Pharmacology, Chapter 1-3 PDF

Chapter 1 The Nursing Process and Drug Therapy  The Nursing Process Thinking like a nurse A research-supported Ensures the delivery of Requires critical thinking Ongoing and constantly organizational thorough, individual...

Chapter 1 The Nursing Process and Drug Therapy  The Nursing Process Thinking like a nurse A research-supported Ensures the delivery of Requires critical thinking Ongoing and constantly organizational thorough, individualized, evolving process framework for and quality nursing care professional nursing to patients practice  Assessment Human Needs Statements (Nursing Diagnoses) Planning: Goals, outcomes Five Steps of the Implementation Nursing Process Evaluation  ´ Data collection, review, and analysis ´ Vital signs ´ Laboratory values ´ History and presentation ´ Medication profile Assessment ´ Any and all drug use ´ Prescriptions ´ Over-the-counter medications ´ Vitamins, herbs, and supplements ´ Compliance and adherence Audience Response Question #1 ´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. (you have to start with assessment) D Evaluate the effectiveness of previous pain medications.  ´ Goals ´ Objective, measurable, and realistic with an established time period for achievement of the outcomes that are specifically stated in the outcome criteria Planning ´ Outcome criteria ´ Concrete descriptions of patient goals ´ Expectations for behavior ´ For drug therapy: outcome is safe and effective administration of medications  ´ Nursing actions related to medication administration ´ Preparation ´ Dosing (sometimes) ´ Administration Implementation ´ Route ´ Patient comfort and level of understanding ´ Education ´ Orders! ´ When to call the prescriber? Audience Response Question #2 ´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.  Right drug Right dose Right time Right route Right patient The “Rights” of Right documentation Medication Administration Right reason or indication* Right response* Right to refuse* Is it “Right?” Audience Response Question #3 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. – check this first MAR- shows what meds were given and who gave them A. Call the pharmacy. B. Review the nurse’s documentation. They don’t necessary always cause harm, but COULD have been prevented is in the definition ´ Any preventable event that may cause or lead to inappropriate medication use or patient harm Medication ´ Patient-related events Errors ´ System-related events Will be discussed further in Chapter 5  ´ Ongoing part of the nursing process ´ Determining the status of the goals and outcomes of care Evaluation ´ Monitoring the patient’s response to drug therapy ´ Expected and unexpected responses ´ Clear, concise documentation Chapter 2 Pharmacologic Principles Overview ´ Lots of vocab! ´ Drug ´ Any chemical that affects the physiologic processes of a living organism ´ Pharmacology ´ Study or science of drugs ´ Encompasses a variety of topics Drug Names YOU WILL NEVER BE ASKED ABOUT THE CHEMICAL NAME (only generic name) ´ 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).  ´ Chemical Name ´ (±)-2-(p-isobutylphenyl)propionic acid ´ Generic name ´ ibuprofen ´ Trade names Name ´ Advil that ´ Motrin ´ Worldwide manufacturers drug! ´ Genpril (India) ´ Bufen/iBufen (Bangladesh) Drug Classifications Drugs are grouped together based on similar properties ´ Drug classifications ´ Structure/Mechanism of Action (ex. beta blocker) ´ Subclass (ex. selective, nonselective) ´ Therapeutic use (ex. antibiotic) ´ Subclass (ex. penicillins) ´ Prototypical drugs: first drug in a class of drugs Pharmacologic Principles Pharmaceutics Pharmacokinetics Pharmacodynamics Pharmacogenomics (pharmacogenetics) Pharmacotherapeutics Pharmacognosy Pharmacoeconomics Toxicology Audience Response Question #1 A patient is prescribed ibuprofen 200 mg PO every 4 hours as needed for pain. The pharmacy sends up enteric-coated tablets, but the patient refuses the tablets, stating that she cannot swallow pills. What will the nurse do? A. Crush the tablets and mix them with applesauce or pudding. (this won’t work because of the medications coating) B. Call the pharmacy and ask for the liquid form of the medication. C. Call the pharmacy and ask for the IV form of the medication. (we don’t have an order to change route) D. Encourage the patient to try to swallow the tablets.(they could choke and die and it’s on you) Pharmaceutics ´ Pharmaceutics = design of drug form ´ Different drug dosage forms have different pharmaceutical properties ´ Dissolve at different rates based on form ´ Form relates to the intended route of administration ´ See Table 2-1 for a listing of various oral drug forms and their dissolution rates ´ KNOW the names of dosage forms/routes and how they are administered  Enteral Route ´ The drug is absorbed into the systemic circulation through the oral or gastric mucosa or the small intestine. ´ Oral (PO), pills, capsules, liquids, terracoated tablets ´ Sublingual – under the tongue (absorb into the tissue to the blood) ´ Buccal- into the cheek (absorbs into the cheek capillaries into the tissue and blood) ´ Rectal (can also be topical) Has to go through some part of the GI system Parenteral Route Generally injections ´ Intravenous (fastest delivery into the blood circulation) ´ Intramuscular- into muscle ´ Subcutaneous- just below surface layer of the skin ´ Intradermal- into the dermis ´ Intraarterial- into an artery ´ Intrathecal- into serebro spinous fluid ´ Intraarticular- into a joint ´ Introseosus- into a bone  Topical Route Right on the target tissue Can treat the skin directly ´ Skin (including transdermal patches) can be used to treat MI symptoms ´ Eyes ´ Ears ´ Nose ´ Lungs (inhalation) ´ Rectum (for local effects) ´ Vagina Might be used to treat something under the skin Audience Response Question #2 The nurse is preparing to administer a transdermal patch to a patient and finds that the patient already has a medication patch on his right upper chest. What will the nurse do? A. Remove the old medication patch and notify the health care provider. B. Apply the new patch without removing the old one. C. Remove the old patch and apply the new patch in the same spot. D. Remove the old patch and apply the new patch to a different, clean area. (rotate sides) Pharmacokinetics What the body does to the drug ´ Absorption ´ Metabolism ´ Distribution ´ Elimination Absorption ´ From site of administration into bloodstream ´ Bioavailability = amount of drug available for action in the bloodstream ´ Some drugs are changed significantly after they absorb, before they reach the bloodstream ´ First pass effect ´ Affects many drugs that pass through the GI system then liver ´ Liver reduces bioavailability by inactivating portion of the drug ´ What dosage forms involve a first pass effect? Bioavailability  Distribution ´ Distribution ´ Transport of a drug by the bloodstream to its site of action ´ Albumin is the most common blood protein and carries the majority of protein-bound drug molecules ´ A drug is less active when bound to protein in the bloodstream ´ Going to take longer to be eliminated ´ Unbound drug is active and reaches target tissues ´ Multiple protein bound drugs ´ When someone is using multiple highly protein-bound drugs, they are more likely to experience toxic levels of medication ´ Why? This Photo by Unknown Author is Pharmacokinetics: Metabolism ´ Drug metabolism is biochemical alteration of a drug into a/an: ´ Inactive metabolite ´ More soluble compound ´ More potent active metabolite (as in the conversion of an inactive prodrug to its active form) ´ Less active metabolite Pharmacokinetics: Excretion ´ Elimination of drugs from the body ´ Renal excretion (primary organ responsible for excretion) ´ Biliary ´ Bowel ´ Half-life ´ 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 ´ Five half-lives = clear ´ Steady state ´ Clearance rate = absorption rate Audience Response Question #3 The nurse is giving a medication that has a high first-pass effect. The health care provider has changed the route from PO to IV. What can the nurse expect with the IV dose? A. The IV dose will be higher because of the first-pass effect. B. The IV dose will be lower because of the first-pass effect. C. The IV dose will be the same as the PO dose. D. The rate of IV infusion must be faster due to first-pass effect. Drug Effects Onset Peak Trough Toxicity know these definitions Pharmacodynamics ´ “What the drug does to the body” ´ Mechanism of action ´ Therapeutic effect ´ Drug–receptor relationships ´ Agonist ´ Antagonist ´ Partial agonist Pharmacotherapeutics ´ Drug interactions: more than one drug changes effects ´ Additive effects (1 + 1 = 2) ´ Synergistic effects (1 + 1 > 2) ´ Antagonistic effects (1 + 1 < 2) ´ Incompatibility ´ Adverse drug event (ADE) ´ Medication error ´ Adverse drug reaction Audience Response Question #4 A patient is complaining of severe pain and has orders for morphine sulfate. The nurse knows that the route that would give the slowest pain relief would be which route? A. IV- fastest B. IM- also directly in the blood C. Subcutaneous- also directly in the blood D. PO- Errors and Adverse Events ´ Can happen anywhere in the medication use process ´ Prescribing, Dispensing, Administering, Monitoring ´ Adverse drug reactions: ´ Pharmacologic reaction ´ Hypersensitivity (allergic) reaction ´ Idiosyncratic reaction- unexplainable ´ Drug interaction ´ Negative effects ´ Teratogenic- could kill a fetus ´ Mutagenic- cause mutations ´ Carcinogenic effects- lead to cancer Pharmacotherapeutics ´ Tolerance: decreasing response to repeated drug doses ´ Dependence: physiologic or psychological need for a drug ´ Physical: needed to avoid physical withdrawal symptoms ´ Psychological: obsessive desire for the effects of a drug Pharmacoeconomics ´ Cost-benefit analysis ´ Examine treatment outcomes in relation to the comparative total costs of treatment with drug(s) Summary ´ Understanding pharmacologic principles is essential for safe, quality nursing practice ´ Applying principles enables the nurse to provide safe and effective drug therapy. Chapter 3 Lifespan Considerations Lifespan Considerations ´ The human body changes from the beginning of life to the end of life ´ Lifespan changes dramatically affect pharmacokinetics ´ Special considerations: ´ Pregnancy ´ Newborn ´ Pediatric ´ Older adult Drug Therapy During Pregnancy ´ Drugs cross the placenta by diffusion ´ Factors affecting safety: ´ Drug properties ´ Fetal gestational age ´ Maternal factors ´ FDA drug safety categories surrounding pregnancy ´ Formerly A, B, C, D, X ´ New categorization system involves subsections ´ Pregnancy ´ Lactation ´ Female and males of reproductive potential ´ Nurses should be aware of both – use a reference for drugs in question when you’re working with someone who is or may become pregnant FDA Drug Risk Categories in Pregnancy: Old ´ Previous Pregnancy-Risk Categories ´ These have been in use since 1979 and are defined as follows: Category A: No risk in human studies in first trimester Category B: No risk in animal studies (there are no adequate studies in humans, but animal studies did not demonstrate a risk to the fetus). Category C: Risk cannot be ruled out. Possible risk based on animal studies, but not human; potential benefits of the drug may outweigh the risks. Category D: Evidence of risk. Studies in pregnant women have demonstrated a risk to the fetus; potential benefits of the drug may outweigh the risks. Category X: Contraindicated. Studies in pregnant women have demonstrated a risk to the fetus, and/or human or animal studies have shown fetal abnormalities; risks of the drug outweigh the potential benefits. FDA Drug Risk Categories in Pregnancy: New ´ Pregnancy (including labor and delivery) 1. Pregnancy exposure registry 2. Risk summary 3. Clinical considerations 4. Data ´ Lactation 1. Risk summary 2. Clinical considerations 3. Data ´ Females and Males of Reproductive Potential 1. Pregnancy testing 2. Contraception 3. Infertility Audience Response System Question #1 When teaching a pregnant woman about the use of drugs during pregnancy, which statement will the nurse include? A. Exposure of the fetus to drugs is most detrimental during the second trimester of pregnancy. B. Pregnant women must never take drugs to control high blood pressure. C. Drug transfer to a fetus is most likely to occur during the last trimester of pregnancy. D. A fetus is at greatest risk for drug-induced developmental defects during the second trimester of pregnancy. SKIPPED 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 ´ Provider will consider risk-to-benefit ratio ´ Use a reference for drugs in question Neonatal and Pediatric Considerations: Pharmacokinetics ´ Absorption ´ 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 ´ Distribution ´ Greater total body water, lower body fat ´ Decreased level of protein binding ´ Immature blood–brain barrier—more drugs enter the brain Neonatal and Pediatric Considerations: Pharmacokinetics ´ Metabolism ´ Liver immature; does not produce enough microsomal enzymes ´ Older children may have increased metabolism, requiring higher doses than infants. ´ Other factors ´ Excretion ´ Kidney immaturity affects glomerular filtration rate and tubular secretion. ´ Decreased perfusion rate of the kidneys may reduce excretion of drugs. Pediatric Drug Dosing: Factors to consider ´ 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. Pediatric Dosage Calc ´ 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 Peds Medication Administration: Considerations ´ Prepare all equipment and supplies first. ´ Have caregivers stay as appropriate. ´ Assess for comfort methods before, during, and after drug administration. ´ Think about how you may need to change your approach for various age children ´ Infants ´ Toddlers ´ Preschoolers ´ School-age children ´ Adolescents Audience Response Question #2 When administering medications to pediatric patients, the nurse understands that the dosage calculations for pediatric patients are different than for adults because pediatric patients A. are more likely to develop edema. B. have more stomach acid. C. have skin that is less permeable. D. have immature liver and kidney function. Older Adults (65+): Common Considerations ´ Polypharmacy ´ Multiple drugs used to treat one condition ´ Noncompliance, nonadherence ´ Increased incidence of chronic illnesses ´ Sensory and motor deficits ´ Decline in organ function occurs with advancing age. ´ Drug therapy in older adults is most likely to result in adverse effects and toxicity 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 ´ Distribution ´ 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) Audience Response Question #3 What does the nurse identify as a pharmacokinetic change that occurs in older adults? A. Gastric pH is more acidic. B. Fat content is decreased because of increased lean body mass. C. There is increased production of proteins by the liver. D. The number of intact nephrons is decreased. Older Adults: Pharmacokinetics ´ Metabolism ´ Aging liver produces fewer microsomal enzymes, affecting drug metabolism. ´ Reduced blood flow to the liver ´ Excretion ´ Decreased glomerular filtration rate ´ Decreased number of nephrons ´ Drugs are cleared less effectively because of decreased excretion ´ Review Table 3.4 for problematic meds in OA population Back to the Nursing Process… Assessment ´ Age ´ Allergies to drugs and food ´ Dietary habits ´ Sensory, visual, hearing, cognitive, and motor-skill deficits ´ Financial status and any limitations ´ List of all health-related care providers ´ Med list ´ Do you see 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 (meds that are deemed “risky” for Older Adult population 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= Goals ´ Outcomes ´ May involve patient, caregiver, or legal guardian ´ Individualized  Be on the lookout for fall risk questions Implementation !!! ´ Rights! ´ Pediatric considerations for safe administration ´ Conceal taste ´ Age-appropriate terminology ´ Comfort and distraction ´ 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 Med Administration: Evaluation ´ Observe and monitor for therapeutic effects ´ Observe and monitor for adverse effects ´ Evaluate patient understanding of drug purpose, dose, dose frequency, adverse effects, special considerations Case Study: Read and complete while studying B. is a 6-month-old male who is being admitted for the treatment of pneumonia. The unit where B. is admitted is a combined adult and pediatric medical unit. The nurse assigned has little pediatric experience and has sought the advice of the experienced charge nurse. 1. What age-related considerations should the nurse take into account when preparing medications for B.? Case Study Continued The nurse reviews the prescriber’s orders and notes the following: Administer acetaminophen 10 mg/kg/dose every 4 hours for fever greater than 102.6 temporal. The nurse needs to administer a dose. 2. What important data would the nurse need to verify? Case Study Continued The nurse verifies the child’s weight on admission: 18.5 pounds. 3. Using the prescribed dose: 10mg/kg/dose Calculate the mg of medication B. will receive per dose. The acetaminophen unit dose label reads: Acetaminophen 160 mg/5 ml. 4. How many ml will the nurse prepare for one dose of acetaminophen for B.? (round to one decimal place) Audience Response Question #4 The nurse caring for a pediatric patient calculates the safe range for the prescribed medication. Based on the nurse’s calculations, the dose ordered exceeds the high limit. What is the nurse’s next action? A. Contact the prescriber immediately. B. Administer only half the ordered dose. C. Proceed with administration of the prescribed dose. D. Contact pharmacy to substitute the prescribed medication with one that will calculate in the safe range.