Fundamentals of Medical-Surgical Nursing: A Systems Approach PDF

Titles of related interest ISBN: 978-1-118-30665-9 ISBN: 978-0-470-67270-9 ISBN: 978-1-1183-9378-9 Review of the first edition: “This comprehensive book will “I instantly felt like I could “Interesting and readable... be indispensable throughout a relate to the book and to the most important book any student’s education.” (Nursing the ideas of the author in healthcare professional or Standard by Sarah Lovie, a way that really built trust healthcare student can own.” nursing student, Royal Cornhill between me as the reader (Amazon reviewer) Hospital) and what the book was teaching me.” (Second year adult nursing student, University of Nottingham) ISBN: 978-1-1184-4877-9 ISBN: 978-1-1184-4885-4 ISBN: 978-1-1184-4889-2 ISBN: 978-1-118-65738-6 “I love this series.... I am truly looking forward to them being published as I can’t wait to get my hands on them.” (Second year nursing student, University of Abertay, Dundee) Fundamentals of Medical-Surgical Nursing: A Systems Approach Fundamentals of Medical-Surgical Nursing: A Systems Approach EDITED BY ANNE-MARIE BRADY CATHERINE McCABE MARGARET McCANN Trinity College Dublin, Dublin, Ireland This edition first published 2014 © 2014 by John Wiley & Sons, Ltd Registered office: John Wiley & Sons, Ltd, The Atrium, Southern Gate, Chichester, West Sussex, PO19 8SQ, UK Editorial offices: 9600 Garsington Road, Oxford, OX4 2DQ, UK The Atrium, Southern Gate, Chichester, West Sussex, PO19 8SQ, UK 111 River Street, Hoboken, NJ 07030-5774, USA For details of our global editorial offices, for customer services and for information about how to apply for permission to reuse the copyright material in this book please see our website at www.wiley.com/wiley-blackwell The right of the author to be identified as the author of this work has been asserted in accordance with the UK Copyright, Designs and Patents Act 1988. 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No warranty may be created or extended by any promotional statements for this work. Neither the publisher nor the author shall be liable for any damages arising herefrom. Library of Congress Cataloging-in-Publication Data ISBN 9780470658239 Fundamentals of medical-surgical nursing : a systems approach / edited by Anne-Marie Brady, Catherine McCabe, Margaret McCann. p. ; cm. Includes bibliographical references and index. ISBN 978-0-470-65823-9 (pbk. : alk. paper) – ISBN 978-1-118-49091-4 (mobi) – ISBN 978-1-118-49092-1 (ePDF) – ISBN 978-1-118-49093-8 (ePub) – ISBN 978-1-118-51479-5 – ISBN 978-1-118-51478-8 I. Brady, Anne-Marie, 1965–, editor of compilation. II. McCabe, Catherine, editor of compilation. III. McCann, Margaret, editor of compilation. [DNLM: 1. Perioperative Nursing. WY 161] RD99.24 617'.0231–dc23 2013017938 A catalogue record for this book is available from the British Library. Wiley also publishes its books in a variety of electronic formats. 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Cover image: Veer/Alloy Photography Cover design by Visual Philosophy Set in 9.5/11 pt Calibri by Toppan Best-set Premedia Limited 1 2014 Contents About the series ix Preface x About the editors xii Contributors xiii How to get the best out of your textbook xviii About the companion website xxi Part 1: Common Principles Underlying Medical and Surgical Nursing Practice 1 Chapter 1 Principles of nursing assessment 2 Naomi Elliott Chapter 2 Principles of drug administration 12 Sue Jordan Chapter 3 Principles of intravenous therapy 26 Lisa Dougherty Chapter 4 Principles of nutritional care 44 Carolyn Best and Helen Hitchings Chapter 5 Principles of infection prevention and control 58 Sile Creedon and Maura Smiddy Chapter 6 Principles of acute care for older people 78 Louise Daly, Debbie Tolson and Anna Ayton Chapter 7 Principles of end of life care 90 Kevin Connaire Chapter 8 Principles of perioperative nursing 104 Joy O’Neill, Bernie Pennington and Adele Nightingale Chapter 9 Principles of high-dependency nursing 124 Tina Day Chapter 10 Principles of emergency nursing 142 Valerie Small, Gabrielle Dunne and Catherine McCabe Contents viii Part 2: Adult Medical and Surgical Nursing 155 Chapter 11 Nursing care of conditions related to the skin 156 Zena Moore and Julie Jordan O’Brien Chapter 12 Nursing care of conditions related to the respiratory system 176 Anne Marie Corroon and Geralyn Hynes Chapter 13 Nursing care of conditions related to the circulatory system 210 Kate Olson and Tracey Bowden Chapter 14 Nursing care of conditions related to the digestive system 240 Joanne Cleary-Holdforth and Therese Leufer Chapter 15 Nursing care of conditions related to the urinary system 262 Margaret McCann, Ciara White and Louisa Fleure Chapter 16 Nursing care of conditions related to the endocrine system 298 David Chaney and Anna Clarke Chapter 17 Nursing care of conditions related to the neurological system 326 Elaine Pierce and Mary E. Braine Chapter 18 Nursing care of conditions related to the immune system 364 Michael Coughlan and Mary Nevin Chapter 19 Nursing care of conditions related to haematological disorders 386 Mairead Ni Chonghaile and Laura O’Regan Chapter 20 Nursing care of conditions related to the musculoskeletal system 422 Sonya Clarke and Julia Kneale Chapter 21 Nursing care of conditions related to the ear, nose, throat and eye 448 Dympna Tuohy, Jane McCarthy, Carmel O’Sullivan and Niamh Hurley Chapter 22 Nursing care of conditions related to reproductive health 478 Debra Holloway and Louisa Fleure Index 510 About the series Wiley’s Fundamentals series are a wide-ranging selection of textbooks written to support pre- registration nursing and other healthcare students throughout their course. Packed full of useful fea- tures such as learning objectives, activities to test knowledge and understanding, and clinical scenarios, the titles are also highly illustrated and fully supported by interactive MCQs, and each one includes access to a Wiley E-Text: powered by VitalSource – an interactive digital version of the book including downloadable text and images and highlighting and note-taking facilities. Accessible on your laptop, mobile phone or tablet device, the Fundamentals series is the most flexible, supportive textbook series available for nursing and healthcare students today. Preface The impetus for this book came from the experience of teaching undergraduate and postgraduate nursing students and the realisation that a comprehensive textbook on medical and surgical nursing was needed to inform and guide learning related to the nursing care of adults. This book is designed to provide a broad overview and a practical understanding of the principles related to adult nursing. It examines the principles underpinning medical and surgical nursing and includes contemporary devel- opments in clinical care, drawing extensively on national and international evidence. Using a systems approach, the book is designed to provide a comprehensive application of the relevant anatomy and physiology, which will inform medical and surgical nursing practice. The book comprises 22 chapters and is presented in two sections that are designed to guide readers so they can reach an understanding of the context and the key aspects of medical and surgical nursing practice. Part 1: Common Principles Underlying Medical and Surgical Nursing Practice Part 2: Adult Medical and Surgical Nursing Part 1 addresses common principles that underpin medical and surgical nursing practice. Chapter 1 presents an overview of the principles underlying the comprehensive nursing assessment of patient care needs. The management of medications is a major component of the everyday work of the nurse in a medical-surgical environment, and Chapters 2 and 3 provide a comprehensive overview of the principles underlying care and the nurses’ responsibilities in relation to drug administration, both oral and parental. Nutritional assessment and support is a key responsibility of medical-surgical nursing care and is given detailed consideration in Chapter 4. The prevention and control of infection is dis- cussed in Chapter 5 as this a fundamental element of all healthcare practice. Influenced by changing demographics, caring for the older person represents a significant proportion of everyday medical- surgical nursing practice, and Chapter 6 seeks to develop an understanding of the unique care needs of this population. Chapter 7 aims to develop the nurse’s ability to provide appropriate and individu- alised care to families at the final stage of life. Chapter 8 provides students with an overview of the principles of perioperative nursing. High-dependency care is an increasing feature of medical and surgi- cal care environments and is addressed in Chapter 9. The final chapter in this section gives the reader an overview of emergency department nursing and an understanding of the diverse nature of present- ing medical/surgical emergencies, trauma and shock. In Part 2, a systems approach is taken to afford an overview of adult nursing in medical and surgical acute care environments. The nursing care related to all the systems is discussed in Chapters 11–22 and covers topics related to the skin and the respiratory, cardiovascular, digestive, urinary, endocrine, neurology, immune, haematological, musculoskeletal, eye/ear,/nose/throat and reproductive systems. Each chapter presents a brief overview of the related anatomy and physiology to enhance students’ understanding. All of the main conditions are considered, with a focus on relating the main concerns and priorities of medical and surgical nursing. Each chapter is associated with additional sources of information such as further reading, professional organisations and online resources. To be used in addition to the traditional text, learning outcomes, conclusion and references, the website provides a series of reflective questions to prompt further discussion in both the classroom and the work setting. Case studies are employed where possible to enable the reader to engage with Preface the content from a service provider/user perspective. Multiple choice questions are also provided to xi enable self-evaluation. The primary market for this textbook is undergraduate students in general nursing at the 3rd level in Ireland and the UK. The book should, however, be of interest to all students undertaking nursing degrees and courses in which general nursing skills are an expectation for professional performance. It will also be relevant to students of other nursing disciplines undertaking health service professional degrees who wish to understand the comorbidities of clients in their care. In additional, it will be a resource for staff already working in medical and surgical nursing. Anne-Marie Brady Catherine McCabe Margaret McCann Acknowledgements The editors wish to acknowledge and thank all of the contributors for their commitment, time and effort in sharing their professional clinical and academic expertise. We also wish to thank the reviewers who have provided us with valuable critique as we have developed this work. About the editors Anne-Marie Brady PhD BSN MSc PG Dip CHSE PG Dip Stats RGN RNT Anne-Marie Brady is an assistant professor at Trinity College Dublin and has been involved in under- graduate and postgraduate education since 2000. She has completed a PhD, PG Diploma in Clinical Health Sciences Education and in Statistics at Trinity College Dublin, and a MSc and BSN at Northeastern University Boston, Massachusetts, USA. Her particular areas of research and teaching interest are general nursing and healthcare management She has considerable international nursing experience, having worked in the UK, USA and Irish Republic. Catherine McCabe PhD MSc BSc RGN RNT Catherine McCabe has been an assistant professor at Trinity College Dublin since 2002. Her particular area of interest in teaching is general nursing and advanced nursing practice. The focus of her research is primarily exploring the effect of technology and multimedia systems on enhancing communications systems and quality of life for patients with chronic and life-threatening illnesses both in acute care settings and in the home. She has written a great deal on communication in nursing and published a number of papers on her research on communication and technology in healthcare. Margaret McCann MSc BSc RGN RNT FFNMRCSI Margaret McCann has been an assistant professor in the School of Nursing and Midwifery, Trinity College Dublin since 2005 and was previously employed as a lecturer in the Faculty of Nursing and Midwifery, Royal College of Surgeons in Ireland. She obtained an MSc in Nursing from the University of Manchester and Royal College of Nursing in 2001. She has been involved in nurse education since 1996. Margaret’s primary teaching and research interests lie in the area of urology and renal care. The focus of her research is on the prevention and control of vascular access infection in haemodialysis, and she has published a number of papers on issues relating to renal care and vascular access. Contributors Part 1 Common Principles Underlying Medical and Surgical Nursing Practice Chapter 1 Principles of nursing assessment Naomi Elliott, PhD, RGN, RNT, Assistant Professor School of Nursing and Midwifery Trinity College Dublin, Dublin, Ireland Chapter 2 Principles of drug administration Sue Jordan, MB, BCh, PhD, PGCE (FE), Reader College of Human and Health Science Swansea University Swansea, West Glamorgan, UK Chapter 3 Principles of intravenous therapy Lisa Dougherty, OBE, RN, MSc, DClinP, Nurse Consultant Royal Marsden NHS Foundation Trust Sutton, Surrey, UK Chapter 4 Principles of nutritional care Carolyn Best, BSc (Hons), RGN, Nutrition Nurse Specialist Royal Hampshire Country Hospital Winchester, Hampshire, UK Helen Hitchings, BSc (Hons), RD, Nutrition Support Dietician Royal Hampshire Country Hospital Winchester, Hampshire, UK Chapter 5 Principles of infection prevention and control Sile Creedon, PhD, MSc, BNS, RMT, RNT, RGN, Lecturer School of Nursing and Midwifery Brookfield Health Sciences Complex University College Cork, Cork, Ireland Maura Smiddy, Doctoral Student Department of Epidemiology and Public Health Western Gateway Building University College Cork, Cork, Ireland Contributors xiv Chapter 6 Principles of acute care for older people Louise Daly, PhD, MSc, BNS, RNT, RGN, Assistant Professor School of Nursing and Midwifery Trinity College Dublin, Dublin, Ireland Debbie Tolson, PhD, MSc, BSc (Hons), RGN, FRCN, Professor School of Nursing, Midwifery and Community Health Glasgow Caledonian University, Glasgow, UK Anna Ayton, MSc, BNS, RGN, Assistant Professor School of Nursing and Midwifery Trinity College Dublin/St James’s Hospital, Dublin, Ireland Chapter 7 Principles of end of life care Kevin Connaire, MSc, FFNMRCSI, PhD, BNS, RPN, RNT, RGN, Director of Education Centre for Continuing Education St Francis Hospice, Dublin, Ireland Chapter 8 Principles of perioperative nursing Joy O’Neill, RGN, BSc (Hons) Nursing Studies, Dip Business Studies, Cert Ed, Senior Lecturer Faculty of Health Edge Hill University, Manchester, UK Bernie Pennington, RGN, RODP, BA (Hons), MA Ed, Senior Lecturer Faculty of Health Edge Hill University, Manchester, UK Adele Nightingale, RODP, PGCE, BSc (Hons), Senior Lecturer Faculty of Health Edge Hill University, Manchester, UK Chapter 9 Principles of high-dependency nursing Tina Day, PhD, MSc, BSc, RN, Cert Ed. RNT, ENB100, Lecturer Florence Nightingale School of Nursing and Midwifery Kings College London, London, UK Chapter 10 Principles of emergency nursing Valerie Small, MSc, PG Dip CHSE, A&E Cert, RGN, RNT, RNP, RANP, Advanced Nursing Practitioner (Emergency) Emergency Department St James’s Hospital, Dublin, Ireland Gabrielle Dunne, MSc, FFNMRCSI, RGN, RANP, Advanced Nursing Practitioner (Emergency) Emergency Department St James’s Hospital, Dublin, Ireland Catherine McCabe, PhD, MSc, BNS, RNT, RGN, Assistant Professor School of Nursing and Midwifery Trinity College Dublin, Dublin, Ireland Contributors Part 2 Adult Medical and Surgical Nursing xv Chapter 11 Nursing care of conditions related to the skin Zena Moore, PhD, MSc, FFNMRCSI, PG Dip, Dip Management, RGN, Lecturer Faculty of Nursing and Midwifery Royal College of Surgeons in Ireland, Dublin, Ireland Julie Jordan O’Brien, MSc, RGN, Tissue Viability Nurse Specialist Beaumont Hospital, Dublin, Ireland Chapter 12 Nursing care of conditions related to the respiratory system Anne Marie Corroon, MSc, PGDip Ed, RGN, Assistant Professor School of Nursing and Midwifery Trinity College Dublin, Dublin, Ireland Geralyn Hynes, PhD, FFNMRCSI, MSc, RGN, RM, Associate Professor Faculty of Nursing and Midwifery Royal College of Surgeons in Ireland, Dublin, Ireland Chapter 13 Nursing care of conditions related to the circulatory system Kate Olson, MA, PG Dip, RN, RNT, Senior Lecturer Adult Years Division School of Health Sciences City University London, London, UK Tracey Bowden, MSc, PGDip Ed, BSc, RN, RNT, Senior Lecturer School of Health Sciences City University London, London, UK Chapter 14 Nursing care of conditions related to the digestive system Joanne Cleary-Holdforth, MSc, BSc, RGN, RM, Lecturer School of Nursing Dublin City University, Dublin, Ireland Therese Leufer, PGDip Ed, BSc, RGN, Lecturer School of Nursing Dublin City University, Dublin, Ireland Chapter 15 Nursing care of conditions related to the urinary system Margaret McCann, MSc, FFNMRCSI, BNS (Hons), Certificate Nephrology Dialysis & Transplantation, RNT, RGN, Assistant Professor School of Nursing and Midwifery Trinity College Dublin, Dublin, Ireland Ciara White, MSc Nursing (Renal), Graduate Certificate Nurse Education, RNT, RGN, Renal Nurse Education Facilitator Centre of Education Beaumont Hospital, Dublin, Ireland Louisa Fleure, MSc, PgDip, BSc (Hons), RN, Prostate Cancer Specialist Nurse Urology Centre Guy’s Hospital, London, UK Contributors xvi Chapter 16 Nursing care of conditions related to the endocrine system David Chaney, PhD, PG Dip CHSE, MSc, BNS (Hons), DPSN, RNT, RGN, Lecturer Nursing Research Institute School of Nursing University of Ulster Derry∼Londonderry, Northern Ireland, UK Anna Clarke, PhD (diabetes education), MSc, Higher Diploma Diabetes Nursing, SCM, RGN, Health Promotion & Research Manager Diabetes Federation of Ireland, Dublin, Ireland Chapter 17 Nursing care of conditions related to the neurological system Elaine Pierce, PhD, BSc (Hons), RCNT, ENB148 Neuromedical and Neurosurgical Nursing, RN (RSA), RM, RGN, Principal Lecturer London South Bank University, London, UK Mary E. Braine, D.Prof, PGCert HEPR, MSc, BSc (Hons), RN, Lecturer School of Nursing and Midwifery College of Health and Social Care University of Salford, Manchester, UK Chapter 18 Nursing care of conditions related to the immune system Michael Coughlan, MEd. BNS, RNT, RGN, RPN, Assistant Professor School of Nursing and Midwifery Trinity College Dublin, Dublin, Ireland Mary Nevin, MSc, BNS (Hons), RNT, RGN, Clinical Nurse Tutor School of Nursing and Midwifery Trinity College Dublin, Dublin, Ireland Chapter 19 Nursing care of conditions related to haematological disorders Mairead Ni Chonghaile, MSc, BNS, RGN, Transplant Co-ordinator Hope Directorate St James’ Hospital, Dublin, Ireland Laura O’Regan, MA (Med Law & Ethics), Cert Tropical Med, Dip Physiology & Counselling, BSc in Cancer Nursing, RGN, BMT Coordinator Faculty of Health and Social Care St George’s, University of London, and Kingston University, London, UK Chapter 20 Nursing care of conditions related to the musculoskeletal system Sonya Clarke, MSc, PGCE (Higher Education), PG Cert (Pain Management), BSc (Hons) Specialist Prac- titioner in Orthopaedic Nursing, RCN, RGN, Teaching Fellow School of Nursing and Midwifery Queen’s University Belfast Belfast, Northern Ireland, UK Julia Kneale, MSc, BSc, RN, Senior Lecturer School of Nursing and Caring Sciences Faculty of Health University of Central Lancashire Preston, Lancashire, UK Contributors Chapter 21 Nursing care of conditions related to the ear, nose, throat and eye xvii Dympna Tuohy, MSc Nursing, Graduate Diploma Medical-Surgical Nursing, BNS (Hons), ICU Certificate, RNT, RGN, Lecturer Department of Nursing and Midwifery University of Limerick, Limerick, Ireland Jane McCarthy, MSc, BNS, RNT, RM, RGN, Lecturer Department of Nursing and Midwifery University of Limerick, Limerick, Ireland Carmel O’Sullivan, RGN, Clinical Nurse Manager 2 ENT Ward Mid-Western Regional Hospital, Limerick, Ireland Niamh Hurley, MHSc (Nursing), ENB 998, ENB 346, RGN, Clinical Nurse Manager 2 Eye Ward Mid-Western Regional Hospital, Limerick, Ireland Chapter 22 Nursing care of conditions related to reproductive health Debra Holloway, MSc, BA (Hons), RGN, Nurse Consultant in Gynaecology McNair Centre Guy’s Hospital, London, UK Louisa Fleure, MSc, PgDIp, BSc (Hons), RN, Prostate Cancer Specialist Nurse Urology Centre Guy’s Hospital, London, UK How to get the best out of your textbook Welcome to the new edition of Fundamentals of Medical-Surgical Nursing: A Systems Approach. 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About the companion website Don’t forget to visit the companion website for this book: www.wileyfundamentalseries.com/medicalnursing You’ll find valuable material designed to enhance your learning, including: Interactive multiple-choice questions Reflective questions Case studies Links to online resources Part 1 Common Principles Underlying Medical and Surgical Nursing Practice Chapter 1 Principles of nursing assessment 2 Chapter 2 Principles of drug administration 12 Chapter 3 Principles of intravenous therapy 26 Chapter 4 Principles of nutritional care 44 Chapter 5 Principles of infection prevention and control 58 Chapter 6 Principles of acute care for older people 78 Chapter 7 Principles of end of life care 90 Chapter 8 Principles of perioperative nursing 104 Chapter 9 Principles of high-dependency nursing 124 Chapter 10 Principles of emergency nursing 142 1 Principles of nursing assessment Naomi Elliott School of Nursing and Midwifery, Trinity College Dublin, Dublin, Ireland Contents Introduction 3 Documenting patient assessment and The purpose of nursing assessment 3 record-keeping 9 Assessment frameworks 4 Conclusion 10 Methods of assessment 6 References 10 Rapid assessment of the acutely ill patient 8 Learning outcomes This chapter will examine the WHY, WHAT, HOW questions of nursing assessment. It will enable you to ask: Why – to explain the purpose of nursing assessment and why it is vital to quality patient care What – to consider what patient information is collected and the rationale for using an assessment framework How – to identify a range of methods available to assess patients and collect information that support clinical decision-making and individualised patient care plans. Fundamentals of Medical-Surgical Nursing: A Systems Approach, First Edition. Edited by Anne-Marie Brady, Catherine McCabe, and Margaret McCann. © 2014 John Wiley & Sons, Ltd. Published 2014 by John Wiley & Sons, Ltd. Principles of nursing assessment Chapter 1 Introduction 3 Assessment is the first step in determining the condition of the patient’s health and their immediate and long-term needs. The nursing assessment of patients on admission to hospital or on attendance at clinics is key to clinical decision-making and to planning patient care that takes account of the indi- vidual patients’ needs and circumstances. Nurses have responsibility for carrying out the initial and ongoing patient assessments, for initiating interventions that take patients’ needs into consideration and for evaluating the effectiveness of these interventions. The nursing assessment is one component within a larger, multidisciplinary team assessment during which the patient is assessed by different healthcare professionals as part of the care pathway and patient referral process. A multifactorial assessment of the older person for falls, for example, can involve the nurse, doctor, physiotherapist, occupational therapist, optician and other healthcare profes- sionals working in specialist areas of practice such as cardiac assessment. As a member of the multi- disciplinary team, the nurse often plays a key role in coordinating the patient assessment and ensuring that appropriate referrals are made and followed up. The principles of nursing assessment presented in this chapter are in line with the national guidelines from the professional nursing board in Ireland, An Bord Altranais, and in the UK the Nursing and Mid- wifery Council (NMC). The principles need to be read in conjunction with local policies and procedures for the nursing assessment, which are usually set by the hospital or healthcare employer. At ward or unit level, more specific assessment procedures may apply; for example, cerebrovascular or stroke units may include an assessment of swallowing and mood as part of the assessment of a patient newly diagnosed with a cerebrovascular accident – a stroke. The purpose of nursing assessment Assessment is the first stage in the nursing process and is key to developing a care plan that is tailored to a patient’s individual needs (Figure 1.1). The purpose of assessment is to achieve the following: Obtain baseline data and track changes. On admission to hospital or on a first visit to the clinic, it is important to carry out a comprehensive assessment of the patient to establish a set of baseline data against which subsequent assessments can be compared and any changes indicating a dete- rioration or improvement in the patient’s condition tracked. Early recognition of the critically ill or deteriorating patient. Identifying patients who are ‘at risk’ is key to initiating a rapid response from the medical emergency or rapid response team. ‘Track and Trigger’ (e.g. Alert® and other early warning systems) incorporate objective physiologi- cal and subjective criteria that can be used to support the nurse’s decision about when to call the medical team for help and avert more serious patient emergencies (National Institute for Health and Clinical Excellence [NICE], 2007). If a Track and Trigger system has not been set up in the hospital, a nurse who is concerned about a patient should take urgent action and notify the medical team. Risk assessment. Assessment is the first step in preventing complications, the aim being to iden- tify patients who are ‘at risk’ of developing complications associated with their healthcare problem, hospitalisation and reduced mobility. Key areas for risk assessment include pressure ulcers, infec- tion, falls and constipation. Local hospital policy may include risk assessment tools as part of the admission procedure, for example the Braden, Waterlow and Norton scores to identify patients at risk of pressure ulcers and to activate an action plan and interventions to prevent pressure ulcers developing. Screening for health problems. Nursing assessment provides an ideal opportunity for health promotion and for screening patients for risk factors associated with obesity, cancer, cardiovascular disease, diabetes mellitus and other major Irish and UK health problems. It also provides the opportunity to screen for specific problems such as emotional distress or organisms important in infection control (e.g. methicillin-resistant Staphylococcus aureus [MRSA] and vancomycin-resistant Enterococcus [VRE]). Part 1 Common Principles Underlying Medical and Surgical Nursing Practice 4 Assessment Identify patient needs and problems Evaluation Identify priorities of care Individualised patient Care delivery care plan Figure 1.1 Assessment – the first stage in the process of planning patient care. Identify actual and potential problems and prioritise care. The patient’s current problems (actual problems) and problems that could develop in the future (potential problems) need to be identi- fied so that the care plan can be tailored to individual patient needs. Importantly, once the range of patient problems has been identified, care can be prioritised so that major problems are dealt with first. Care planning, tailored to individual patient needs. The purpose of assessment is not only to determine and document the patient’s current condition, but also to provide evidence for the planning and provision of nursing care. Although standardised care plans are available in some units or hospitals, the nursing actions that are required to meet a patient’s needs and problems should be tailored to take account of individual patient needs. Discharge planning. Patient assessment also includes the early identification of patients’ needs for forward planning and organising the supports and community services necessary to facilitate a timely discharge from hospital. Recent trends indicate that patients’ stay in hospital is shortening, the use of day surgery is increasing, and policies on early discharge and discharge planning are setting the standards for healthcare practice (Capelastegui et al. 2008; Saczynski et al. 2010; Shep- perd et al. 2010). Although the reasons for a delay in discharging the patient home from hospital are multifactorial, patient assessment that includes information about the patient’s home and social circumstances, family and community supports will help prevent problems arising from a poor knowledge of a patient’s home situation or the support available, and will avert delays related to non-medical reasons. Assessment frameworks An important principle underpinning the nursing approach to patient assessment is that it is systematic, comprehensive and person-centred. Many of the assessment frameworks used in clinical practice are linked to nursing theories such as the activities of living (Roper et al. 2000) or the self-care deficit theory of nursing (Orem 2001), or to other theory including Maslow’s (1999) hierarchy of needs. Nursing models and theories serve as a guide for clinical practice and provide for a structured approach insofar as they map out what areas to include in a patient assessment. The number of new or modified assessment frameworks for nursing practice is ever increasing, but a common feature across different nursing assessments is the inclusion of the core aspects of physical, psychosocial and spiritual assessment within the context of family, community and environment (Figure 1.2). The deci- sion of which assessment framework to use is made by healthcare organisations and nursing manage- ment, who then oversee its implementation in their admission procedures and nursing documentation. This is important because it provides a way of assuring a standardised approach to nursing assessment and quality patient care. Principles of nursing assessment Chapter 1 Family 5 Psychosocial Physical Spiritual Community Environment Figure 1.2 Key aspects to include in a patient assessment. In terms of how this translates into practice and what information is gathered during the nursing assessment, the broad areas to consider include biographical and health data, a systematic review of patient systems and functions, and a social assessment: Biographical and health data. Obtaining information about the patient’s health history is vital for putting the current problem or illness into context (Kaufman 2008). Assessment of...... in relation to the following aspects The patient’s understanding of the reason Identifying significant information that for admission affects current health status and Biographical and contact details care-planning Religion Past medical and surgical history Previous history of healthcare- associated infections, e.g. MRSA, VRE and Clostridium difficile Allergies Drugs and medications The patient’s knowledge of hospital policy, such as visiting, patients’ property and valuables Patient assessment. This involves a ‘head-to-toe’ systematic review of the patient. A review of systems and functions enables the nurse to elicit information about problems and provide vital clues to support a clinical diagnosis or uncover a problem of which the patient is unaware. The depth of the patient assessment will depend on the patient’s condition and the urgency of the clinical situation (Tagney 2008). Assessment of...... in relation to the following aspects Breathing; smoking history The key problem as identified by the patient Cardiovascular system Changes in function Communication Coping strategies in dealing with changes Diet, nutrition and hydration Level of dependence/independence Elimination The patient’s normal activity, function and Mobility behaviour Personal hygiene Health beliefs and lifestyle behaviour Skin condition Preventive health measures including Sleep patterns screening and immunisation Sexual health Concerns, anxieties, fears and mood Part 1 Common Principles Underlying Medical and Surgical Nursing Practice Social assessment. Taking a social history enables an early identification of patients’ needs and problems that might delay discharge from hospital. Social history-taking is not always considered 6 a priority in acute healthcare services, but it helps nurses to identify the patient’s needs so that appropriate referrals can be made to the health and social services and service delivery is coordi- nated (Atwal 2002). Assessment of...... in relation to the following aspects Marital status Impact of the health problem on work, Occupation day-to-day living, lifestyle and family Whether the patient is living alone or with Coping strategies – how the patient others, has a carer or is providing care for currently manages to deal with problem another person Current supports used by the patient Social networks and supports Identification of unmet support service Housing or accommodation situation needs Informal support from family, neighbours or voluntary community groups Current community or home services – does the patient have a home help or meals-on-wheels, go to a day centre or receive support from a public health (or community) nurse or other personnel? Access to shops for food, chemist, doctor, dentist, health clinic, bank/post office Access to exercise or sports facilities Visit www.wileyfundamentalseries.com/medicalnursing and read Reflective Question 1.1 to think more about this topic. Methods of assessment The methods of assessment that are used to gather the information for clinical decision-making include interviewing the patient and obtaining a health history, carrying out a physical examination, making clinical observations and using risk assessment tools. Interviewing and obtaining a health history Taking a patient history is an essential part of assessment as an accurate history can provide over 80% of the information required for diagnosis (Epstein et al. 2008). Obtaining an accurate history is not just about asking a list of questions, but also requires establishing an effective patient–nurse relationship in which the patient feels that the nurse is interested in understanding their healthcare problems (Elliott 2010). This involves putting patients at their ease, providing as much privacy as possible, ensuring the nurse is familiar with any information already gathered, being sensitive to cultural differences and inviting patients to tell their story (Tagney 2008). Once the introductions have been completed, obtaining a health history begins with inviting the patient to tell their story and using an open question such as, ‘Can you tell me what has brought you here today?’ After an explanation has been given, the nurse moves to asking key and targetted ques- tions to build up a comprehensive picture of the patient’s problem: ‘How has it affected you? Have you noticed what makes it worse or what helps? Have you noticed any changes in... ? How does this compare with previous times you have had this problem?’ More targetted questions are used to focus on eliciting whether there are any associated symptoms so the nurse needs to be familiar with the patterns associated with specific health problems. Investing in the end of the interview and considering the closing questions is vital to ensuring ongoing continuity in the patient–nurse relationship in future consultations. Ending the interview involves Principles of nursing assessment Chapter 1 summarising, framing information using the patient’s perspective and providing opportunity for the patient to add further information. A closing question such as ‘Is there anything else we haven’t covered that you would like to discuss?’ enables patients to provide additional information. During the first 7 nurse–patient encounter, some patients may find it difficult to disclose problems and may be unwilling to do so until they know and have established a trusting relationship with the nurse. One helpful way in which the nurse can let the patient know there will be further opportunities to discuss issues is by saying, for example, ‘If you think of anything else later on, let me know and we can have a chat then.’ Physical examination Physical examination provides objective data and is used to corroborate evidence gathered from the patient interview and clinical observation. Examination involves measurement of the ‘vital signs’, includ- ing temperature, heart rate, respiratory rate and blood pressure. The patient’s weight is recorded and, if indicated, the patient’s body mass index may also be calculated to determine whether the patient has a normal weight or is under- or overweight. Urinalysis using a dipstick reagent strip and a clean sample of fresh urine from the patient is used to screen for abnormal substances such as glucose or protein. Any abnormalities detected in the urinalysis should be followed up by more specific laboratory tests to investigate the cause and perhaps detect a previously undiagnosed condition such as diabetes mellitus. The patient’s skin condition is examined; in addition to carrying out a pressure ulcer risk assessment, any abnormalities such as the presence of bruises, rashes and peripheral oedema are noted. Clinical observation Observation is an integral part of patient assessment as it provides an additional layer of information gathered during the patient–nurse interaction, physical examination and routine ward-based tests. Observation provides a means of gathering vital indicators about the patient’s condition and well-being, and this information contributes to the overall evidence supporting clinical decision-making. During the interaction with the patient, the nurse takes note of non-verbal cues. Indicators of patient anxiety or distress can prompt the nurse to investigate further using gentle questioning or to return for a follow-up visit if the patient is unwilling or not ready to discuss their problems at that time. Observing patients as they walk around the ward, move from chair to bed, get dressed and close buttons or zips can provide important information about their mobility, balance and dexterity. Observ- ing the patient’s general appearance includes noting the colour of the face and body and any abnormal signs such as nasal flaring, which can indicate respiratory distress. Abnormal smells or odours such as the odour of ketones on the patient’s breath may indicate fasting or diabetic ketoacidosis. Observing the patient’s behaviour noting inappropriate responses and actions can indicate neurological, meta- bolic, endocrine or mental health problems. Information gathered from observing the patient is used along with that assimilated from the patient interview and physical examination to make sense of the patient’s health problem and to support clini- cal decision-making. Assessment tools Nurses can make use of a range of assessment tools and rating scales as part of their assessment of the patient. These provide a standardised approach to assessing specific aspects of the patient’s condi- tion that can otherwise be difficult to measure (Table 1.1). The Glasgow Coma Scale (Teasdale & Jennett 1974), for example, provides a means of assessing a patient who is becoming increasingly drowsy and unresponsive and, importantly, enables nurses to com- municate the findings in a way that other healthcare professionals will understand. Using the Glasgow Coma Scale, the patient is assessed on three specific items of (1) best eye-opening, (2) best verbal response, and (3) best motor response. The patient’s response on each of these items is converted into a numerical score, with the total score used to determine the level of consciousness. The Early Warning Score (EWS; McGaughey et al. 2007) is an example of another type of tool that not only measures the patient’s status, but also identifies an action plan for the healthcare professional Part 1 Common Principles Underlying Medical and Surgical Nursing Practice Table 1.1 Examples of assessment tools and rating scales 8 Assessment aspect Assessment tools and rating scales Level of Glasgow Coma Scale (Teasdale & Jennett 1974) consciousness AVPU (Alert, Voice, Pain, Unresponsive; McNarry & Goldhill 2004) Acutely ill or patient Alert® (Smith 2003) deteriorating Manchester Triage Scale (Manchester Triage Group 2006) Early Warning Score (McGaughey et al. 2007) Pressure ulcer risk Braden scale (Bergstrom et al. 1987) Waterlow score (Waterlow 2005) Norton score (Norton et al. 1975) Moving and handling Manual Handling Assessments in Hospitals and the Community: An RCN Guide (Royal College of Nursing 2003) Falls Falls – the Assessment and Prevention of Falls in Older People (NICE 2004) Pain Pain thermometer – numeric rating scale Abbey Pain Scale for patients who are unable to verbalise or articulate their needs (Abbey et al. 2004) Patient distress National Comprehensive Cancer Network Guidelines Distress Management, Version 1.2011 (National Comprehensive Cancer Network 2011) Bowel elimination Bristol Stool Form Chart (Lewis & Heaton 1997, © 2000 Norgine Ltd.) Rome III criteria (Longstreth et al. 2006) Eton scale for constipation (Kyle et al. 2005) to follow. In the EWS, the physiological parameters are set and used to initiate further interventions. For example, if a patient’s temperature exceeds a predetermined level, blood cultures will be taken. Other assessment tools are used to identify patients at risk, for example, of developing pressure ulcers. These predictive tools help nurses to identify at-risk patients so that interventions can be put in place to prevent pressure ulcers occurring. Pressure ulcer risk assessment tools are, however, only one component of risk assessment. Gould et al. (2002) found that tools such as the Braden, Waterlow and Norton scales are not always accurate as they can either over- or underpredict risk. Therefore, pressure ulcer risk assessment tools serve as guides, and the nurse’s own clinical judgement should also be taken into consideration. Patient self-assessment tools are also available whereby patients use a visual analogue scale or brief questionnaire to assess themselves. The pain thermometer is one example – on this, the patient scores how severe the pain is by using a rating scale of 1–10 where 1 is no pain and 10 is the worst pain imaginable. Another example of such a tool is the patient distress self-assessment tool developed by the National Comprehensive Cancer Network (2011) in America. This uses a distress ‘thermometer’ along with a tick box checklist of practical, family, emotional and physical problems and spiritual or religious concerns encountered with cancer patients. Rapid assessment of the acutely ill patient A full patient assessment that includes a detailed review of physical, psychosocial and preventive health needs, a physical examination and routine tests can take several hours to complete. An in-depth assess- ment requires time and is appropriate for elective, non-emergency cases and for patients on their first visit or admission to the hospital or clinic. Given that nurses also work in acute care situations, however, Principles of nursing assessment Chapter 1 rapid assessment skills are also important, especially as the early recognition of a deterioration in the critically ill or unstable patient is vital to managing the care of such acutely ill individuals. Depending on how acute or unstable the patient’s condition is, some examples of rapid assessment systems are 9 outlined here. ‘Track and Trigger’ Delays in recognising patients who are acutely ill on admission to hospital or in detecting clinical dete- rioration during their hospital stay can result in serious consequences. An analysis of 425 patient deaths that occurred in UK acute hospitals in 2005 showed that 64 deaths were related to a failure to detect and recognise changes in patients’ vital signs, a failure to act upon the worsening vital signs or delays in the patient receiving medical attention (National Patient Safety Agency 2007). To avoid delays in the detection and recognition of acute illness and in starting appropriate inter- ventions, NICE (2007) recommends that a physiological Track and Trigger system is used to monitor all adult patients in acute hospital care settings. NICE recommends that the patient’s heart rate, respiratory rate, systolic blood pressure, level of consciousness, oxygen saturation and temperature are monitored and that key changes in these physiological observations are used to trigger a response. The response to a low score involves increasing the frequency of observations and alerting the nurse in charge to changes in the patient’s condition. The response to a medium score involves making an urgent call to the patient’s primary medical team, and the response to a high score involves making an emergency call to the medical team, which includes a doctor skilled in assessing critically ill patients and in advanced airway management and resuscitation skills. In addition to initiating appro- priate interventions, the Track and Trigger system includes information about when to transfer the patient to the critical care area for ongoing care. Alert® For use in situations in which a patient is deteriorating, some hospitals have introduced the Alert® system for rapid assessment of the critically ill patient. This acts as a decision-making tool to alert healthcare professionals to patients who are acutely ill, to determine the level of urgency and to know when to call the emergency medical team. The Alert® framework (Smith 2003) is just one example of a rapid and systematic approach to assessment that trains healthcare professionals to rapidly assess a patient whose condition is deteriorating. It follows an ABCDE sequence in which A is airway, B is breath- ing, C is circulation, D is disability (neurological assessment including assessment of the level of con- sciousness and/or use of the Glasgow Coma Scale) and E is exposure (anything that may contribute to the patient’s deterioration). Cardiopulmonary resuscitation In emergency, cardiac arrest and life-threatening situations in which the patient is unresponsive, the immediate priorities are to assess the patient for signs of life (Resuscitation Council UK 2010). If the patient shows no signs of life, the nurse calls the resuscitation team and if no carotid pulse is present, starts cardiopulmonary resuscitation. Once these priorities have been addressed, other important assessments can then be made. Documenting patient assessment and record-keeping After assessing the patient, it is important that nurses record their findings and so provide documentary evidence about the patient’s condition. This written information is vital for providing baseline data and ensuring continuity of patient care. It provides information that other nurses and healthcare profes- sionals can refer to when planning and coordinating patient care. Although patient assessment forms and nursing documentation are set by local hospital policy and procedures, the national professional guidelines for recording nursing practice and patient assessment advise the following: Part 1 Common Principles Underlying Medical and Surgical Nursing Practice An accurate assessment of the person’s physical, psychological and social well-being, and, when- ever necessary, the views and observations of family members in relation to that assessment’ 10 should be included in a patient record. (An Bord Altranais 2002, p. 2) Evidence in relation to the planning and provision of nursing care should be included as part of a patient record. (An Bord Altranais 2002, p. 2) Record details of any assessment and reviews undertaken, and provide clear evidence of the arrangements made for future and ongoing care. This should also include details of information given about care and treatment. (NMC 2009, p. 4) The information gathered from an assessment when the patient is first admitted to hospital or first visits an outpatient clinic needs to be recorded. It provides the evidence to support clinical decisions and a rationale for the individualised patient care plan. Ongoing or continuous patient assessment when monitoring to evaluate changes in a patient’s condition in changing circumstances also needs to be recorded, and nursing actions documented. Nursing assessment may also identify patient problems that need to be referred for further assessment by an appropriate healthcare professional such as a physiotherapist, dietitian, social worker, speech therapist or occupational therapist. The importance of nursing documentation is emphasised by policy-makers and professionals in Ireland (An Bord Altranais, 2002), the UK (NMC, 2009) and internationally (Wang et al. 2011). However, evidence from a review of quality audits of nursing documentation in actual clinical practice has revealed some deficiencies (Wang et al. 2011). Although documentation does not always capture the full extent of what happens in actual nursing practice, Wang et al. found several studies that revealed insufficient recording of psychological, social, cultural and spiritual aspects of care. Other deficiencies highlighted by these authors included a lack of documentation of the patient’s vital signs, diagnosis leading to hospitalisation, assessment of pressure ulcers and assessment for specific care issues, including older patients with chronic heart failure, the physical characteristics of wounds or patients with pain and cognitive impairment. The implications for practice, therefore, are that if docu- mentation is to serve as a vital communication tool between nurses and other caregivers for the exchange of information gathered at assessment, attention needs to be paid to ensuring there are no gaps in documenting patient assessment. Conclusion The nursing assessment of the patient is complex as it involves using different methods to gather information on diverse aspects of patient care across a range of acute and chronic healthcare situations. Nursing assessment generates information that is used to inform nursing actions and inter- ventions. From this information, the patient’s problems are identified, further investigations to deter- mine the cause of the problem are selected, and decisions are made about what observations need to be tracked and which referrals to other healthcare professionals are needed. The pace at which nursing assessment is carried out is determined by the patient’s condition and whether it is an emergency, the level of patient distress, how quickly the patient’s condition is deterio- rating, whether the patient’s condition is stable or unstable, and whether the patient is presenting with an acute or chronic illness. The principles of nursing assessment in this chapter are intended to serve as a framework to guide nurses in organising their patient assessment. The key to nursing assessment, however, is to listen to the patient and work towards an understanding the nature of the healthcare problem from the patient’s perspective. Now visit the companion website and test yourself on this chapter: www.wileyfundamentalseries.com/medicalnursing References Abbey, J., Piller, N., DeBellis, A. et al. (2004) The Abbey pain scale: a 1-minute numerical indicator for people with end-stage dementia. International Journal of Palliative Nursing, 10(1):6–13. An Bord Altranais (2002) Recording Clinical Practice: Guidance to Nurses and Midwives. Dublin: An Bord Altranais. Principles of nursing assessment Chapter 1 Atwal, A. (2002) Nurses’ perceptions of discharge planning in acute health care: a case study in one British teaching hospital. Journal of Advanced Nursing, 39(5):450–8. Bergstrom, N., Braden, B.J., Laguzza, A. & Holma, V. (1987). The Braden Scale for predicting pressure sore risk. Nursing 11 Research, 36(4):205–10. Capelastegui, A., España, P.P., Quintana, J.M. et al. (2008) Declining length of hospital stay for pneumonia and post- discharge outcomes. American Journal of Medicine, 121(10):845–52. Elliott, N. (2010) ‘Mutual intacting’: a grounded theory study of clinical judgement practice issues. Journal of Advanced Nursing, 66(12):2711–21. Epstein, O., Perkin, D., Cookson, J., et al. (2008). Clinical Examination, 4th ed. Edinburgh: Mosby. Gould, D., Goldstone, L., Gammon, J., Kelly, D. & Maldwell, A. (2002) Establishing the validity of pressure ulcer risk assessment scales: a novel approach using illustrated patient scenarios. International Journal of Nursing Studies, 39(2):215–28. Kaufman, G. (2008) Patient assessment: effective consultation and history taking. Nursing Standard, 23(4): 50–6. Kyle, G., Prynn, P., Oliver, H. & Dunbar, T. (2005) The Eton Scale: a tool for risk assessment for constipation. Nursing Times, 101(18):50–1. Lewis, S.J., & Heaton, K.W. (1997) Stool form scale as a useful guide to intestinal transit time. Scandinavian Journal of Gastroenterology, 32:920–4. Longstreth, G., Thompson, W.G., Chey, W., Houghton, L., Mearin, F. & Spiller, R. (2006) Functional bowel disorders. Gastroenterology, 130:1480–91. McGaughey, J., Alderdice, F., Fowler, R., Kapila, A., Mayhew, A. & Moutray, M. (2007) Outreach and Early Warning Systems (EWS) for the prevention of intensive care admission and death of critically ill patients on general hospital wards. Cochrane Database of Systematic Reviews, (3):CD005529. McNarry, A.F., & Goldhill, D.R. (2004). Simple bedside assessment of level of consciousness: comparison of two simple assessment scales with the Glasgow Coma Scale. Anaesthesia, 59:34–7. Manchester Triage Group (2006) Emergency Triage/Manchester Triage Group, 2nd ed. London: BMJ. Maslow, A.H. (1999) Toward a Psychology of Being. New York: Wiley. National Comprehensive Cancer Network (2011) NCCN Clinical Practice Guidelines in Oncology, Distress Manage- ment. Version 1.2011. Retrieved 7th March 2011 from http://www.nccn.org/professionals/physician_gls/pdf/ distress.pdf. 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(2000) The Roper-Logan-Tierney Model of Nursing: Based on Activities of Living. Edinburgh: Churchill Livingstone. Royal College of Nursing (2003) Manual Handling Assessments in Hospitals and the Community: An RCN Guide. London: RCN. Saczynski, J.S., Lessard, D., Spencer, F.A. et al. (2010) Declining length of stay for patients hospitalized with AMI: impact on mortality and readmissions. American Journal of Medicine, 123(11):1007–15. Shepperd, S., McClaran, J., Phillips, C.O., et al. (2010) Discharge planning from hospital to home. Cochrane Database of Systematic Reviews, (1):CD000313. Smith, G. (2003) ALERT: Acute Life Threatening Events, Treatment and Recognition. Portsmouth: University of Portsmouth. Tagney, J. (2008) Skills in taking an accurate cardiac patient history. British Journal of Cardiac Nursing, 3(1):8–13. Teasdale, G., & Jennett, B. (1974) Assessment of coma and impaired consciousness. A practical scale. Lancet, 13(2), 81–4. Wang, N., Hailey, D. & Yu, P. 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London: Wound Care Society. 2 Principles of drug administration Sue Jordan College of Human and Health Science, Swansea University, Swansea, West Glamorgan, UK Contents Introduction 13 Conclusion 21 Drug formulation 13 References 21 How the body handles drugs: Further reading 23 Pharmacokinetics 13 Glossary 24 Therapeutics 21 Learning outcomes Having read this chapter, you will be able to: Understand how changes in drug formulations affect drug absorption and therapeutic outcome Discuss the nursing implications of the pharmacokinetics of oral administration Relate principles of drug absorption, distribution and elimination to the management of medications Describe the precautions taken to ensure that changes in drug elimination do not adversely affect patients Fundamentals of Medical-Surgical Nursing: A Systems Approach, First Edition. Edited by Anne-Marie Brady, Catherine McCabe, and Margaret McCann. © 2014 John Wiley & Sons, Ltd. Published 2014 by John Wiley & Sons, Ltd. Principles of drug administration Chapter 2 Introduction Medical advances of the latter half of the 20th century produced drugs powerful enough to correct pathophysiological disturbance; however, alterations in physiology may have unintended consequences. 13 It is estimated that twice as many people die from medical errors as from breast cancer, motor vehicle accidents or HIV/AIDS (Kohn et al. 1999), and preventable adverse drug reactions (ADRs) account for some 3.7% of hospital admissions (Howard et al. 2007). Medication administration is increasing in complexity. More physiologically vulnerable patients are sustained by complex regimens, narrowing the margin for error. Without due attention to drug administration and elimination, the amount of drug entering or leaving the body can fluctuate, resulting in either therapeutic failure or ADRs. Drug formulation The formulation of a medicine refers to its physical and chemical composition. This includes both the specified active ingredients and other chemicals present, the excipients or ‘packing chemicals’, as listed on the product label. The formulation, together with absorption (see the section on ‘Absorption’), determines the extent to which the drugs reach their destinations, i.e. their bioavailability. Excipients Excipients stabilise the active ingredient or modify its release. They may be responsible for ADRs. For example, some medicines contain sodium ions (e.g. some penicillins and warfarin) or potassium ions (e.g. some multivitamin preparations). The sodium content of many antacid indigestion remedies and some proprietary analgesics can be sufficient to precipitate fluid retention and breathlessness in people with incipient heart failure. Aspartame is present in many drugs, for example co-amoxiclav and dida- nosine; these products should be avoided by people with phenylketonuria. Oral medicines containing sugar promote dental caries (Mentes 2001). Medicines available in ‘sugar-free’ forms contain sorbitol, which can cause diarrhoea, particularly when administered via enteral feeding tubes (Phillips & Nay 2008). Excipients may also be responsible for hypersensitivity responses. Excipients may differ between brands; therefore, the release of the active ingredients, and hence their bioavailability, may be different. Important examples include antiepileptic drugs, lithium prepara- tions, antipsychotic agents, ciclosporin and modified-release formulations. Where a condition, such as epilepsy, is controlled on a certain branded product, changing to another brand or a (cheaper) generic drug may result in a loss of disease control (Chappell 1993). Visit www.wileyfundamentalseries.com/medicalnursing and read Reflective Question 2.1 to think more about this topic. Liquids and solids The physical formulation of a drug affects its rate of absorption. Before being absorbed, tablets must disintegrate and the active ingredients must dissolve. The rate at which this occurs depends on the formulation. For example, drugs will be absorbed more rapidly and completely from liquids than tablets. This can be useful: for example, paracetamol liquid relieves pain more rapidly than tablets, and liquid risperidone is an effective alternative to injections of antipsychotic agents (Currier & Simpson 2001). However, when the formulation of a medicine is changed from tablets to liquid, its bioavailability increases, and ADRs may appear for the first time. How the body handles drugs: Pharmacokinetics Pharmacokinetics describes how the body absorbs, distributes and eliminates drugs. Part 1 Common Principles Underlying Medical and Surgical Nursing Practice Route Oral 14 Liver Rectal Vaginal Buccal Inhalation Organs, tissues, Circulation fetus and breast milk Injections Eyes Ears Skin Epidural injection Central nervous system Intrathecal injection Figure 2.1 Routes of administration. Arrows represent the passage of drugs. Adapted from Jordan (2010) with permission from Palgrave Macmillan. Absorption Absorption makes drugs available to the body fluids for distribution, and determines their bioavailabil- ity. Regardless of the route of administration, drugs enter the circulation; the rate and extent of absorp- tion are reduced only by topical administration (Figure 2.1). Important barriers to drug absorption and distribution include the gut wall, capillary walls, cell membranes, the blood–brain barrier, the placenta and the blood–milk barrier. Drugs administered orally pass to the liver, where they are metabolised, whereas drugs administered by other routes pass directly into the circulation. Therefore, the latter may be more effective, but they may also cause more severe ADRs. The proportion of drug passing straight into the circulation cannot be predicted with rectal, epidural or spinal administration. Drug administration Practitioners avoid touching medicines if at all possible (Railton 2007). Gloves are worn when handling drugs that could be absorbed through skin (e.g. creams, transdermal patches, anticancer drugs and nitrates) or can cause irritation and contact dermatitis (e.g. chlorpromazine) (Smith et al. 2008). Oral administration Most drugs are given orally, for convenience. All tablets and capsules should be swallowed with a full glass of water with the patient sitting upright and remaining upright for 30 minutes (McKenry et al. 2006). This prevents prolonged contact between the drug and the lining of the mouth and oesophagus, which is vulnerable to corrosive substances, particularly bisphosphonates, aspirin, iron and potassium salts. Older adults may find tablets and liquids difficult to swallow and may prefer to take orodispersible preparations with soft food, such as puddings. Principles of drug administration Chapter 2 Crushing or breaking tablets Crushing tablets alters their bioavailability, usually by hastening absorption, and this sudden rise in drug concentration can cause ADRs. Breaking, crushing or chewing enteric-coated tablets destroys their modified-release mechanisms. If a tablet is crushed or a capsule is opened, fine particles may be 15 released into the air. This may result in: absorption through the respiratory tract or skin of the administrator (cytotoxics, hormones, ster- oids or prostaglandins); the growth of resistant microorganisms in non-disposable equipment or in the lungs or skin of the administrator (antibiotics). Breaking or splitting tablets can cause large dose deviations or weight losses, with important clinical consequences. Splitting devices are used when this cannot be avoided (Verrue et al. 2011). Food Food and herbs can affect drug bioavailability by binding the drug, increasing gastric acidity, blood and bile flow, delaying gastric emptying, impairing transport across the intestine and altering elimination (Custodio et al. 2008; Tarirai et al. 2010). Foods, vitamins and herbs can also counteract or augment drug actions. Optimising drug absorption may require administration on an empty stomach or with food. Administration on an empty stomach Some drugs, for example bisphosphonates and tetracyclines, will be not be absorbed at all if given with food. These drugs should be administered 1–2 hours before or 2 hours after a meal. Food, antacids, bulk-forming laxatives and guar gum may bind to drugs, keeping them within the intestines and to a varying degree decreasing their absorption. Examples include furosemide (fruse- mide), calcium-channel blockers, erythromycin stearate, tetracyclines and iron preparations. Drugs whose absorption is decreased by food also have the potential to interact with enteral feeds. If these drugs are administered within 2 hours of an enteral feed, there is a risk that their therapeutic effect will be lost. Where enteral feeds are set to run throughout the day, specialist advice should be sought. The absorption of some drugs (e.g. iron, ketoconazole, some antifungal or antiviral agents, a few antibiotics and dipyridamole) depends on gastric acidity. Gastric acidity may be too low for drug absorp- tion between meals in older patients and those with HIV/AIDS, or if antacids, H2-receptor antagonists (e.g. ranitidine) or proton pump inhibitors (e.g. omeprazole) are co-administered (Lahner et al. 2009). Acidity may be increased by vitamin C or Coca-Cola (Schmidt & Dalhoff 2002). A few drugs, such as ampicillin and some forms of erythromycin, are destroyed by gastric acid; others, such as furosemide, metformin, atenolol and pravastatin, are less soluble in acidic environments (Marasanapalle et al. 2009). Full absorption is achieved if administration is separated from meals by 2 hours. Several enzymes and transporters (carrier proteins) are important in the absorption of nutrients and drugs from the small intestine. Some of these are inhibited by grapefruit and orange juice. The extent of this interaction varies between individuals as well as with different batches of juice. When co-administered within 2–4 hours of some drugs (e.g. the antihistamine fexofenadine, l-thyroxine, ciclosporin and atenolol), fruit juices decrease the absorption and effectiveness of the drug (Dresser et al. 2002, Bailey 2010). Protein-containing meals may reduce the absorption of some anti-Parkinson medications (such as co-beneldopa and co-careldopa), worsening the tremor, stiffness and pain, as rated by the patients themselves. Amino acids in the meal may compete with l-dopa for sites on transporters across the blood–brain barrier and the gut (Nyholm et al. 2002). Administration with food For some drugs, for example nifedipine, a drug–food interaction is beneficial in that it prevents the sudden onset of the drug’s action. Co-administration with food may ameliorate nausea or irritation of the gastrointestinal tract, although sometimes at the cost of reduced or delayed absorption, as is seen with carbamazepine, valproate, iron and aspirin. Part 1 Common Principles Underlying Medical and Surgical Nursing Practice The type of food may also be important (Custodio et al. 2008). For example, tetracyclines are not absorbed in the presence of calcium-containing foods such as dairy products, and digoxin is not absorbed with a high-fibre meal. The fat content of the meal may also be important, either because 16 the drugs dissolve in fat (e.g. isotretinoin) or because fat stimulates bile secretion, which increases drug absorption (e.g. griseofulvin) (Schmidt & Dalhoff 2002). Many studies on drug–food interactions have been undertaken with unfortified meals. The extra constituents of vitamin- or mineral-enriched foods may bind to some drugs, reducing their absorption (Wallace & Amsden 2002). For example, calcium-fortified orange juice impairs the absorption of fluoro- quinolones (Neuhofel et al. 2002). For most drugs, it is important to maintain a constant relationship between medication and meals, so that plasma concentrations of the drug do not vary from day to day. Distribution Distribution is the movement of drugs around the circulation and into the tissues and fat for storage (Figure 2.2). Distribution is affected by: Plasma protein binding. Some drugs (including antiepileptics, warfarin and anticancer agents) circulate bound to plasma proteins. When plasma protein levels are low (e.g. with malnutrition, burns or pregnancy, or in neonates), ADRs may occur. Lipid solubility, that is, whether the drug dissolves in fatty tissues, including the brain All drugs acting on the central nervous system are highly lipid soluble. Distribution and storage are affected by adiposity, age and sex. For example, those with generous fat deposits need more nitrous oxide to achieve analgesia for wound dressing and take longer to recover. Transporters embedded in cell membranes in tissues and organs, for example P-glycoprotein. Transporters regulate drug uptake and efflux, and their action may be accelerated or inhibited by co-administered drugs (Zhang et al. 2010). For example, omeprazole delays the elimination of methotrexate, risking its accumulation (Haidar & Jeha 2011). The binding properties of the drug. Some drugs have unusual binding characteristics. For example, tetracyclines bind to growing bones and teeth and should not be administered to anyone who is growing, pregnant or breast-feeding. Administration and Actions and absorption Tissue fluid adverse effects Circulation/plasma Fat for storage Fetus Elimination Breast milk Arrows represent passage of drug Figure 2.2 Drug distribution and body compartments. Arrows represent the passage of drugs. NB: The return of metabolites from fetus to mother varies between drugs. The fetus and the breast milk are distinct body compartments, which should always be considered when medicines are administered. Adapted from Jordan (2010) with permission from Palgrave Macmillan. Principles of drug administration Chapter 2 Tissues Circulation Liver Kidney Urine 17 Bile for a few drugs Arrows represent passage of drug Figure 2.3 Usual routes of drug elimination. Arrows represent the passage of drugs. Adapted from Jordan (2010) with permission from Palgrave Macmillan. Blood flow. Conditions affecting the circulation, such as heart failure, blood loss or a heart attack, divert blood, and circulating drugs, away from the peripheries and gut and towards the heart, brain and lungs. The reduced circulation to the gut means that drugs administered orally may be poorly absorbed. Visit www.wileyfundamentalseries.com/medicalnursing and read Reflective Question 2.2 to think more about this topic. Drug elimination The route of elimination varies between drugs. A few drugs are eliminated unchanged, whereas others are extensively metabolised (Figure 2.3). Drug metabolism Most metabolism occurs in the liver, but the gastrointestinal tract and the central nervous system contain enzymes responsible for the metabolism of some drugs. Metabolic processes allow the body to utilise and detoxify foreign substances. There are no simple tests to assess the liver’s capacity to metabolise and eliminate drugs (Perucca et al. 2006). Drug metabolism depends on: genetic make-up; the liver’s environment, i.e. the chemicals reaching the liver from the gut and the circulation; liver impairment, for example due to malnutrition, cirrhosis or hepatitis; the stage in the life cycle. If metabolism is accelerated, drugs will be removed too rapidly, and signs and symptoms of illness will return. However, if metabolism is inhibited or blocked, the drug will accumulate. Some foods and herbs can interfere with metabolism and increase or decrease the effects of certain drugs, and re-timing the administration of medicines may not prevent these interactions. Accelerated clearance The regular ingestion of some foods (barbecued meats, caffeine or alcohol) or drugs (including some antiepileptics, rifampicin, rifabutin, St John’s Wort and some antiviral agents) or exposure to tobacco accelerates the action of enzymes in the gut lining and liver. This can increase the rate of elimination of some drugs, for example diazepam, clozapine and oestrogens. Ciclosporin or digoxin may be ren- dered ineffective by St John’s Wort (Fugh-Berman 2000). To accommodate this, the prescriber may increase the dose of medication. Part 1 Common Principles Underlying Medical and Surgical Nursing Practice Visit www.wileyfundamentalseries.com/medicalnursing and read Reflective Question 2.3 to think more about this topic. 18 Reduced clearance The activity of certain enzymes in the gut lining and liver is inhibited not only by certain drugs, such as ketoconazole, fluoxetine, erythromycin, cimetidine and high doses of alcohol, but also by grapefruit, and possibly by grapefruit and other juices. These reduce the elimination of several drugs, particularly in the elderly: 200–250 mL of grapefruit juice can double the bioavailability of most calcium-channel blockers (except for diltiazem), the effect lasting for some 24 hours (Dresser et al. 2000). For other drugs (e.g. dextromethorphan, a cough suppressant), clearance remains low for over 3 days. Further work may expand the list of drugs affected: carbamazepine, warfarin, amphetamines, some statins, most calcium-channel blockers, some antiviral agents, sildenafil and related drugs, zopiclone, benzodi- azepines, pimozide, tacrolimus, ciclosporin, amiodarone, sertraline, buspirone, ergotamine (including LSD), some cytotoxics and ranolazine (Kiani & Imam 2007; Seden et al. 2010; British National Formulary 2011). Visit www.wileyfundamentalseries.com/medicalnursing and read Reflective Question 2.4 to think more about this topic. Drug excretion Most drugs depend on the kidneys for elimination and clearance. However, some drugs such as corti- costeroids and oestrogens are excreted via the bile (see Figure 2.3). The kidneys control salt and water balance and eliminate waste products to maintain a stable internal environment for the rest of the body. Two processes are involved: glomerular filtration (in the Bowman’s capsules), which is measured by the glomerular filtration rate (GFR), and tubular secretion and reabsorption. Drug excretion may rely on either or both of these processes, depending on the drug involved. The GFR is usually considered the best overall measure of the kidneys’ ability to eliminate drugs in health and disease (Levey et al. 1999). For several drugs, prescribers need to know the GFR before initiating therapy. If the GFR is too low, some drugs, such as lithium or metformin, will not be given. For other drugs, a reduced dose will be prescribed at prolonged intervals, as seen with gentamicin. If the GFR falls, the elimination of most drugs is impaired, causing their accumulation and ADRs. GFR is therefore regularly checked to assess any changes in the patient’s ability to eliminate drugs. It is affected by: changes in the blood flow to the kidneys, for example with dehydration (including the administra- tion of diuretics, and excess alcohol or caffeine), shock, heart failure and the administration of non-steroidal anti-inflammatory drugs (NSAIDs) or angiotensin-converting enzyme inhibitors (ACEIs); renal disorders and the loss of nephrons (e.g. repeated infection, pre-eclampsia, hypertension and long-term prostatic enlargement); acute illness, as blood flow and renal function can change rapidly, affecting drug concentrations. A urine output below 30 mL per hour must be reported because renal damage may be occurring and drugs could rapidly accumulate. sex, as women have lower GFRs than men. The combined effect of age and gender means that older women have a reduced ability to eliminate drugs, and therefore an increased risk of ADRs; the life cycle. The composition of the urine can affect drug elimination. For example, lithium is excreted more completely if salt intake is high; however, if the sodium concentration decreases, due to reduced salt intake, diarrhoea and vomiting or excessive sweating, lithium is no longer passed into the urine and can accumulate, causing toxicity. Some drugs pass more readily into an alkaline urine; therefore, a Principles of drug administration Chapter 2 100 19 Amount of drug in body (%) 75 50 25 12.5 0 1t1/2 2t1/2 3t1/2 4t1/2 5t1/2

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