CHAPTER 2 I.

A.

APPLICATION OF PHARMACOLOGY IN NURSING PRACTICE

EVOLUTION OF NURSING RESPONSIBILITIES REGARDING DRUGS

FIVE RIGHTS OF DRUG ADMINISTRATION - give the right drug to the right patient in the right dose by the right route at the right time - proper delivery is only the beginning of responsibilities: Important events will take place after the pill is delivered, and these must be responded to. - a broad base of pharmacology knowledge is needed so as to contribute fully to achieving the therapeutic objective - should include a patient advocate position PRE-TEST ? When applying pharmacology to patient care what is most important: assessment of the patient

II.
A.

APPLICATION OF PHARMACOLOGY IN PATIENT CARE

- pharmacologic knowledge is applied in patient care and patient education PRE-ADMINISTRATION ASSESSMENT 1. Goals a. collecting baseline data needed to evaluate therapeutic and adverse responses b. identifying high-risk patients . assessing the patients capacity for self care

B. C.

COLLECTING BASELINE DATA - baseline data are needed to evaluate drug responses, both therapeutic and adverse IDENTIFYING HIGH RIS! PATIENTS - predisposing factors are pathophysiology (especially liver and kidney function), genetic factors, drug allergies, pregnancy, old age, and e treme youth - tools for identification are the patient history, physical e amination and laboratory tests - need to know what to look for: factors that can increase the risk of severe reactions to the drug in !uestion PRE-TEST ? What predisposing factor can make a patient high risk when giving medications: pathophysiological conditions

D.

DOSAGE AND ADMINISTRATION 1. 2. ". #. $. %. "ead the medication order carefully# $f the order is unclear, verify it with the prescribing physician# %erify the identity of the patient by comparing the name on the wristband with the name on the drug order or administration record# "ead the medication label carefully# %erify the identity of the drug, the amount of drug (per tablet, volume of li!uid, etc#) and its suitability for administration by the intended route# %erify dosage calculations# $mplement any special handling the drug may re!uire# &ont administer any drug if you dont understand the reason for its use#

E.

EVALUATING AND PROMOTING THERAPEUTIC EFFECTS 1. E&al'a()*+ T,-.a/-'() R-s/o*s-s ' evaluation is one of the most important aspects of drug therapy - process that tells us whether or not our drug is doing anything useful - need to know the rationale for treatment and the nature and time course of the intended response P.o0o()*+ Co0/l)a* - - drugs an be of great value to patients, but only if they are taken correctly I0/l-0-*()*+ No*-1.'+ M-as'.-s ' supportive measures directly, through patient education, or by coordinating the activities of other healthcare providers

2. ".

F. MINIMI2ING ADVERSE EFFECTS ' all drugs have the potential to produce undesired effects# $n order to help reduce adverse effects, you must know the following about the drugs youre working with: - major adverse effects that the drug can produce - time when these reactions are likely to occur - early signs that an adverse reaction is developing - interventions that can minimi(e discomfort and harm G. MINIMI2ING ADVERSE INTERACTIONS ' when a patient is taking two or more drugs, those drugs may interact with one another to diminish therapeutic effects or intensify adverse effects# Ways to help reduce adverse interactions include: - taking a thorough drug history - advising the patient to avoid over the counter drugs that can interact with the prescribed medication - monitoring for adverse interactions known to occur between the drugs the patient is taking - being alert for as-yet unknown interactions MA!ING PRN DECISIONS ' )"* medication order is one in which the nurse has discretion regarding how much drug to give and when to give it# - )"* is an abbreviation that stands for pro re nata (+atin for as needed or as the occasion arises) - in order to implement a )"* order rationally, the reason for the drug use and the patients medication needs must be known PRE-TEST ? What does )"* mean: as needed I. MANAGING TO3ICITY ' some adverse drug reactions are e tremely dangerous, if to icity is not diagnosed early and responded to !uickly, irreversible injury or death can result# - early signs of to icity and the procedure for to icity management must be known

H.

III.

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-s a patient educator, you must give the patient the following information: - drug name and therapeutic category - dosage si(e - dosing schedule - route and techni!ue of administration - duration of treatment - method of drug storage - e pected therapeutic response and when it should develop - non-drug measures to enhance therapeutic responses - symptoms of major adverse effects and measure to minimi(e discomfort and harm - major adverse drug-drug and drug-food interactions

- whom to contact in the event of therapeutic failure, severe adverse reactions, or severe adverse interactions A. DOSAGE AND ADMINISTRATION 1. D.'+ Na0- ' if the drug has been prescribed by trade name, the patient should be given its generic name too - this information will reduce the risk of overdose that can result when a patient fails to reali(e that two prescriptions that bear different names actually contain the same medicine Dosa+- S)6- a*1 S ,-1'l- o4 A10)*)s(.a()o* ' patients need to be told how much drug to take and when to take it T- ,*)7'- o4 A10)*)s(.a()o* ' patients must be taught how to administer their drugs D'.a()o* o4 D.'+ Us- ' just as patient must know when to take their medicine, they must know when to stop D.'+ S(o.a+- ' certain medications are chemically unstable and hence deteriorate rapidly if stored improperly# )atients must be taught how to store their medications correctly# - all drugs should be stored where children cannot reach them

2. ". #. $.

B.

PROMOTING THERAPEUTIC EFFECTS ' patients must know the nature and time course of e pected beneficial effects - non-drug measures can complement drug therapy, teaching patients about non-drug measures can greatly increase the chances of success MINIMI2ING ADVERSE EFFECTS ' knowledge of adverse drug effects will enable the patient to avoid some adverse effects and minimi(e others through early detection MINIMI2ING ADVERSE INTERACTIONS ' patient education can help avoid ha(ardous drug-drug and drug-food interactions# 888IF IT9S NOT DOCUMENTED: IT9S NOT BEEN ADMINISTERED888

C. D.

IV.
A.

APPLICATION OF NURSING PROCESS IN DRUG THERAPY

REVIE; OF NURSING PROCESS 1. Ass-ss0-*( ' consists of collecting data about the patient - methods of data collection are: patient interview medical and drug use histories physical e amination observation of the patient laboratory tests 2. A*al5s)s< N'.s)*+ D)a+*os)s ' nurses analy(e the database to determine the actual and potential health problems, which can be physiologic, psychologic or sociologic - nursing diagnosis ' states each problem as an actual or potential health problem that nurses are !ualified and licensed to treat - consists of two statements that are usually separated by the phrase related to: a. statement of the patients actual or potential health problem b. statement of the problems probable cause or risk factors Pla**)*+ ' the nurse delineates specific interventions directed at solving or preventing the problems

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identified in analysis - in the care plan, the nurse must define goals, set priorities, and identify nursing interventions performed by other healthcare providers I0/l-0-*(a()o* =I*(-.&-*()o*> ' begins with carrying out the interventions identified during planning - collaborative interventions ' re!uire a physicians order - independent interventions ' do not re!uire a physicians order - involves coordinating actions of other members of the healthcare team - is completed by observing and recording the outcomes of treatment E&al'a()o* ' performed to determine the degree to which treatment has succeeded - accomplished by analy(ing the data collected during implementation - should identify those interventions: - that should be continued - those that should be discontinued - potential new interventions that should be implemented

B.

APPLYING THE NURSING PROCESS IN DRUG THERAPY ' overall objective in drug therapy is to produce ma imum benefit with minimum harm - therapy must be individuali(ed 1. P.--a10)*)s(.a()o* Ass-ss0-*( ' establishes the baseline data needed to tailor drug therapy to the individual a. .asic /oals ). collection of baseline data needed to evaluate therapeutic responses - in order to know what baseline measurements to make, the reason for the drug use must be known )). collection of baseline data needed to evaluate adverse effects - all drugs have the ability to produce undesired effects - knowing what data to collect comes directly from your knowledge of the drug under consideration ))). identification of high-risk patients - just which individual characteristics will predispose a patient to an adverse reaction depends on the drug under consideration - multiple factors that can increase the patients risk of adverse reactions to a particular drug include: - impaired liver and kidney function - age - body composition - pregnancy - diet - genetic heritage - other drugs being used - practically any pathophysiological conditions - distinguish between factors that put the patient at e tremely high risk versus factors that put the patient at moderate or low risk - contraindication ' a pre-e isting condition that precludes use of a particular drug under all but the most desperate circumstances - precaution ' a pre-e isting condition that significantly increases the risk of an adverse reaction to a particular drug, but not to a degree that is life threatening )&. assessment of the patients capacity for self-care - for drug therapy to succeed, the outpatient must be willing and able to self-

administer medication as prescribed - factors that can affect the capacity for self-care and probability of adhering to the prescribed regimen include: - reduced visual acuity - limited manual de terity - limited intellectual ability - severe mental illness - inability to afford drugs - individual and0or cultural attitude toward drugs - conviction that the drug was simply not needed in the dosage prescribed - methods of data collection include: - interviewing the patient and family - observing the patient - physical e amination - laboratory tests - patients medical history - patients drug history (including prescription drugs, over the counter drugs, herbal medications, non-medical drugs, such as alcohol, nicotine, caffeine, illicit drugs) - prior drug reactions should be noted b. Co0/o*-*(s o4 D.'+ H)s(o.5 ). -llergies to medications (123 and prescribed) or food 444$f there are more than 5 medications, .6 -W-"6444 )). 7abits - dietary - recreational drug usage (alcohol, tobacco, stimulants, illicit drugs) ask the patient 87ow much do you smoke9 drink9: 8What social drugs do you use9: ))). ;ocioeconomic ;tatus - age - occupation - education level - insurance coverage )&. +ife ;tyle .eliefs - marital status - childbearing status - personal support system - utili(ation of health care system - typical pattern of daily activities &. ;ensory &eficit 0 3apacity for self-care &). )re-e isting conditions &)). )rescription and 123 &rugs: - reasons for use - knowledge of drugs - fre!uency of dosage - effectiveness or reaction - pattern and route of administration

2.

A*al5s)s a*1 N'.s)*+ D)a+*os)s a. T,.-- ob?- ()&-s< ). <irst, judge to appropriateness of the prescribed regimen - the data collected during assessment must be analy(ed to determine if the proposed treatment has a reasonable likelihood of being effective and safe - judgment is made by considering: - medical diagnosis - known actions of the prescribed drug

)). ))).

- patients prior responses to the drug - presence of contraindications - !uestion the drugs appropriateness: - if the drug has no actions that are known to benefit individuals with the patients medical diagnosis - if the patient failed to respond to the drug in the past - if the patient has a serious adverse reaction to the drug in the past - if the patient has a condition or is using a drug that contraindicates the prescribed drug ;econd, identify potential health problems that the drug might cause - accomplished by synthesi(ing knowledge of the drug under consideration and the data collected during assessment 2hird, determine the patients capacity for self-care - should indicate potential impediments to self-care (visual impairment, reduced manual de terity, impaired cognitive function, insufficient understanding of the prescribed regimen) - nursing diagnosis applicable to almost every patient is 8deficient knowledge related to the drug regimen:

b.

Pla**)*+ ' consists of defining goals, stabling priorities, identifying specific interventions, and establishing criteria for evaluating success ). D-4)*)*+ Goals ' the goal of drug therapy is to produce ma imum benefit with minimum harm - ma imi(e therapeutic responses while preventing or minimi(ing adverse reactions and interactions S-(()*+ P.)o.)()-s - highest priority is given to life threatening conditions and reactions that cause severe, acute discomfort and to reactions that can result in longterm harm I1-*()45)*+ I*(-.&-*()o* ' heart of planning ). =ajor /roups: - drug administration > must consider dosage si(e and route of administration as well as less obvious factors, including timing of administration with respect to meals and with respect to administration of other drugs - enhanced therapeutic effects > non-drug measures can help promote therapeutic effects and should be included in the planning - interventions to minimi(e adverse effects and interactions > distinguish between reactions that develop !uickly and reactions that are delayed - patient education > well planned patient education is central to success - address the following: - techni!ue of administration - dosage si(e and timing - duration of treatment - method of drug storage - measures to promote therapeutic effects - measures to minimi(e adverse effects

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Es(abl)s,)*+ C.)(-.)a 4o. E&al'a()o* ' the need for objective criteria by which to measure desired drug responses is obvious: without such criteria we could not determine if our drug was doing anything useful

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I0/l-0-*(a()o* a. <our =ajor 3omponents: ). drug administration )). ))). interventions to promote therapeutic effects )&. interventions to minimi(e adverse effects patient education

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E&al'a()o* ' over the course of drug therapy, the patient must be evaluated for: a. therapeutic responses - how fre!uently evaluations are performed depends on the e pected time course of therapeutic and adverse effects - based on laboratory tests, observation of the patient, physical e amination and patient interview - to evaluate therapeutic responses, compare patients current status with baseline data - to evaluate treatment, know the reason for drug use, criteria for success, and e pected time course of responses adverse drug reactions and interactions - to make evaluates, know which adverse effects are likely to occur, how they are manifested, and their probable time course compliance (adhere to prescribed regimen) - include measurement of plasma drug levels, interviewing patient and counting pills satisfaction with treatment - satisfaction with drug therapy increases !uality of life and promotes compliance - factors that can cause dissatisfaction include unacceptable side effects, inconvenient dosing schedule, difficulty of administration, and high cost

b. . 1.

C.

USE OF A MODIFIED NURSING PROCESS FORMAT TO SUMMARI2E NURSING IMPLICATIONS 1. 2. ". #. P.--a10)*)s(.a()o* Ass-ss0-*( ' summari(es the information you should have before giving a drug I0/l-0-*(a()o* A10)*)s(.a()o* ' summari(es the routes of administration guidelines for dosage adjustment, and special considerations in administration I0/l-0-*(a()o*< M-as'.-s (o E*,a* - T,-.a/-'() E44- (s ' addresses issues such as diet modification, measures to increase comfort and ways to promote adherence to the prescribed regimen O*+o)*+ E&al'a()o* a*1 I*(-.&-*()o* ' summari(es nursing implications that relate to drug responses, both therapeutic and undesired a. ;ubsections: ). summary of monitoring > summari(es the physiologic and psychologic parameters that must be monitored in order to evaluate therapeutic and adverse responses )). evaluating therapeutic effects > summari(es criteria and procedures for evaluating therapeutic responses ))). minimi(ing adverse effects > summari(es the major adverse reactions that should be monitored for and presents interventions to minimi(e harm )&. minimi(ing adverse interactions > summari(es the major drug interactions to be alert for and gives interventions to minimi(e them

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managing to icity ' describes major symptoms of to icity and treatment

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