antibiotics, antihypertensives, antidepressants)

• Within the broad classification, each class may have subclasses (pp. 20)

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PHARMACOLOGIC PRINCIPLES • 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

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

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PHASES OF DRUG ACTIVITY


PHARMACOLOGIC PRINCIPLES • Pharmacotherapeutics • The clinical use of drugs to prevent and treat diseases • Defines principles of drug actions—the cellular processes that change in response to the presence of drug molecules • Drugs are organized into pharmacologic classes 24


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

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PHARMACEUTICS (PP.21) • 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 • liquid 26


PHARMACEUTICS (PP.21) • Extended-release oral dosage forms must not be crushed, as this could cause accelerate release of drug from the dosage form and possible toxicity. • Enteric- coated tablets also are not recommended for crushing

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Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

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PHARMACOKINETICS • A drug’s 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

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PHARMACOKINETICS: ABSORPTION • Movement of a drug from its site of administration into the bloodstream for distribution to the tissues http://www.youtube.com/watch?v=xiuWdJYyIKs •Bioavailability: term used to express the extent of drug absorption, amount of drug available after metabolism •First-pass effect: the concentration of a drug is greatly reduced before it reaches the systemic circulation. It is the fraction of lost drug during the process of absorption 30


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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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)

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PARENTERAL ROUTE • Intravenous (fastest delivery into the blood circulation) • Intramuscular • Subcutaneous • Intradermal • Intraarterial • Intrathecal • Intraarticular

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TOPICAL ROUTE • Skin (including transdermal patches) • Eyes • Ears • Nose • Lungs (inhalation) • Rectum • Vagina 34


DISTRIBUTION (PP. 26) 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 https://www.youtube.com/watch?v=kLvYCOSnPDc 35


PROTEIN BINDING OF DRUGS

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METABOLISM/BIOTRANSFORMATION (PP. 27) 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 37


DRUG TRANSPORT IN THE BODY

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METABOLISM/BIOTRANSFORMA TION (CONT’D.) Factors that decrease metabolism • Diseases • Cardiovascular dysfunction • Renal insufficiency • Liver diseases

• Conditions • Starvation • Obstructive jaundice

• Drugs • rifampin • Ketoconazole therapy

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EXCRETION (PP.27) The elimination of drugs from the body • Kidneys (main organ) • Liver • Bowel • Biliary excretion • Enterohepatic recirculation https://www.youtube.com/watch?v=4X8 pAizadWI 40


HALF-LIFE • The time it takes for one half (50%) 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: physiologic state in which the amount of drug removed via elimination is equal to the amount of drug absorbed with each dose. 41


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 • Includes onset, peak, and duration of action

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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

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THERAPEUTIC DRUG MONITORING Peak level • Highest blood level Trough level • Lowest blood level

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PHARMACODYNAMICS: MECHANISMS OF ACTION • Receptor interactions • Enzyme interactions • Nonselective interactions

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PHARMACOTHERAPEUTICS: TYPES OF THERAPIES • • • • • • •

Acute therapy Maintenance therapy Supplemental/replacement therapy Palliative therapy Supportive therapy Prophylactic therapy Empiric therapy

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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!

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MONITORING • Evaluating the clinical response of the patient to the treatment • One must be familiar with the drug’s: • Intended therapeutic action (beneficial) • Unintended but potential adverse effects (predictable, adverse drug reactions)

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MONITORING (CONT’D) • Therapeutic index • The ratio of a drug’s toxic level to the level that provides therapeutic benefits. • A low therapeutic index means that the difference between a therapeutically active dose and a toxic dose is small.

Drug concentration Patient’s condition Tolerance and dependence Drug interactions (additive effect, synergistic effect, antagonistic effect, incompatibility) • Adverse drug events • • • •

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MONITORING (CONT’D) Adverse drug reactions • Pharmacologic reactions, including adverse effects • Hypersensitivity (allergic) reaction • Idiosyncratic reaction • Drug interaction

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OTHER DRUG-RELATED EFFECTS • Teratogenic • Mutagenic • Carcinogenic

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CHAPTER 5 MEDICATION ERRORS: PREVENTING AND RESPONDING


• Medication errors (pp. 65) • Institute of Medicine studies (1999, 2006) • Number of death from medical errors in U.S. ranged from 44,000 to 98,000 annually

ADVERSE • Adverse drug reactions

DRUG EVENT

• Allergic reaction • Idiosyncratic reaction

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MEDICATION ERRORS • Preventable • Common cause of adverse health care outcomes • More potential for harm with “highalert” medications

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ISSUES CONTRIBUTING TO ERRORS

• Errors can occur during any step of medication process: • Prescribing • Transcribing • Dispensing • Administering • Monitoring

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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

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PREVENTING MEDICATION ERRORS (CONT’D) • 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

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PREVENTING MEDICATION ERRORS (CONT’D) • 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 • Check patient allergies and identification

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PREVENTING MEDICATION ERRORS (CONT’D) • NEVER use a “trailing zero” 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

• 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 63


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

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REPORTING MEDICATION ERRORS (CONT’D) • 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

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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

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CHAPTER 7 OVER-THE-COUNTER DRUGS AND HERBAL AND DIETARY SUPPLEMENTS


OVER-THE-COUNTER (OTC) DRUGS • Nonprescription drugs • Use for short-term treatment of common minor illnesses • More than 300,000 OTC drugs available • OTC Drug Review (1972) • Safety and efficacy • Appropriate labeling standards • Reclassification (drug products are approved for OTC use and changed from prescription to OTC status)

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RECLASSIFIED OTC DRUGS • • • • • •

ibuprofen (Advil) naproxen (Aleve) diphenhydramine (Benadryl) loratadine (Claritin) famotidine (Pepcid AC) omeprazole (Prilosec OTC)

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CLASSROOM RESPONSE QUESTION The nurse associates use of which over-the-counter medication with the development of hepatotoxicity? A.acetylsalicylic acid (aspirin) B.ibuprofen (Motrin) C.pseudoephedrine (Sudafed) D.acetaminophen (Tylenol)

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HERBAL AND DIETARY SUPPLEMENTS • Dietary supplement—orally administered alternative medicines including herbal supplements • Herbs—plant components, including bark, berries, roots, leaves, gums, seeds, stems, and flowers, used for their medicinal qualities • Herbal medicine—using herbs to heal

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CONDITIONS TREATED WITH HERBAL PRODUCTS • Anxiety • Colds and cough • Depression • Headache • Insomnia • Ulcers • Premenstrual syndrome (PMS)

• Arthritis • Constipation • Fever • Infection • Stress • Weakness

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HERBS Chamomile

• Increases anticoagulants effect (risk for bleeding)

Cranberry

• Decreases renal elimination of drugs

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HERBS Echinacea

• Interference with immunosuppressant drugs and antivirals

Evening primrose

• Interaction with antipsychotic drugs

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HERBS Garlic

• Interferes with hypoglycemics and anticoagulant (warfarin)

Gingko

• Increases risk for bleeding with anticoagulants and antiplatelet

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HERBS Ginger root

• Interferes with cardiac , antidiabetic or anticoagulants

Grapefruit

• Decreases erectile drugs effect, estrogens and psychotherapeutic drugs

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HERBS Hawthorn

• May lead to toxic levels of cardiac glycoside

kava

• May increase the effect of barbiturates and alcohol

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HERBS Saw Palmetto

• Changes effects of hormones

St. John’s wort

• May lead to serotonin syndrome if used with other serotogenic drugs

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HERBS • Valerian • Increases central nervous system depression if used with sedatives

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CLASSROOM RESPONSE QUESTION A patient tells the nurse that he wants to stop taking his antilipemic drugs and start taking garlic to lower his cholesterol. The nurse’s best reply would be: A. “That decision is up to you.” B. “You have every right to switch to herbal remedies.” C. “You should not go against what the doctor has prescribed for you.” D. “Let’s explore the evidence that supports the use of garlic to lower your cholesterol.”

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NURSING IMPLICATIONS • Obtain thorough medication history, documenting all medications used (prescription, OTC, herbal products, vitamins, minerals, other dietary supplements) • Assess level of education and understanding • Assess for information specific to various products • Assess system functions (especially renal, liver, and cardiac) • Assess for conditions that are contraindications • Assess for potential drug-drug and drug-herb interactions 81


NURSING IMPLICATIONS (CONT’D) • Provide thorough and individualized patient education • Ensure that patients recognize that manufacturers of herbal products/dietary supplements are not required to prove safety and effectiveness • Herbal products may not be safe for pregnant or breastfeeding women, infants, children • “Natural” does not mean safe • Teach patients to monitor themselves for unusual or adverse reactions as well as therapeutic responses

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