N114 General Pharmacology

• Welcome to N114 General Pharmacology

Recommended Textbooks

• Lilley et al. (2021) and Photo Atlas (2019) are recommended
• Potter & Perry (2024), 7th Edition is recommended
• Students will be tested on readings from Potter & Perry (2024)
• Boyer (2019) – Math for Nurses 10th Edition is recommended
• Davis's Drug Guide for Nurses (2021), 17th Edition is recommended
• Davis's Drug Guide for Nurses (2021), 17th Edition will not be tested on exams, but is used in clinicals

Assessment of Knowledge

• Drug dose calculation exam is worth 20%
• An 85% pass mark must be achieved by the third attempt to pass the drug dose calculation exam
• The mark from the first attempt will count toward grade
• Online midterm exam is worth 25%
• The group presentation is worth 15%
• The online final exam is worth 40% and is comprehensive

Expectations

• Assigned readings, required readings, and video resources should be reviewed
• There are two choices for the oral medication safety presentation
• In-person attendance for the medication safety group presentation is mandatory

Lab

• Assignments for lab are to be completed before attending
• Lab attendance is mandatory

Tips for Studying

• Understand how drugs act on the body
• Concentrate studies on major characteristics of drug classifications
• Compare drugs to prototypes when possible
• Required texts should be studied
• Keep and use an up-to-date drug reference
• Use personal words when taking notes and researching meds for clinical and exams
• One should mentally practice applying drug knowledge during nursing care

Medication Safety

• Medications can improve the quality of life and extend life expectancy
• Acuity and complexity of patients continues to increase
• Many factors need to be considered regarding meds such as, increasing cost, drug shortages, staff shortages, and advancement in technology
• Medications can potentially be harmful causing serious, even fatal adverse effects (overuse, underuse, misuse, abuse, etc.)

Pharmacology and the Role of the Nurse

• Nurses must be more accountable and have increased attention focused on safe medication practices
• Evaluating and promoting therapeutic effects, reducing harm, adverse effects, adverse interactions, and drug toxicity are all important
• Excellent critical thinking and decision making skills are needed when deciding about the administration of PRN medication
• Factors include:
  • Drugs
  • Client
  • Agency Policy
  • Nursing Process (Assessment, Nursing Diagnosis, Planning, Implementation, Evaluation)

The Nursing Process

• Ensures delivery of thorough, individualized, and quality nursing care to patients regardless of age, gender, ethnicity, culture, medical diagnosis, or setting
• The nursing process is ongoing and used throughout nursing practice
• This can be applied to all areas of nursing, including medication administration
• Knowledge and skills combined prepares the nurse to uncover effective solutions to meet patient needs
• Critical thinking is the foundation of good nursing care and allows the providing of best possible care

Assessment

• Assessment includes subjective and objective data
• Subjective Data:
  • Includes spoken information, (complaints, problems, and stated needs)Example:
  • "I've had a cough, nasal congestion and sore throat for 4 days"
• Objective Data:
  • Includes information available through the use of the senses
  • Vital signs on assessment BP-135/68, P-98, R-22, T-38C, sp02-92%
  • Sources include the chart, laboratory test results, diagnostic procedure reports, health history, physical assessment, and examination findings

Nursing Diagnosis

• The data from the assessment is then analyzed, and the nursing diagnosis is formulated
• Nursing diagnoses are prioritized in order of critical problems first A-B-C often used as a basis
• Common nursing diagnoses:
  • Deficient knowledge
  • Risk for injury
  • Non-adherence
  • Deficits or excesses
  • Impairments in bodily function
• Diagnoses are created based on analysis of collected data about patients or drugs

Planning

• The planning phase prioritizes the nursing diagnosis and specifies goals and outcome criteria, including time frames for achievement
• The plan consists of two parts: patient outcomes, or expected outcomes, which describe behaviours or results achieved within a specific time frame and nursing interventions needed to achieve those outcomes

Implementation

• During medication administration, nurses need to know and understand all information about the patient and about each medication prescribed
• Implementation is based on the nurse's clinical judgement and knowledge
• Standards for nursing practice and Code of Ethics are upheld at all times
• Implementation involves the 10 rights and 3 checks, and it is the phase in which the drug is administered

Evaluation

• Evaluation occurs after the collaborative plan is implemented
• It is a systematic, ongoing, and dynamic part of the nursing process
• Monitoring the patient's therapeutic response, adverse effects, and outcomes are all involved
• Documentation and charting takes place in this step
• Monitoring of nursing practice standards also takes place in this step

Example in Action

• Example of the nursing process in action:
  • Assessment: patient assessed upon shift, confirmed bowel obstruction yesterday requiring surgical intervention. Blood pressure noted to be elevated, pain rated 9/10 on pain scale with obvious facial expression of discomfort and speaking in short incomplete sentences
  • Nursing diagnosis: acute pain related to a surgical procedure
  • Planning: administer medication as ordered and to educate patient on the importance of medication for prophylactic treatment for increased effectiveness. With reduction in pain the patient will then participate in prophylactic treatments to prevent complications
  • Implementation: administer scheduled narcotic analgesic and morphine IR for breakthrough relief
  • Evaluation: patient VS found to be WNL, pain rated 1/10 on the same scale, the patient is able to mobilize to washroom unassisted and participate in DB & C exercises

Physician's Order Requirements

• Complete information on the medication order must be obtained for:
  • Client's name
  • Date order was written
  • Name of drug
  • Dosage (size, frequency, # of doses)
  • Route of delivery
  • Signature of a prescriber
• Once these six elements have been transcribed and verified, the drug should be researched by the nurse if they is unfamiliar with it

Essential Components of a Prescription

• Patient's name, address, health insurance number (or identification number)
• Date prescription was written
• The Rx symbol, meaning “take thou”
• Medication name, dosage, and strength
• Route of administration
• Dispensing instructions for the pharmacist
• Directions for administration to be given to the patient
• Number of refills
• Signature of the prescriber

Traditional Five Rights to Medication Administration

• Right Drug
• Right Dose
• Right Time
• Right Route
• Right Patient

Right Drug

• Nurses check all medication orders and prescriptions
• The nurse check both the drug order & medication labels when administering
• One should always consider if the drug is appropriate for the client
• Orders must always be written and contain all needed components
• Verbal and telephone orders are only acceptable in emergency situations, never by students
• One should consider a clients hx, and lab values
• The nurse is responsible for administering the medication RIGHT DRUG, watching for, and always documenting allergies

Right Dose

• Every medication order must identify a dosage
• The nurse must check dosage and ensure it is appropriate for client's age and size
• The nurse must double-check any math calculations
• Extra caution is needed for neonates, peds, and geriatric clients as they are more sensitive to medications
• The nurse is responsible to ensure administration of medications

Right Time

• Agencies have policies regarding routine times for medications
• The nurse must assess each client for any specific time considerations
• Scheduled meds must be given within half an hour before or after the actual time specified
• Military time(24 hour time) is used to record medication times
• Any variations in the time of med admin and their rationale should always be documented
• One should always consider drug-drug or drug-food interactions (breakfast, lunch, supper)

Right Route

• The route is specified in a physician's order
• Clarification with the physician is needed if not specified, and a route shouldn't be assumed
• The nurse must ensure right route is being used and that right technique is used when administering medication

Right Client

• The client's identity should be checked before giving each dose using at least two identifiers
• The client should be asked to state their name and date of birth
• The client's identification band or bracelet should be checked to confirm the client's name, age, and identification number (not usually used) along with allergies

Areas for Potential Liability for Nurses

• Failure to assess and evaluate
  • Failure to see significant changes in a patient's condition
  • Failure to report changes in condition after taking medication
  • Failure to take a complete medication history and nursing assessment/history
  • Failure to monitor the patient after medication administration
• Failure to ensure safety
  • Lack of adequate monitoring
  • Failure to identify patient allergies and other risks related to medications
  • Inappropriate drug administration technique
  • Failure to implement appropriate nursing actions based on lack of proper assessment of a patient's condition
• Medication Errors
  • Failure to clarify unclear orders
  • Failure to identify and react to adverse drug reactions
  • Failure to be familiar with medications prior to administration
  • Failure to maintain level of professional nursing skills for current practice
  • Failure to identify a patient
  • Failure to document medication on profile

Knowing Legal Implications Allows you to

• Interpret drug data
• Evaluate desired response
• Recognize responsibilities (narcotic and controlled drugs)
• Remain within the bounds of the law
• Know responsibilities in clinical trials

Ethical Considerations

• Ethical principles are useful strategies for health care providers
• Include standards or truths by which ethical actions are made
• Principles include:
  • Autonomy
  • Beneficence
  • Nonmaleficence
  • Justice
  • Fidelity
  • Veracity
• RPNAS Code of Ethics (See RPNAS website)
• International Council of Nurses (ICN) Code of Ethics for Nurses

Legal and Ethical Considerations in Nursing

• Safe, compassionate, competent, and ethical care
• Privacy and confidentiality
• Promotion of justice
• Accountability
• Preservation of dignity
• Informed decision making
• Promotion of health and well-being

Right of Nurse to Refuse

• A nurse's personal ethical principles cannot be violated
• Nurses should speak to a supervisor or manager to request a unit transfer in such instances, but must not abandon the patient
• The nurse is responsible for providing nonjudgemental nursing care
• The nurse always acts in the best interest of the patient while remaining an objective patient advocate

Importance of Safe Medication Practices

• Safe medication practices:
  • Decrease medication errors
  • Decrease patient injuries
  • Increase nurse-patient trust
  • Protect the nursing license

Medication Adherence (Compliance) and Nonadherence

• Adherence means active, voluntary and collaborative involvement of the patient in the mutually acceptable, prescribed course of treatment or therapeutic plan
• Nonadherence means an informed decision by a patient not to adhere to or follow a therapeutic plan or suggestion

Medication Legislation and Standards

• The Food and Drugs Act gave the federal government control of the manufacturing and sale of all drugs (except narcotics), all foods, all cosmetics & certain medical devices
• The Controlled Drugs & Substances Act controls the manufacturing, distribution & sale of narcotic drugs
• Administration of these acts is carried out by the Health Protection Branch (HPB) of the federal gov't
• The federal government has also passed legislation that regulates the manufacturing & sale of herbs & other natural health products

Provincial, Territorial and Local Regulation of Medication

• Provinces & territories do not directly regulate the manufacturing or sale of drugs (that's the federal government), but they indirectly affect the use & sale of drugs within their boundaries
• Provinces and territories are largely responsible for healthcare

Drug Standards

• The Canadian Formulary sets standards for drug strength, quality, purity, packaging, safety, labelling, & dosage form to ensure clients receive pure drugs in safe & effective dosages

Canadian Food and Drug Act

• The Canadian Food and Drugs Act is legislation governing foods, drugs, cosmetics, and medical devices in Canada
• Food and Drug Regulations are the current consolidated regulations of the Food and Drug Act

Food and Drug Administration (FDA)

• According to the FDA, a drug is removed from the market when its risks outweigh its benefits
• A drug is usually taken off the market because of safety issues with the drug that cannot be corrected, for example: when it is discovered that the drug can cause serious side effects that were not known at the time of approval
• The FDA also takes into account the number of people taking a drug being considered for removal in order not to harm them

Drug Schedules of OTC Medications

• Schedule I: Available only by prescription
• Schedule II: Restricted access, retained behind the counter; requires pharmacist dispensing and subject to counselling
• Schedule III: Pharmacy only non-prescription
• Schedule IV: Maybe prescribed by a pharmacist according to specific guidelines
• Unscheduled drugs: can be sold in any store by a non-pharmacist

Prescription Drug Access and Costs

• High drug expense is a significant barrier for access to prescription drugs that are not covered under the Canada Health Act for low incomes, those with no drug benefits, and poor health

Controlled Drugs and Substances Act (CDSA)

• The CDSA replaced the Narcotic Control Act
• Provides requirements for the control and sale of narcotics, controlled drugs, and substances of misuse
• The letters "N" and the symbol "C" are printed on the label of every narcotic drug
• The RCMP is responsible for enforcement of the CDSA

Narcotics

• Has a high abuse potential
• Legislation determines who can sell and who can possess them
• Often stored "locked"
• Often subject to "automatic reorders"

Drug Use Terminology

• Drug Use means using a medication as prescribed (intended), as directed by a healthcare professional (GP)
• Drug misuse means using a prescription medication improperly, not adhering to directions from healthcare professionals
• Drug abuse means excessive use of a drug in a way that is detrimental to self, society, or both, and can cause a direct path towards both physical and psychological dependence

Compendium of Pharmaceuticals and Specialties (CPS)

• Contains vital information for the safe preparation and administration of every approved drug
• A CPS MUST be located on every nursing unit that administers medications
• Concerns regarding safe dose ranges, side effects, adverse reactions, and compatibilities can be found
• Ignorance is not an excuse for unsafe medication administration

New Drug Process

• Process is ongoing
• The Canadian system of drug research and development is one of the most stringent in the world
• Is developed out of concern for patient safety and drug efficacy
• Canadian National Health Products Regulations (2003)
• Health Canada drug approval process
• Once approved, a drug is assigned a Drug Identification Number (DIN)

Clinical Phases of Investigational Drug Studies

• Informed consent must be obtained
• Phase I: small number of healthy subjects (usually fewer than 100)
• Phase II: larger numbers of volunteers who have the disease or ailment (usually 100 to 300)
• Phase III: larger number of patients who are followed by medical research centres (1000 to 3000)
• Phase IV: postmarketing studies voluntarily conducted by drug companies to obtain information of the therapeutic and adverse effects of the new drug

Use of Placebos

• A placebo is a drug dosage form without pharmacological activity
• Is often used in experimental drug studies
• Except in new drug studies, placebo use is considered unethical creating mistrust
• Canada has no specific formal guidelines on the use of placebos

Use of Placebos in Research

• The informed consent process must be followed
• Patients are informed of their right to:
  • Leave the study without pressure or coercion
  • Leave the study with no consequences to medical care
  • Receive full and complete information about the study
  • Be made aware of alternative options, receiving information on all treatments, including placebo therapy

Medication Errors

• Are a major problem in all health care settings
• Are defined as “any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the health care provider, patient, or consumer
• Patient-related and system-related factors must be considered when examining
• All nurses must adhere to the "10 Rights" during all steps of the medication order process

Ethnocultural Considerations

• It is never appropriate to assume another person's genotype based off either their physical appearance or their health care history
• Acknowledgements and acceptance of a patient's cultural beliefs is mandatory – is never optional within nursing care
• Some general considerations:
  • Language (vocabulary)
  • Diet
  • Use of substances (tobacco, alcohol, etc.) and how they are affected by cultural and religious beliefs
  • Modesty (can be male or female)
  • Stoicism (can be male or female, or universal)
  • Beliefs on death and dying
  • Hygiene practices
  • Reproductive health
  • Use of blood products
• Considerations for particular cultural groups:
  • Asians:
  • May believe in traditional medicines: hot and cold foods; herbs/teas/soups; use of acupuncture, acurpressurist, and herbalist
  • May exhibit high respect, especially to those with authority, and might not be comfortable shaking hands with the opposite sex
  • May have close extended family ties: family needs usually outweigh the individual's needs
  • Antipsychotic and antianxiety drugs: typically require a lower dose than other populations
  • Common medical conditions among this population: drug interactions (and decreased dosages for some drugs), lactose intolerance, or thalassemia
    • Black people of African Descent:
    • May practice folk medicine, combining traditional healing practices, using herbal medicine, spirituality, and manual therapies or exercise
    • Asking personal questions may be seen as intrusive, or improper, and direct eye contact may be interpreted as rude
    • Typically have extended family ties, where women play an important role in making health care decisions -Antihypertensive drugs: might respond better to diuretics than beta blockers, or angiotensin-converting enzyme inhibitors and respond best to calcium channel blockers, and combination drugs -Common medical conditions: keloid formation, sickle cell anemia, and lactose intolerance
      • Indigenous cultures:
      • May believe in harmony with nature and that ill spirits cause disease
      • May use a medicine wheel and herbs like tobacco (used in pipe ceremonies for thanks), sweetgrass (smudging and cleansing), cedar (ceremonial & medicinal), and sage (traditional medicine, used in smudging ceremonies)
      • Commonly engage with traditional healers, attending/undergoing ceremonies like smudge ceremonies, healing circles, and sweat lodge ceremonies
      • Other notes on indigenous people:
      • Polite to speak in a low tone of voice
      • Light touch of a person's hand is preferred to a firm handshake for greetings
      • Direct eye contact can be rude, especially w/ authority
      • Strong emphasis on family, extended families
      • Grandparents may take an active role in raising children
      • Common medical conditions: lactose intolerance, or cleft uvula problems
• Respecting culture allows someone to feel good and allows our patients to be their authentic self without fear of judgement, discrimination, or racism; which improves health outcomes

Drug Use Terminology

• Drug Use means using a medication as prescribed (intended), as directed by a health care professional (GP)
• Drug misuse means using a prescription medication improperly, not adhering to directions from health care professionals
• Drug abuse means excessive use of a drug in a way that is detrimental to self, society, or both, and can cause a direct path towards both physical and psychological dependence

The Importance of Health Teaching

• Communicate all pertinent information for self-administration of medications including:
  • Identification of risks, and adverse effects to look out for
  • Identify proper use of the drug (medication), when to take forgotten or missed doses, avoidance of certain foods and drug-drug interactions, etc
  • Advise patients that side effects are typically worse in the first three weeks of starting a medication and will typically decrease over time
  • Advocate for the patient to talk with a GP if their medication side effects are not tolerable after three weeks
• Have the patient communicate back what they need to do/look out for, as a demonstration of knowledge retention, in order to improve nursing education

The Right to Live at Risk

• Registered psychiatric nurse (RPN) must understand patients have a right to choose whether to participate in treatments. The decision should be done after informed consent.
• Informed consent requires receiving all information for making an informed decision regarding interventions being received. Patients typically sign a formal consent form, accepting all liabilities & understanding the procedure, its benefits, and risks, before certain interventions being received
• The right to be certified is only superseded when the person is in a psychiatric unit for assessment and treatment

Polypharmacy

• Polypharmacy: using many different drugs concurrently in treating a patient, often one who has several health problems (Lilley, 2021, p. 52)
• A patient taking 8+ drugs, concurrent, being red flagged
  • The patient's risk of drug interaction of taking two drugs increases ~6%, while five drugs concurrently increases to 50%. 10+ meds increases the patient's concurrent risk to 100%
• Adverse reactions aren't always apparent, they might become insidious resulting in organ tissue degradement
• Patients might use herbal remedies or natural supplements, having serious interactions w/ prescription drugs, which requires an accurate patient medical profile