Chapter 1^J2^J3^J4^J5^J7.pptx

Chapter 1 The Nursing Process and Drug Therapy The Nursing Process • A research-supported organizational framework for professional nursing practice • Ensures the delivery of thorough, individualized, and quality nursing care to patients • Requires critical thinking • Ongoing and constantly evolving process 2 Contemporary Trends: The Quality and Safety Education for Nurses (QSEN) Project • Initiated in 2005 • Preparing future nurses with the knowledge, skills, and attitudes (KSAs) needed to continuously improve the quality and safety of patient care within the health care system • KSAs flow out of the QSEN initiatives and are being integrated into nursing education curricula and clinical outcomes. 3 • • • • • • Six Major Initiatives of QSEN Patient-centered care Teamwork and collaboration Evidence-based practice (EBP) Quality improvement (QI) Safety Informatics 4 Contemporary Trends: Interprofessional Education Collaboration (IPEC) • Formed in 2009 • Objective: Develop core competencies for interprofessional collaborative practice • Interprofessional education occurs when students from two or more professions learn from and with each other. • Goal: Improve health outcomes 5 Contemporary Trends: Next Generation NCLEX (NGN) • Focus on clinical reasoning and clinical judgement skills • New format of questions will appear on upcoming NCLEX • Nursing programs are adjusting education programs to increase focus on critical thinking and clinical judgement in the clinical setting 6 Five Steps of the Nursing Process • Assessment • Human Needs Statements (formerly Nursing Diagnoses) • Planning • Goals • Outcome criteria • Implementation (including patient education) • Evaluation 7 Assessment • Data collection, review, and analysis • Medication profile • • • • • All drug use Prescriptions Over-the-counter medications Vitamins, herbs, and supplements Compliance and adherence 8 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 • Expectations for behavior • For drug therapy: outcome is safe and effective administration of medications 9 Implementation • Initiation and completion of specific nursing actions as defined by the Human Needs Statements, goals, and outcome criteria • Independent, collaborative, and dependent 10 The “Rights” of Medication Administration • • • • • • Right drug Right dose Right time Right route Right patient Right documentation Current practice standards suggest these additional “Rights”: • Right reason or indication • Right response • Right to refuse 11 Medication Errors • Any preventable event that may cause or lead to inappropriate medication use or patient harm • Patient-related events • System-related events Will be discussed further in Chapter 5 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 13 Chapter 2 Pharmacologic Principles Overview • Drug • Any chemical that affects the physiologic processes of a living organism (person) • Pharmacology • Study or science of drugs • Encompasses a variety of topics 15 Drug Names Chemical name • Describes the drug’s chemical composition and molecular structure • Ex: Tylenol: N-acetyl-p-aminophenol Generic name (nonproprietary name) • Name given by the United States Adopted Names Council • Ex: Tylenol: Acetaminophen Trade/Brand name (proprietary name) • The drug has a registered trademark; use of the name is restricted by the drug’s patent owner (usually the manufacturer). • Ex: Tylenol 16 Drug Classifications Drugs are grouped together based on similar properties • Drug classifications • Structure (ex. beta blocker) • Subclass (ex. selective, nonselective) • Therapeutic use (ex. antibiotic) • Subclass (ex. penicillins) Prototypical drugs: first drug in a class of drugs 17 Pharmacologic Principles • • • • • • • • Pharmaceutics Pharmacokinetics Pharmacodynamics Pharmacogenomics (pharmacogenetics) Pharmacotherapeutics Pharmacognosy Pharmacoeconomics Toxicology 18 Definition of Pharmaceutics • The study of how various drug forms influence the way in which the drug affects the body. • Dissolution—dissolving of solid dosage forms and their absorption 19 Definition of Pharmacokinetics • Pharmacokinetics: Is the 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 • Absorption: is the movement of a drug from its site of administration into the bloodstream for distribution to the tissues • Distribution: Refers to the transport of a drug by the bloodstream to its site of action. (Keep in mind: drugs are distributed first to those areas with extensive blood supply. Areas of rapid distribution include the heart, liver, kidneys, and brain. Areas of slower distribution include muscle, skin, and fat • Metabolism: The organ most responsible for the metabolism of drugs is the liver. Other metabolic tissues include skeletal muscle, kidneys, lungs, plasma, and intestinal mucosa • Excretion: Excretion is the elimination of drugs from the body. The primary organ responsible for this elimination is the kidney. 20 Definition of Pharmacodynamics • The study of what the drug does to the body • Mechanism of Action: Drugs can produce actions (therapeutic effects) in several ways. Drugs can exert their actions in three basic ways: through receptors, enzymes, and nonselective interactions. 1. Drug-receptor relationships: Drug-receptor interaction is the joining of the drug molecule with a reactive site on the surface of a cell or tissue. Most commonly, this site is a protein structure within the cell membrane. https://www.osmosis.org/learn/Pharmacodynamics 21 Definition of 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. 22 Definition of Toxicology • Science of the adverse effects (unwanted effects) of drugs and other chemicals on living organisms 23 Definition of Pharmacognosy • The source of all early drugs was nature, and the study of these natural drug sources (plants and animals) is called pharmacognosy. 24 Definition of Pharmacoeconomics • Study of the economic factors influencing the cost of drug therapy • Example: is performing a cost-benefit analysis of one antibiotic versus another when competing drugs are considered for inclusion in a hospital formulary. • Such studies typically examine treatment outcomes data (e.g., how many patients recovered and how soon) in relation to the comparative total costs of treatment with the drugs in question. 25 Pharmaceutics • Different drug dosage forms have different pharmaceutical properties. • Dosage form determines drug dissolution rate. 26 Enteral Route • The drug is absorbed into the systemic circulation through the oral or gastric mucosa or the small intestine. • Oral • Sublingual • Buccal • Rectal • Topical 27 Parenteral Route • Intravenous (fastest delivery into the • • • • • blood circulation) Intramuscular Subcutaneous Intradermal Intraarterial Intrathecal (area between the spinal cord and the thin, strong membranes that surround and protect it) • Intraarticular (administered by entering a joint) 28 Topical Route • • • • • • • Skin (including transdermal patches) Eyes Ears Nose Lungs (inhalation) Rectum (for local effects) Vagina 29 Pharmacokinetics • Absorption: Is the movement of a drug from its site of administration into the bloodstream for distribution to the tissues • Bioavailability: Is the term used to express the extent of drug absorption. (Keep in mind: If a large proportion of a drug is chemically changed into inactive metabolites in the liver, then a much smaller amount of drug will pass into the circulation (i.e., will be bioavailable) • First pass effect • Large proportion of a drug is chemically changed into inactive metabolites by the liver. • Much smaller amount will be bioavailable. • Distribution • Transport of a drug by the bloodstream to its site of action • Drugs are distributed first to those areas with extensive blood supply. • Albumin is the most common blood protein and carries the majority of protein-bound drug molecules. • https://www.youtube.com/watch?v=BQQns7RAUzA 30 Pharmacokinetics (Cont.) • Metabolism • Also referred to as biotransformation • Biochemical alteration of a drug into an inactive metabolite, a more soluble compound, a more potent active metabolite, or a less active metabolite. 31 Pharmacokinetics (Cont.) • Metabolism (cont.) • Cytochrome P-450 enzymes (or simply P-450 enzymes), also known as microsomal enzymes • Lipophilic: “fat loving” • Hydrophilic: “water loving” • Enzymes 32 Pharmacokinetics (Cont.) • Excretion: Elimination of drugs from the body • Renal excretion- Kidneys (primary organ responsible for excretion) • Liver excretion • Bowel excretion 33 Pharmacokinetics (Cont.) • Half-life: is the time required for half (50%) of a given drug to be removed from the body. • Measures the rate at which the drug is eliminated from the body • After approximately five half-lives, most drugs are considered to be effectively removed from the body. • Steady state • Physiologic state in which the amount of drug removed via elimination is equal to amount of drug absorbed with each dose. 34 Pharmacokinet ics (Cont.) • Peak level: highest blood level of a drug • Trough level: lowest blood level of a drug • Toxicity: occurs if the peak blood level of the drug is too high 35 Pharmacokinetics (Cont.) Drug Effects • The length of time for onset, peak of action and the duration of action play an important part in determining the peak level (highest blood level) and trough level (lowest blood level) of a drug. • If the peak blood level is too high, then drug toxicity may occur. 36 Pharmacodynamics • The study of what the drug does to the body • The mechanism of drug actions in living tissues • • • • Therapeutic effect Drug–receptor relationships Enzymes Nonselective Interactions 37 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. 38 Pharmacotherapeutics (Cont.) • Acute therapy: Acute therapy often involves more intensive drug treatment and is implemented in the acutely ill or the critically ill. It is often needed to sustain life or treat disease. Examples are the administration of vasopressors to maintain blood pressure, the use of volume expanders for a patient who is in shock, and intensive chemotherapy for a patient with newly diagnosed cancer. • Maintenance therapy: It is used for the treatment of chronic illnesses such as hypertension. • Supplemental (or replacement) therapy: Supplemental (or replacement) therapy supplies the body with a substance needed to maintain normal function. Examples are the administration of insulin to diabetic patients and of iron to patients with iron-deficiency anemia. • Palliative therapy: The goal of palliative therapy is to make the patient as comfortable as possible. Palliative therapy focuses on providing patients with relief from the symptoms, pain, and stress of a serious illness. The goal is to improve quality of life for both the patient and the family. It is typically used in the end stages of an illness when attempts at curative therapy have failed; • Supportive therapy: Supportive therapy maintains the integrity of body functions while the patient is recovering from illness or trauma. Examples are provision of fluids and electrolytes to prevent dehydration in a patient who is vomiting and has diarrhea, administration of fluids, volume expanders, or blood products to a patient who has lost blood during surgery. • Prophylactic/Empirical therapy: Prophylactic therapy is drug therapy provided to prevent illness or other undesirable outcome during planned events. A common example is the use of preoperative antibiotic therapy for surgical procedures. 39 Pharmacotherapeutics (Cont.) • Monitoring: Evaluating the clinical response requires familiarity with both the drug’s intended therapeutic action and its unintended. • Therapeutic action: Ex: Reduced blood pressure following administration of antihypertensive drugs • Adverse effects: Undesirable effects that are a direct response to one or more drugs. • Cumulative effects: An effect that occurs when several successive doses of a medication are administered or when absorption of a medication occurs faster than excretion or metabolism. • Therapeutic index: The ratio between the toxic and therapeutic concentrations of a drug. • Drug concentration: The length of time the concentration of a drug in the blood or tissues is sufficient to elicit a response. • Patient condition: How the patient is responding 40 Pharmacotherapeutics (Cont.) • Tolerance: decreasing response to repeated drug doses • Dependence: physiologic or psychological need for a drug • Physical dependence: physiologic need for a drug to avoid physical withdrawal symptoms • Psychological dependence: also known as addiction and is the obsessive desire for the euphoric effects of a drug 41 Pharmacotherapeutics (Cont.) • Drug interactions • Additive effects (1 + 1 = 2) • Synergistic effects (1 + 1 > 2) • Antagonistic effects (1 + 1 < 2) think antidotes • Incompatibility 42 Pharmacotherapeutics (Cont.) • Adverse drug event (ADE) • Medication error • Adverse drug reaction 43 Pharmacotherapeutics (Cont.) • Medication use process in which errors can occur: • Prescribing • Dispensing • Administering • Monitoring 44 Pharmacotherapeutics (Cont.) • Adverse drug reactions: • Pharmacologic reaction: Is an extension of the drug’s normal effects in the body. For example, a drug that is used to lower blood pressure in a patient causes a pharmacologic ADR when it lowers the blood pressure to the point at which the patient becomes unconscious. • Hypersensitivity reaction: An allergic reaction involving the patient's immune system. • Idiosyncratic reaction: Unpredictable reactions that occur in only a small percentage of patients receiving the drug and which do not involve known pharmacological properties of the drug. • Drug interaction: Alteration in the pharmacologic or pharmacokinetic activity of a given drug caused by the presence of one or more additional drugs. 45 Pharmacotherapeutics (Cont.) • Other drug effects • Teratogenic: Teratogenic effects of drugs or other chemicals result in structural defects in the fetus. • Mutagenic: Mutagenic effects are permanent changes in the genetic composition of living organisms and consist of alterations in chromosome structure, the number of chromosomes, or the genetic code of the deoxyribonucleic acid (DNA) molecule. • Carcinogenic effects: Carcinogenic effects are the cancer-causing effects of drugs, other chemicals, radiation, and viruses. 46 Pharmacognosy • Four main sources for drugs: • • • • Plants Animals Minerals Laboratory synthesis 47 Pharmacoeconomics • Cost-benefit analysis • Examine treatment outcomes in relation to the comparative total costs of treatment with drug(s) 48 Toxicology • Science of adverse effects of chemicals on living organisms • Clinical toxicology: Care specifically to the poisoned patient • Poison Control Centers • Treatment based on system of priorities • ABCs • Prevent absorption of the toxic substance and/or speed its elimination from the body 49 Summary • Thorough understanding of pharmacologic principles is essential for safe, quality nursing practice. • Application of principles enables the nurse to provide safe and effective drug therapy. 50 Chapter 3 Lifespan Considerations Lifespan Considerations • The human body changes from the beginning of life to the end of life. • These lifespan changes have dramatic effects of the four phases of pharmacokinetics (absorption, distribution, metabolism, and excretion). • Special considerations: • • • • Pregnancy Newborn Pediatric Older adult 52 Drug Therapy During Pregnancy Drugs cross the placenta by diffusion • • Factors affecting safety: • Drug properties • Fetal gestational age • Maternal factors • FDA has implemented pregnancy safety categories. • New pregnancy safety categories are in progress 53 • Three subsections in the prescribing New Rule information: • Pregnancy • Lactation • Female and males of reproductive potential •Because this is a phase-in process, nurses may see the A to X classifications and the new rule classifications. 54 Drug Therapy During Breastfeeding • Breastfed infants are at risk for exposure to drugs consumed by the mother. • Drug levels in breast milk are usually lower than those in the maternal circulation. • Consider risk-to-benefit ratio. 55 Neonatal and Pediatric Considerations: Pharmacokinetics • Absorption is altered due to • Gastric pH less acidic until 1 to 2 years of age • Gastric emptying slowed • First-pass elimination is reduced due to an immature liver • Intramuscular absorption faster and irregular 56 Neonatal and Pediatric Considerations: Pharmacokinetics (Cont.) • Distribution • Greater total body water means lower fat content. • Decreased level of protein binding • Immature blood–brain barrier—more drugs enter the brain 57 Neonatal and Pediatric Considerations: Pharmacokinetics (Cont.) • Metabolism • Liver immature; does not produce enough microsomal enzymes • Older children may have increased metabolism, requiring higher doses than infants. 58 Neonatal and Pediatric Considerations: Pharmacokinetics (Cont.) • Excretion • Kidney immaturity affects glomerular filtration rate and tubular secretion. • Decreased perfusion rate of the kidneys may reduce excretion of drugs. 59 Factors Affecting Pediatric Drug Dosages • • • • Skin is thin and permeable. Stomach lacks acid to kill bacteria. Lungs have weaker mucous barriers. Body temperatures less well regulated, and dehydration occurs easily. • Liver and kidneys are immature, impairing drug metabolism and excretion. 60 Methods of Dosage Calculation for Pediatric Patients • Body surface area method • Uses the West nomogram • Always use weight in kilograms, not pounds • Always use centimeters, not inches • Body weight dosage calculations • Uses mg/kg 61 General Considerati ons • Prepare all equipment and supplies first. • Have caregivers stay as appropriate. • Assess for comfort methods before, during, and after drug administration. 62 Considerations for Older Adult Patients • Decline in organ function occurs with advancing age. • Drug therapy in older adults is most likely to result in adverse effects and toxicity. 63 Considerations for Older Adult Patients (Cont.) • • • • • • Older adults: older than age 65 years High use of medications Polypharmacy Noncompliance, nonadherence Increased incidence of chronic illnesses Sensory and motor deficits Older Adults: Pharmacokinetics • Absorption • Gastric pH less acidic • Gastric emptying and movement through the GI tract is slowed • Blood flow to GI tract reduced • Absorptive surface of GI tract reduced 65 • Older Adults: Distribution Pharmacokinetics (Cont.) • Lower total body water percentages • Increased fat content • Decreased production of proteins by the liver, resulting in decreased protein binding of drugs (and increased circulation of free drugs) 66 Older Adults: Pharmacokinetics (Cont.) • Metabolism • Aging liver produces fewer microsomal enzymes, affecting drug metabolism. • Reduced blood flow to the liver 67 Older Adults: Pharmacokinetics (Cont.) • Excretion • Decreased glomerular filtration rate • Decreased number of nephrons • Drugs are cleared less effectively because of decreased excretion. 68 Older Adults: Problematic Medications 69 Medication Administration, Lifespan Considerations, and the Nursing Process Assessment • Age • Allergies to drugs and food • Dietary habits • Sensory, visual, hearing, cognitive, and motorskill deficits • Financial status and any limitations • List of all health-related care providers Medication Administration Considerations: Assessment • • • • • • Listing of medications Existence of polypharmacy Self-medication practices Laboratory test results History of smoking and use of alcohol Risk situations related to drug therapy identified by the Beers criteria Medication Administration Considerations: Planning Human Needs Statements • Alteration in fluids and nutrients (less than body requirements) • Ineffective perception • Altered safety, risk for injury • Related to adverse effects • Related to idiosyncratic reactions Outcomes • May involve patient, caregiver, or legal guardian • Individualized 72 Medication Administration Considerations: Implementation • Basic Nine Rights of medication administration • Pediatric considerations for safe administration • Mixing medications to disguise taste • Age-appropriate terminology • Safety considerations • Older adult considerations for safe administration • Take as directed; do not double-up doses or discontinue without guidance from prescriber • Safety considerations • Be alert for polypharmacy 73 Medication Administration Considerations: Evaluation • Observe and monitor for therapeutic effects • Observe and monitor for adverse effects • Evaluate understanding of drug purpose, dose, dose frequency, adverse effects, special considerations 74 Chapter 4 Cultural, Legal, and Ethical Considerations Ethnopharmacology • Body of knowledge for understanding the specific impact of cultural factors on patient drug response • Lack of clarity in terms: race, ethnicity, and culture 76 Cultural Considerations • Pharmacogenomics: study of how certain genetic traits affect drug response • • • • • • Drug polymorphism Adherence with therapy Environmental and economic considerations Pharmacokinetics Pharmacodynamics Varying drug responses in different racial or ethnic groups 77 Cultural Considerations • Health beliefs and practices (Cont.) • Barriers to adequate health care for the culturally diverse U.S. patient population • Language, poverty, access, pride, and beliefs regarding medical practices • Medications may have a different meaning to different cultures. 78 Cultural Assessment • Languages spoken: need for interpreter • Health beliefs and practices • Past uses of medicine • Herbal treatments, folk remedies, and home remedies • Use of over-the-counter drugs 79 Cultural Assessment • Usual response (Cont.) to illness • Responsiveness to medical treatment • Religious practices and beliefs • Support from the patient’s cultural community • Dietary habits 80 Legal Considerations • Food and Drug Administration (FDA) • Drug Enforcement Agency (DEA) • Individual state laws 81 HIPAA • Health Insurance Portability and Accountability Act (HIPAA) • 1996 • Maintain privacy regarding protected health information 82 New Drug Development • Food and Drug Administration (FDA): primary purpose of the FDA is to protect patients and ensure drug effectiveness. • Dietary Supplement Health and Education Act of 1994 • National Center for Complementary and Alternative Medicine of 1998 83 New Drug Development • Expedited drug (Cont.) approval process • U.S. FDA drug approval process • • • • Preclinical testing Clinical studies Investigational drug studies Expedited drug approval 84 U.S. FDA Drug Approval Process • • • • Informed consent Investigational new drug study Preclinical investigational drug studies Clinical phases of investigational drug studies • Phase I • Phase II • Phase III • Phase IV 85 U.S. FDA Drug Approval Process (Cont.) • Black box warning • Drug recall • Class I (most serious) • Class II • Class III 86 Legal Considerations Related to Drug Nursing Practice • State andTherapy federal and legislation • Nurse practice acts • • • • • • Scope of nursing practice Expanded nursing roles Educational requirements Standards of care Minimally safe nursing practice Differences between nursing and medical practice 87 Legal Considerations Related to Drug Therapy and Nursing Practice (Cont.) • Guidelines from professional nursing groups • American Nurses Association (ANA) • Institutional policies and procedures; state and federal hospital licensing • Specific Nurse Practice Acts • Standards of Practice • HIPPA 88 Ethical Terms Related to Nursing Practice • • • • • • • Autonomy Beneficence Autonomy Confidentiality Justice Nonmaleficence Veracity 89 Legal and Ethical Principles: Elements of Liability for Nursing Malpractice • • • • Duty Breach of duty Causation Damage 90 Ethical Considerations • ANA Code of Ethics for Nurses • International Council of Nurses Code of Ethics for Nurses • Use of placebos 91 Chapter 5 Medication Errors: Preventing and Responding “ Too Err Is Human” • 1999 report by Institute of Medicine (IOM) • Brought medical errors to the public’s attention • Preventable errors were responsible for 7000 deaths per year. • 3% to 6.9% of hospitalized patients experience a medication error. • Two follow up reports from the IOM found no significant change in rates of preventable errors. 93 Medication Errors: Prevention • Most medication errors occur as a breakdown in the medication use system, as opposed to being the fault of the individual. • Key to preventing errors: • Reporting of errors • Reporting of potential errors • Nonpunitive approach to error reporting or “Just Culture” • QSEN initiatives 94 Medication Errors and • Adverse drug events Adverse Drug Events • Medication errors • Adverse drug responses (ADRs) • Allergic reaction (often predictable) • Idiosyncratic reaction (usually unpredictable) 95 Adverse Drug Events The intersection of medication errors with adverse drug events 96 Medication Errors • Preventable • Common cause of adverse health care outcomes • Drugs commonly involved in severe medication errors: central nervous system drugs, anticoagulants, and chemotherapeutic drugs • More potential for harm with “high-alert” medications 97 Medication Errors (Cont.) • SALAD (sound-alike, look-alike drugs) • LASA (look-alike, sound-alike) Example: buspirone and bupropion prednisone and prednisolone 98 Issues Contributing to Errors • Errors can occur during any step of medication process • Procuring • Prescribing • Transcribing • Dispensing • Administering • Monitoring 99 Issues Contributing to Errors (Cont.) • • • • Organizational issues Educational system issues Sociologic factors Use of abbreviations 100 • Near Miss: Near Miss • Event or situation that did not produce patient injury, but only because of chance • Must still be reported so that safety issues can be addressed and future incidents are prevented 101 Strategies to Minimize • Awareness (“speak-up”) Errors • Computerized prescriber order entry (CPOE) • • • • Bar codes and scanning devices Automated dispensing machines Effective communication T.A.C.I.T. 102 Types of Medication • No error, although circumstances or Errors events occurred that could have led to an error • Medication error that causes no harm • Medication error that causes harm • Medication error that results in death 103 Preventing Medication • Multiple systems of checks and balances Errors should be implemented to prevent medication errors. • Prescribers must write legible orders that contain correct information, or orders should be entered electronically. • Authoritative resources, such as pharmacists or current (within the past 3 to 5 years) drug references or literature, must be consulted. 104 Preventing Medication • Nurses need to always check the Errors (Cont.) medication order three times before giving the drug. • The Rights of medication administration should be used consistently. 105 Preventing Medication • Assessment Errors (Cont.) • Two patient identifiers • Do not administer if you did not draw up or prepare yourself. • Minimize verbal or telephone orders. • Repeat order to prescriber. • Spell drug name aloud. • Speak slowly and clearly. • List indication next to each order. 106 Preventing Medication • Never assume anything about items not Errors (Cont.) 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 the prescriber for clarification. • Do not use unapproved abbreviations, acronyms. 107 Preventing Medication • Never use a “trailing(Cont.) zero” with Errors medication orders. • Do not use 1.0 mg; use 1 mg. • 1.0 mg could be misread as 10 mg, resulting in a 10-fold dose increase. 108 Preventing Medication • Always useErrors a “leading zero” for decimal (Cont.) dosages. • Do not use .25 mg; use 0.25 mg. • .25 mg may be misread as 25 mg. 109 Preventing Medication • Take time to learn special administration Errors (Cont.) techniques of certain dosage forms. • Always verify new medication administration records. • Read labels. • Use generic names to avoid sound-alike trade names. 110 Preventing Medication • Always listen to and honor any concerns Errors (Cont.) expressed by patients regarding medications. • Check patient allergies and identification. • Know where to find information on medications, preparation, side-effects; Use only current sources. • Mandatory second nurse verifications for highrisk medications and/or patient population • Minimize interruptions when preparing/delivering medications. 111 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 and follow-up orders 112 Reporting Medication Errors (Cont.) • External reporting of errors • United States Pharmacopeia Medication Errors Reporting Program • MedWatch, sponsored by the Food and Drug Administration • Institute for Safe Medication Practices • The Joint Commission or other accreditation agencies 113 Preventing Pediatric • Obtain and document accurate weight (kg) Medication Errors • Report all medication errors. • Know the drug thoroughly. • Follow the Rights of medication administration. • Avoid verbal orders in general. • Avoid distractions. • Communicate with everyone. 114 Issues • NotificationEthical of patients • Possible consequences for nurses 115 Medication • ContinuousReconciliation assessment and updating of patient medication information • Verification • Clarification • Reconciliation 116 Medication • Process in which medications are Reconciliation (Cont.) “reconciled” at all points of entry and exit to or from a health care entity • Patients provide a list of all the medications they are currently taking (including herbals and over-the-counter drugs). • Prescriber then assesses the medications and decides if they are to be continued upon hospitalization. 117 Medication • Designed to ensure that there are no Reconciliation (Cont.) discrepancies between what the patient was taking at home and in the hospital. 118 Medication • Should be done at each stage of health Reconciliation (Cont.) care delivery: • Admission • Status change (e.g., from critical to stable) • Patient transfer within or between facilities or provider teams • Discharge (the latest medication list should be provided to the patient to take to the next health care provider). 119 Chapter 7 Over-the-Counter Drugs and Herbal and Dietary Supplements Over-the-Counter (OTC) • Nonprescription Drugs 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 from prescription to OTC 121 Over-the-Counter Drug Criteria 12 2 OTC Drug Label Sample OTC drug label with active ingredients and uses 123 Reclassified OTC Drugs • • • • • • • Ibuprofen Naproxen Diphenhydramine Loratadine Cetirizine Famotidine Omeprazole 124 Use of OTC Drugs: • May postpone effective treatment of more Potential Hazards chronic disease states • May delay treatment of serious or lifethreatening disorders • May relieve symptoms of a disorder but not the cause 125 Use of OTC Drugs: • Toxicity Potential Hazards (Cont.) • Interactions with current prescription medications may occur • Abuse 126 Herbal and Dietary • Dietary supplement—orally administered Supplements 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 127 National Center for Complementary and Alternative Medicine (NCCAM) • Complementary medicine (integrative medicine): simultaneous use of both traditional and alternative medicine • NCCAM classifies complementary and alternative medicine. • Alternative medical systems • Mind–body interventions • Biologically based therapies • Manipulative and body-based methods • Energy therapies 128 Consumer Use of Herbs • Therapeutic agents for treatment and cure of diseases • Prophylactic agents for long-term prevention of disease • Proactive agents to maintain health and wellness and “boost” one’s immune system 129 Conditions Treated with Herbal Products • • • • • • • Anxiety Colds and cough Depression Headache Insomnia Ulcers Premenstrual syndrome • • • • • • Arthritis Constipation Fever Infection Stress Weakness 130 Commonly Used Herbal Products • • • • • • • Aloe Feverfew Gingko Goldenseal St. John’s wort Valerian Kava • • • • • • • Echinacea Garlic Ginseng Hawthorn Saw palmetto Cranberry Ginger root 131 Nursing Process: • Obtain thorough medication history, Assessment documenting all medications used (prescription, OTC, herbal products, vitamins, minerals, other dietary supplements). • Assess allergies. • Assess level of education and understanding. • Assess for information specific to various products. 132 Nursing Process: • Assess Assessment system functions (Cont.) (especially renal, liver, and cardiac). • Assess for conditions that are contraindications. • Assess for potential drug–drug and drug– herb interactions. • Assess lifespan considerations: • Herbal products may not be safe for pregnant or breastfeeding women, infants, or children. 133 • • • • • • • Nursing Process: Altered GI elimination Human Needs Statements Altered knowledge Altered need for sleep Altered physical activity Altered safety needs Altered interchange of gases Freedom from pain 134 Nursing Process: Nursing Diagnoses (Cont.) Ineffective health maintenance • • Insomnia • Risk for injury • Urinary retention 135 • Nursing Process: Goals and outcomes Planning • Individualized • Realistic • Achievable 136 Nursing Process: Implementation • Patient education is important for patient safety. • • • • Information about safe use Frequency of dosing, dose How to take (with food, empty stomach, etc.) Strategies to prevent adverse effects, drug interactions, toxicity • Ensure that patients recognize that manufacturers of herbal products and dietary supplements are not required to prove safety and effectiveness. • “Natural” does not always mean safe. 137 Nursing Process: Evaluation • Patients need to carefully monitor themselves for therapeutic responses as well as adverse effects. • Therapeutic responses will vary based on supplemental product used. 138

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