question

nursing management of drug therapy

answer

is the process of planning and implementing actions that will maximize the therapeutic effects and minimize the adverse effects of a drug. -maximizing therapeutic effect -minimizing adverse effects -providing patient and family education

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core drug knowledge

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-pharmacotherapeutics -pharmacokinetics -pharmacodynamics -contraindications and precautions -adverse effects -drug interactions

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core patient variables

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-health status -life span and gender -lifestyles, diet, and habits -environment -culture and inherited traits

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Pharmacotherapeutics:

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the desired therapeutic effect of the drug

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Pharmacokinetics

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the changes that occur to the drug while it is inside the body

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Pharmacodynamics

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the effects of the drug on the body

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Contraindications and precautions:

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conditions under which the drug should not be used or must be used carefully with monitoring

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Adverse effects

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unintended and usually undesired effects that may occur with use of the drug

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Drug interactions:

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effects that may occur when the drug is given along with another drug, food, or substance

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Health status:

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the presence of disease, illness, and allergy; chronic conditions causing system or organ dysfunction; diminished memory or mental capacity

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Life span and gender

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age, physiologic development, reproductive stage, and gender

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Lifestyle, diet, and habits:

answer

amount of activity and exercise; sleep-wake patterns; occupation; financial resources or access to health insurance coverage to offset the cost of the drug, or both; eating preferences and patterns; use or abuse of substances (e.g., nicotine, alcohol, and illegal drugs); use of over-the-counter (OTC) drugs; use of alternative health practices (e.g., herbal medicine, folk rem-edies); and ability to read and write

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Environment:

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location in which the drug therapy will be administered, such as hospital, home, or long-term care facility; properties of the physical environment that may alter a drug's action or effect, induce adverse effects from a drug, or set limitations on whether the drug may be administered in that setting; and exposure to potentially harmful substances, or a pathology induced from a harmful environmental substance, that requires drug therapy for treatment

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Culture and inherited traits:

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religious, social, and ethnic backgrounds that may affect the individual's receptiveness to drug therapy; also, genetic traits that affect a drug's pharmacokinetic and pharmacodynamic properties

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Nursing management of drug therapy helps ensure quality and comprehensive nursing care and occurs in all settings including:

answer

hospitals, long-term care facilities, outpatient centers and clinics, health care providers' offices, and patients' homes.

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Managing Drug Therapy Through The Nursing Process includes the following steps:

answer

-assessment -nursing diagnosis and outcome identification -planning -intervention -evaluation

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assessment

answer

-determine specific drug and identify drug core knowledge -assess patient and identify significant core patient variables

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Nursing Diagnosis and Outcome Identification

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identify significant interactions between core drug knowledge and core patient variables

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planning

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identify actions to maximize therapeutic effects and actions to minimize adverse effects

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intervention

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-integrate and implement strategies to maximize therapeutic effects and minimize adverse effects -provide patient and family education

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evaluation

answer

evaluation

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drug usage in the united states

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-prescription drug use increases with each age group -approx. 85% of adults age 65 and older are receiving one prescription per month -almost 50% of adults age 65 and older are receiving three or more prescriptions per month

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Assessment of Core Drug Knowledge

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-The nurse needs to be familiar with every drug the patient is taking, to determine whether interactions with core patient variables are likely to occur and consider what nursing management is required. -nurse is responsible for using available, current drug references to review unfamiliar data before administering the drug or instructing the patient to self-administer the drug.

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prototype approach

answer

An effcient way to learn and understand as much as possible of the vast information about drugs

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prototype drug

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-is typical of a group of drugs within a drug class. -typically the first drug of a class -drug has similar characteristics to all drugs in a class of drugs -provides a systematic way to increase knowledge of medications EXAMPLE: hydrochlorothiazide is a prototype drug that represents all of the thiazide diuretics (a class of drugs in this class that increases urine output).

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three sources of assessment data

answer

-patient interview and history -physical examination -medical record

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components of the patient interview

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-health status -life span and gender -lifestyle, diet, and habits -environment -culture and inherited traits

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health status

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-Presence of acute or chronic disease (physical or mental) -Drug history -Sensory deficits (vision, hearing, speech) -Ability to understand spoken instruction -Cognitive or memory deficits

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life span and gender

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-Age -Developmental level -Ability to read and write -Female patients: reproductive status (e.g., pregnant or planning pregnancy, lactating), premenopausal, postmenopausal

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Lifestyle, Diet, and Habits

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-Occupation -insurance and other economic resources to pay for drug therapy -Activity and exercise patterns -Sleep and rest patterns -Dietary patterns: frequency of meals and snacks, foods usually eaten, foods avoided -Dietary supplements, including vitamins, minerals, and herbal or folk remedies -Use of complementary medicine -Street (illegal) drugs used: frequency and route of street drugs, last time street drugs were used -Alcohol used: amount of alcohol consumed daily, last time alcohol consumed -Cigarettes or other nicotine-containing products used: amount used daily, pack years of use -Caffeine used: amount of daily caffeine consumption

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environment

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-Description of home setting or living accommodations -Location of home (city, industrial, suburban, rural)

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culture and inherited traits

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-Religious beliefs -Ethnic practices

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COMPONENTS OF A COMPLETE DRUG HISTORY

answer

-Currently prescribed medications -Prescribed dosages and routes of the medications -When each medication was last taken -Patient's description of why the medication was prescribed -Other prescribed medications taken in the recent past but not currently -Reason the medications were stopped -Known drug allergies -When allergic effect occurred -Description of specific allergic effects that occurred -Known food or environmental allergies -Over-the-counter (OTC) medications used, such as cough and cold remedies, vitamins and minerals, and headache remedies -Frequency of OTC drug use -Last time the OTC medications were used

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physical examination

answer

-focuses on the core patient variables of health status and life span and gender and should be comprehensive. -Approximate age and pregnancy can be determined by general observation -Physical assessment of the systems (e.g., the respiratory system) will provide information about disease or illness. -vital signs, height, and weight, must be measured. (An accurate measurement of body size is an important factor in computing the correct dose of many drugs) -inspect the skin of all patients for rashes and document their appearance and location. (Failure to do so could result in the rash being misinterpreted as a drug reaction.)

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medical record

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-provides information about the patient's health status, lifestyle, diet, habits, and environment. -Areas of the medical record that are specifically important include laboratory and other diagnostic test results -Past medical records may be used to verify the patient's drug history. Moreover, they may provide details relevant to the patient's current treatment. -This part of the assessment can be done either before or after the interview and physical examination.

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purpose of data collection

answer

-interpretation of data based on their relevance of drug therapy -the nurse uses the drug knowledge and patients variables to determine any significant drug interactions

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planning

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Planning begins with identifying interventions necessary to reach the desired outcome. Planning continues by defining what needs to be done to achieve the identified outcomes.

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maximizing therapeutic effects

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-Administer the drug in a manner that will promote its absorption. A drug administered orally may be given with meals or on an empty stomach, depending on the drug. When giving a drug parenterally, use the appropriate administration technique for the desired route. A route different from that prescribed may alter absorption and the desired effect. -Administer the drug at the appropriate time to maintain blood levels of the drug that will promote therapeutic effects. -Monitor laboratory values, when appropriate, to determine that the prescribed dose achieves a therapeutic drug level.

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minimizing therapeutic effects

answer

-Before initiating drug therapy, verify that the patient is not allergic to the drug and that the drug is not contraindicated for this patient for some reason. -Administer the drug in a manner consistent with standard safety protocols. For example, some drugs must be administered intravenously at a regular, steady rate, and the use of an IV infusion controller, or pump, is consid-ered standard for these drugs. -Monitor the patient and relevant laboratory findings closely for evidence of known adverse effects from drug therapy. Patients at high risk for developing a particular adverse effect should be monitored especially carefully. -Discontinue or withhold a drug if the laboratory findings warrant doing so. Notify the prescriber of the findings and your actions. -Report evidence of adverse effects to the prescriber as soon as possible. -Modify administration techniques, when appropriate, to decrease the incidence of adverse effects. For example, if the drug causes the patient gastrointestinal distress on an empty stomach, administer the drug with food. -Implement appropriate techniques for certain drugs to detect the onset of adverse effects. For example, moni-tor blood pressure before administering each dose of an antihypertensive drug to determine whether the blood pressure has decreased too much to administer the drug.

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intervention (performing the plan)

answer

the nurse integrates the devised strategies into the nursing care plan for the patient receiving drug therapy. These strategies are relevant to the physical act of drug administration and to patient and fam-ily education about drug therapy, an essential part of implementing any therapeutic plan. The nurse integrates the recognized interactions of the core drug knowledge and the core patient variables into this patient and family education.

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core drug knowledge

answer

-understand the drug's response -basics of teaching patient and family about drug therapy -name of the drug -reason the drug was prescribed (pharmacotherapeutics) -intended effect of the drug (pharmacodynamics) -important adverse effects that may occur

question

patient education guidelines

answer

see box 1.4 in book

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safe and effective home-based drug therapy

answer

see box 1.5 in book

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evaluation

answer

-measure the patients progress -consider whether the drug achieved the desired effect -outcomes that are not achieved -reassess to identify barriers to success -must identify the reason behind any treatment failure

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sources of drugs

answer

-plants -animals -synthetic chemicals -genetically engineered chemicals

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drugs from plant sources

answer

Drug sources from the plant world date to primitive times. Common drugs from plants include digitalis (purple fox-glove), morphine (opium poppy), and vincristine (periwin-kle). Drugs that come from plants are classified according to their physical and chemical properties: -alkaloids -glycosides -gums -oils -resins

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Alkaloids

answer

(alkaline substances) react with body acids to form a salt, which is readily soluble in body fluids.

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Glycosides

answer

contain a carbohydrate or sugar molecule.

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Gums

answer

are mucilaginous secretions—usually polysaccharides—with the ability to attract and hold water.

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Oils

answer

are insoluble in water and are classified as volatile or fixed. Volatile oils, which are derived strictly from plants, evaporate when exposed to air. Fixed oils, also known as fatty oils, are derived from both animals and plants; their consistency varies with temperature.

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Resins

answer

are solid or semisolid, water insoluble, organic substances of vegetable origin that are commonly used as laxative or caustic agents.

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drugs from animal sources

answer

include agents such as insulin, pituitary hormones, some vitamins, antibiotics, and biologic agents (such as vaccines and immune serums) but today, genetically engineered hormones (including insulin, pituitary hormone, and erythropoietin) are rapidly replacing animal-based drugs.

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synthetic chemicals

answer

-most drugs used today are either partially or wholly synthetic chemical compounds -a partially synthetic agent contains a derivative of a natural substance combined with a pure chemical -an advantage of synthetic drugs is that they are pure chemicals

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genetically engineered chemicals

answer

-are drugs created using DNA technologies

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Genomics

answer

-the study and identification of genes and gene function. -This new knowledge has enabled researchers to manipulate the chemical formulas of drugs to produce more specifically targeted drugs with fewer adverse effects.

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Proteomics

answer

-the study of protein structure and function. -The term proteome describes the entire complement of proteins in a given biological organism or system at a given time -Proteomic technology is essential in biomarker discovery.

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biomarker

answer

-a substance that is introduced in an organism as a means to examine organ function—such as a radioactive isotope used to evaluate perfusion of heart muscle—to detect particular disease, or to indicate exposure to various environmental substances. -in genetics, a biomarker is a fragment of DNA sequence that is associated with a specific disease.

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Transcriptomics

answer

-is the study of the transcriptome, the complete set of RNA transcripts produced by the genome at any one time. -aids in understanding the development and differentiation of a cell or an organism as well as its adaptation to variable conditions.

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Metabonomics

answer

-is the study of metabolic responses to drugs, environmental changes, and diseases. - in pharmacotherapy, metabonomics can possibly predict an individual patient's response to drug treatment.

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Pharmacogenomics

answer

is the application of the "omics" technology for the prediction of the sensitivity or resistance of an individual patient's disease to a specific drug or a group of drugs.

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Pharmacogenetics

answer

is the study of how genetic variables affect the pharmacodynamics of a drug in a specific patient.

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DRUG NOMENCLATURE

answer

-chemical name -generic name -trade name (see figure 2.1)

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chemical name

answer

describes the drug's atomic and molecular structure, using exact chemical nomenclature (language) and terminology.

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generic name

answer

-also known as its nonproprietary name. -Each drug has only one generic name, which identifies the drug's active ingredient. -easily recognizable because the first letter of the name is typically not capitalized.

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trade name

answer

-also known as a brand or proprietary name, is given to a drug by its manufacturer. -Trade names, which are usually easy to say and remember, are protected by trademark. -the trade name is easily recognizable because the first letter is capitalized and the™ or ® symbol may be present.

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Implications for Nurses

answer

-nurse has the responsibility of accurately transcribing drug orders, administering the drugs correctly, and documenting the patient's response. -a drug is ordered by the generic name because numerous brand names may exist for the same drug. -To prevent an error when administering any drug, the nurse checks the drug name at least three times—before, during, and after obtaining the drug. -To decrease the potential for medication errors, many hos-pitals have implemented a pharmacy bar-code system.

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bar-code system

answer

When entering the hospital, the patient receives a bar-coded identification wristband that can transmit information to the hospital's computer. The nurse uses a bar-code scanner to scan the patient's wristband and the medications to be given. If the patient record and the medication do not match, a warning box appears on the computer screen.

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DRUG CLASSIFICATIONS (FAMILIES)

answer

-Drugs that share similar characteristics are classified as a pharmacologic group or family. -Drugs that share similar characteristics can be classified by: -chemical classification -physiologic classification -therapeutic classification

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SOURCES OF DRUG INFORMATION

answer

-new drugs are continually being developed and new uses for existing drugs are frequently discovered -Nurses need reliable and up-to-date drug reference information -nurses can obtain drug information from drug publications, pharmacists, internet based drug guides (see table 2.1)

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standards for drug purity and content

answer

-pure food and drug acts -federal food, drug, and cosmetics act of 1938 -Kefauver-Harris Amendment -best pharmaceuticals for children act (2002)

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United States Pharmacopeia (USP)

answer

-the source for standards of strength, quality, purity, and preparation of medicinal compounds. -USP is the current authoritative source for drug standards and is revised every 5 years by a group of experts in chemistry, microbiology, nursing, pharmaceutics, and pharmacology.

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National Formulary (NF)

answer

another source to set national standards for drug quality.

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Procedure for Drug Development and Approval

answer

-The first step in the development of a new drug is in the discovery or synthesis of a potential new drug molecule -preclinical trials -clinical trials -only about 10% of new drugs that begin clinical trials are approved

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Preclinical trials

answer

-designed to provide basic safety, bioavailability, pharmacokinetic, and initial efficacy data about the drug and are carried out in animal subjects in the laboratory setting. -testing lasts approximately 3½ years. -For every 1,000 compounds that enter laboratory testing, only one makes it to human testing.

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clinical trials

answer

-are performed on humans -occur in four phases (I-IV) and may require from 5 to 9 years for completion (see figure 2.2)

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phase 1 testing

answer

-introduces the drug into humans. -The goal of this testing is to determine the metabolic and pharmacologic actions of the drug in humans as well as the adverse effects that occur with increasing doses, and, if possible, to gain early evidence of the drug's effectiveness.

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phase 2 testing

answer

-are well-controlled, closely monitored, and conducted in a small cohort of several hundred people. -goal is to obtain some preliminary data on the effectiveness of the drug for a particular indication or indications in patients with the disease or condition. -Results from the long-term animal studies are reviewed and compared with the human results—especially concerning the effects, if any, on fertility and reproduction.

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phase 3 testing

answer

-intended to uncover some infrequent or even rare adverse effects that sometimes affect only a small portion of the population. -volunteers are enrolled in double-blind studies (studies in which neither the patient nor the researcher knows whether the drug or a placebo was given) and crossover-design studies (studies com-paring the study drug with an existing drug).

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phase 4 testing

answer

-FDA conducts post-marketing surveillance to monitor the drug for safety and any new developments while it is in widespread distribution. -If safety problems appear, the agency limits the drug's approved uses or removes the drug from the market. In addition to postmarketing surveillance, the FDA may direct the drug company to do additional clinical drug trials -the pharmaceutical company that markets the drug keeps careful records on the results of therapy and must advise the FDA of any adverse effects and other effects on therapy.

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Legislation to Promote Truth in Advertising

answer

-in 1912, congress passed the sherley amendment -the FFDCA of 1938 provided labeling requirements for the first time -today, the federal trade comission regukates the advertisement of medications aimed at the general public

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legislation regarding controlled substances

answer

-harrison narcotic law of 1914 provided regulations regarding the manufacture and distribution of certain drugs -the 1970 comprehensive drug abuse prevention and control act -established the Drug Enforcement Agency (DEA) -five categories, known as schedules, were created

question

schedule of controlled substances

answer

see table 2.2 on page 24

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Nursing Management of Controlled Substances

answer

-The prescribing, dispensing, and storing of controlled substances is subject to considerably greater governmental control than the use of conventional prescription drugs -Procedures are precisely defined by law for virtually every step from manufacture to administration to wasting or discarding. -Many hospitals use an automated system to electronically track the use of stock drugs, including controlled substances.

question

online pharmacies

answer

-increased usage of online pharmacies -not all are regulated -the ryan haight internet pharmacy consumer protection act of 2008 amends the Controlled Substances Act with respect to the sale of controlled substance drugs through the Internet. The overall effect of this law is to restrict the delivery, distribution, or dispensing of controlled substances by means of the Internet without a valid prescription obtained through a provider in a one-to-one in-person medical evaluation.

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PATIENT EDUCATION AS A SAFEGUARD IN DRUG THERAPY

answer

-is a key safeguard in drug therapy. -improves adherence to drug therapy and promotes therapeutic outcomes -Patient education requires a nurse to have skills in gathering data, individualizing instructions, prompting and supporting the patient, and assessing and evaluating the pharmacotherapeutic response for determining patient outcomes.

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Patient Learning Needs

answer

-Some variations result from clinical factors, such as the nurse-patient relationship. -Others are related to the scope or complexity of drug therapy in relation to pharmacotherapeutic, pharmacokinetic, and pharmacodynamic parameters; contraindications, precautions, and adverse effects of therapy

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Teaching Focus and Content

answer

-individualize and communicate information so that the patient or the caregiver can understand it and act on it appropriately. - If possible, the nurse prepares written or audiovisual materials for the patient to consult as needed

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Evaluating and Documenting Educational Outcomes

answer

-time of teaching, content of teaching, the patient's response to the teaching session, an evaluation of the patient's grasp of the subject matter, and an assessment of unmet or future learning needs. -becomes part of the clinical and legal record, serving as a reference for other health care professionals and helping guide future educational efforts.

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Consumer Drug Information on the Internet

answer

-The quality of information provided on some Internet sites has become a concern for health care providers. -Consumers may have difficulty recognizing the difference between accurate drug information and personal web pages that have biased opinions from nonmedical personnel. -patients are counseled to discuss contradictory information they obtain from a website with the health care provider before changing a medication regimen.

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local effects

answer

exert their effect at the site of administration

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systemic effects

answer

certain drugs given topically are absorved by the skin and are distribuited throughout the body systems

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DRUG ADMINISTRATION ROUTES: GENERAL CONSIDERATIONS

answer

-enteral route -parenteral route -topical route

question

enteral route

answer

-uses the gastrointestinal (GI) tract for the ingestion and absorption of drugs. -most common method of administering drugs through the enteral route is orally. -also includes drugs that are administered through a nasogastric (NG) or a gastrostomy (G) tube.

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parenteral route

answer

-avoids or circumvents the GI tract and is associated with all forms of injections: intramuscular (IM), subcutaneous (SC or SQ), and intravenous (IV). -Less commonly used parenteral routes than IM, SC, and IV are intradermal (into the dermis), intrathecal (into the cerebrospinal fluid), intra-articular (into a joint), and intra-arterial (into an artery).

question

topical route

answer

-is technically another parenteral route because it also bypasses the GI tract. -Drugs administered topically are applied to the skin or mucous membranes, including those of the eyes, ears, nose, vagina, rectum, and lungs.

question

ENTERAL ROUTE AND FORMS

answer

-tablets -Sublingual and Buccal Tablets -Troches -Capsules -Syrups -Elixirs -Emulsions and Suspensions

question

tablets

answer

-a solid dosage form that is prepared by compressing or molding a drug into various sizes and shapes. -designed to be easily broken at a point so that one half or one quarter of the dose may be given. -active ingredients in tablets are commonly mixed with lactose or other sugars, binding agents, or other inert materials to facilitate manufacturing and ensure stability of the preparation.

question

Drugs that are appropriate for use in tablet form have some limitations.

answer

-drug must be stable in gastric contents -flavor -Drugs determined by the pharmaceutical company to be bitter, irritating, or unpleasant tasting are not usually manufactured in conventional tablet form because they would be accepted poorly by patients. -imitations can be overcome by using a special coating on the tablet.

question

enteric coating

answer

-a wax-like layer that is used on some tablets. -resists the acid environment of the stomach but dissolves in areas in which the local pH is neutral or slightly alkaline (e.g., the small intestine). -may be used to protect acid-labile drugs, to provide a sustained-release dose, or to guard against local adverse effects from a drug

question

Sustained-release

answer

(also called controlled-, timed-, extended-, or prolonged-release) tablets are formulated to release a drug slowly over an extended period, rather than rapidly like conventional tablets.

question

Sustained release occurs by several methods:

answer

-Layers of enteric coatings may be applied, and the drug is released in response to changes in the surrounding pH of the GI fluid. -The tablet may be formulated to release the drug in a steady, controlled manner. -The tablet may be formulated to release the drug in a series of pulsations.

question

Sublingual and Buccal Tablets

answer

-not used as often as oral tablets. -These small, hard, compressed tablets are designed to dissolve rapidly in the vascular mucous membranes of the mouth. -Buccal tablets are placed in the buccal pouch (between the cheek and gum), and sublingual tablets are placed under the tongue. -must be relatively nonirritating, flavorless, and highly water soluble. -Because the buccal and sublingual areas are highly vascular, drugs are quickly absorbed into the bloodstream, and a rapid onset of drug effect occurs.

question

Troches

answer

-also called pastilles or lozenges, are commonly used to achieve a local effect in the mouth or pharynx (throat). -The drug is embedded in hard candy or another suitably flavored vehicle that the patient holds within the mouth, where it slowly dissolves. -Antitussives, anti-infectives, local anesthetics, antihistamines, and analgesics are administered this way

question

Capsules

answer

-are solid dosage forms in which the drug is usually encased in a shell of hard or soft gelatin. -foul-tasting drugs can be easily administered in capsules -many patients find gelatin capsules easier to swallow than tablets. -sustained-release capsules may contain higher doses than those found in regular-release forms, but the patient may safely take the higher dose because the drug is released in a controlled fashion.

question

Syrups

answer

-concentrated solution of sugar, such as sucrose, in water is known as a syrup. -Most syrups that contain 65% or more sucrose are also resistant to mold, yeasts, and other micro-organisms, and they have a reasonable shelf life with no need for refrigeration

question

Elixirs

answer

-a clear hydroalcoholic mixture that is usually sweetened or otherwise pleasantly flavored. -contain ethanol and water, but glycerin, sorbitol, propylene glycol, flavoring agents, aspartase, and even syrups -alcohol content of elixirs varies greatly and can exceed 25%. -stored at room temperature, and the alcohol content usually prevents the growth of any mold or other microorganisms. -Elixirs should always be clear. Cloudiness indicates contamination.

question

Emulsions and Suspensions

answer

-An emulsion is created when two liquids that do not mix well are combined, and one liquid distributes uniformly through the other -Most emulsions consist of a nonaqueous agent (oil or lipid phase) dispersed with an aqueous (water) agent -A suspension is a drug preparation consisting of two agents: a finely divided solid dispersed within a liquid. The stability of the preparation depends on the ability of the dispersing medium to wet the solid particles.

question

nursing management in enteral drug administration

answer

-core drug knowledge -assessment of relevant core patient variables

question

core drug knowledge

answer

-not all drugs can be administered orally. -Gastric acids and enzymes destroy many drugs -Food may interfere with the dissolution and absorption of certain drugs, especially enteric-coated drugs, because of the considerable variation in individual gastric emptying times and therefore in the length of time a drug spends in the stomach.

question

Assessment of Relevant Core Patient Variables

answer

-primary consideration for administering an oral drug is the patient's condition -If the patient cannot swallow at all but has a working GI system, the drug may be given through an NG or a G tube. -a liquid drug form may be substituted. -Sublingual drugs may be administered even to unconscious patients because these drug forms are so rapidly absorbed by the vasculature. The high sugar content of syrups can mask unpleasant drug flavors, making syrups useful vehicles for administering drugs orally to both adults and children.

question

maximizing therapeutic effects

answer

-Medications may be mixed with food or fluids. -Shake liquid medication immediately before -Drugs administered through an NG or a G tube are instilled slowly. -NG and G tubes need to be flushed after administration of medications

question

Minimizing adverse effects

answer

-Drugs that have enteric coatings and drugs in sustained-release form should never be chewed, crushed, or broken. -Repeated doses of sucrose-containing syrups may increase the risk of gingivitis or dental caries. -Before administering drugs through an NG or G tube, the tube is assessed for proper placement. -To ensure safety, the nurse must closely follow the cardinal rules of drug administration.

question

The Five (or ten) Rights of Medications

answer

Right Patient Right Assessment Right Medication Right Dose Right Time Right Route Right Patient Education Right Documentation Right Evaluation Right to Refuse

question

To administer a drug to "the right patient"

answer

he nurse should use two unique patient identifiers (such as the name and the patient history number, never the room number).

question

To administer the "right drug," at the "right time" using the "right route,"

answer

-the nurse must be able to read and interpret the medication order correctly. -Standard abbrevia-tions are frequently used in medication orders -Some abbreviations are likely to be misinterpreted and cause medication errors, these should be avoided.

question

Abbreviations Related to Medication Administration

answer

see table 3.1 page 52

question

The Joint Commission Official "Do Not Use" List 2005

answer

see table 3.2 page 52

question

To administer the "right dose"

answer

-The most accurate method for doing dosage calculations is to use a calculator. -Any drug dosage calculation book contains all of the necessary specific information. -Many institutions require that all drug calculations be confirmed by two nurses before drug administration to prevent drug errors.

question

Parenteral Delivery Routes

answer

• Intravenous • Subcutaneous • Intramuscular • Intradermal • Intra-articular • Intra-arterial • Intrathecal

question

intramuscular (IM)

answer

-involves injecting drugs into certain muscles. -requires specific knowledge of anatomy and aseptic technique. -drugs that are injected into a muscle move directly into the bloodstream without having to be broken down and absorbed -Drugs such as oils or irritating chemicals can be administered intramuscularly in solutions or suspensions -The needle length chosen for injection should be long enough to enter the muscle, not the subcutaneous tissue. Patients who are overweight or obese may need longer needles than other patients to correctly place the medication -The sites for IM injection are the ventrogluteal, deltoid, rectus femoris, and vastus lateralis muscles SEE FIGURE 3.1 PAGE 53

question

Subcutaneous (SC)

answer

-administered under the skin into fat and connective tissue. -These drugs must be highly soluble, low volume (less than 2 mL in a good-sized adult), and nonirritating (to prevent tissue damage, tissue necrosis, and sterile abscess formation). -may be used for vaccines, insulin, heparin, and narcotics. -The sites used for this route are the upper, lateral arm; anterior thigh; abdomen; and midback above the scapula (although this last is infrequently utilized) SEE FIGURE 3.2 PAGE 55

question

intravenous

answer

-administers a drug directly into the bloodstream, bypassing the need for absorption from the GI tract or transportation from other parts of the body, such as muscle or subcutaneous tissue -Has immediate effect (e.g., nitroprusside lowers blood pressure in hypertensive crisis). -Allows administration of a large volume of drug (e.g., with certain antibiotics, such as cefoxitin). -Avoids tissue irritation or injury resulting from IM or SC administration (e.g., with chemotherapeutic drugs, vasopressors such as norepinephrine [Levophed], or cardiac glycosides such as digoxin [Lanoxin], because the blood buffers the drug). -Is acceptable when no other route is possible (e.g., in an unconscious patient). -Circumvents impaired circulation -Has the potential for prolonged, continuous administration of solutions, such as lidocaine (Xylocaine) to control cardiac arrhythmias, which can be titrated (adjusted in small increments upward or downward) for the desired effect.

question

Intradermal injections

answer

-made into the dermis just below the epidermis. -used primarily for local anesthesia and for sensitivity tests, such as allergy and tuberculin tests. -A small needle (25- or 27-gauge) and small-volume syringes (less than 1 mL) are used

question

An intra-articular injection

answer

-performed only by a skilled practitioner and involves injecting a drug into a joint -Corticosteroids are typically administered by intra-articular injection to relieve pain in an acutely inflamed joint -effect is local -Nurses do not commonly administer medications by this route.

question

Intra-arterial drug administration

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-requires a surgeon to insert a catheter into an artery leading directly to the targeted treatment area. -drug is delivered under positive pressure through the catheter. The positive pressure overcomes the pressure within the arterial system.

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In intrathecal administration

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-drug is delivered into the cerebrospinal fluid. -may be administered directly into the spinal subarachnoid space (a spinal) or outside the subarachnoid space (an epidural). -Drugs are introduced into these areas by a catheter placed by specially trained health care providers. -The drugs most commonly administered by this route are local anesthetics, antibiotics, and radiographic contrast media. -This route is commonly used to deliver an anesthetic during labor and delivery.

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Assessment of Relevant Core Patient Variables

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• Health status -A parenteral route may be chosen because the patient cannot tolerate oral drugs, cannot swallow, or has a condition that warrants resting the GI tract or keeping it empty. • Life span and gender -infants have small muscle mass. The largest muscle mass at birth is the vastus lateralis, which is the preferred site for IM injections in infants, although the rectus femoris may also be used. The deltoid is never used for IM injections in infants. The gluteal muscles develop with walking and usually are not used for injections until the child has been walking for 1 year. Elderly people have decreased muscle mass overall and decreased tissue elasticity, which may result in drugs oozing from injection sites. Muscle mass must be determined before IM injections. • Lifestyle, diet, and habits -Parenteral forms of drugs are more expensive than oral forms. Parenteral administration requires specialized skills, equip-ment, and education. Placing IV access devices into peripheral veins may be difficult in patients who are IV substance abusers. • Environment -Patients, particularly diabetic patients who receive insulin, can be taught to give themselves SC injections at home. The techniques for IM injections can also be taught to patients and their families for home use, although this practice is not as common.

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Topical Route

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• Apply the drug preparations to the skin or mucous membranes, including the eyes, ears, nose, rectum, vagina, and lungs. • The most common and widely used topical agents applied to the skin include lotions, creams, liquids, ointments, and emollients.

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Pharmacotherapeutics

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is the achievement of the desired therapeutic goal from drug therapy. •Absorption •Distribution •Metabolism •Excretion

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Pharmacokinetics

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is the movement of the drug particles inside the body.

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Absorption

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• Several variables affect the rate of drug absorption. - route of administration - speed at which the drug dissolves - Food or other drugs can interfere with absorption. - Blood flow - ph

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Protein-Bound Drugs

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• Protein binding of drugs affects the distribution of a drug. • When the drug is bound to protein, it is unable to pass through the capillary walls. • When the patient has a lower-than-expected protein level, the distribution of the drug is altered.

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Blood-Brain Barrier

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This structure prevents drug molecules, and other foreign substances, from passing through and entering the brain.

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Placental Membrane

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• The placental membrane separates the maternal circulation from the fetal circulation. • It is not a barrier like the blood-brain barrier. • Any drug that can pass through a membrane can pass through the placenta.

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Metabolism

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• Metabolism of drugs occurs primarily in the liver. • When drugs are metabolized, they are changed from their original form to a new form. • Metabolism is sometimes referred to as biotransformation.

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Metabolites

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• Drugs that are metabolized are generally changed into an inactive form. • Metabolism can convert a drug that has little or no therapeutic effect in its original form into the active form. • Drugs that are inactive until metabolized into an active form are called prodrugs.

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First-Pass Effect

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• Drugs that are highly metabolized lose much of their effectiveness during this first pass through the liver. • This loss of effectiveness is called the first-pass effect. • Drugs that experience a high first-pass effect may need higher oral doses to achieve a therapeutic level of circulating drug.

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P-450 System

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-a combination of several types of cytochromes, called families. Of these, only three families—CYP1, CYP2, and CYP3—are involved in drug metabolism. The other enzymes in the P-450 group metabolize naturally occurring substances, such as fatty acids. -The enzyme CYP3A4 is the most common and is responsible for the metabolism of most drugs.

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Excretion

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• Excretion is the process of removing a drug, or its metabolites, from the body. • The most common route for drug excretion is through the urine.

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Factors That Affect Renal Excretion

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• Drug excretion can be increased if the pH of the urine encourages the drug to become an ion. • Overuse of the active transport system also affects excretion. • Two drugs can be given together to slow deliberately the rate of excretion of one or both of the drugs.

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Half-Life

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The amount of time that is required to remove half (50%) of the blood concentration of a drug is called half-life.

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Steady State

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• The point at which the amount of drug being administered and the amount being eliminated balance off are equal • At four to five half-lives, steady state is achieved.

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Clearance

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• The rate at which drug molecules disappear from the circulatory system is effected by several factors.

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Pharmacodynamics

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• Pharmacodynamics is the biologic, chemical, and physiologic actions of a particular drug within the body. • Drugs; -can only turn on, -turn off, -promote, or -block a response that the body is inherently capable of producing. •Drugs cannot create new responses in the body

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Drug-Receptor Interactions

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Most drugs create their effects in the body by attaching to special sites, called receptors. -AGONISTS, meaning that they promote a function -ANTAGONISTS OR BLOCKERS, when attaching to a receptor, drug molecules can prevent something else from attaching and causing an effect.

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Variables that Influence the Dose of a Drug

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• Potency and efficacy -The amount of a drug that must be given in order to produce a particular response • Minimum concentration • Maintenance and loading doses -Once a dose is chosen and administered consistently over time • Therapeutic index -The relation of LD50 to ED50

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Drug Dosage and Blood Concentration

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As drug levels within the body increase, the patient is more likely to experience adverse effects from drug therapy.

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Adverse Effects

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An adverse effect of drug therapy is a usually undesirable effect other than the intended therapeutic effect. -It may occur even with normal drug dosing -result from too much of a therapeutic effect or from other pharmacodynamic effects of the drug

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Drug Interactions

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A drug interaction occurs when two drugs or a drug and another element have an effect on each other.

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Allergic and Idiosyncratic Response

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• An allergic response is an immune system response. • The most serious allergic response is called anaphylaxis. -During anaphylaxis, changes occur throughout the body, including constriction of bronchial smooth muscles (bronchospasms), vasodilation, and increased vascular permeability -symptoms of anaphylaxis include acute respiratory distress, marked hypotension, edema (most importantly laryngeal edema), rash, tachycardia, cyanosis, and pale, cool skin. Convulsions may occur. • Idiosyncratic responses -Related to an individual's unique response to a drug, rather than to the dose of a drug

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Toxicities

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• Neurotoxicity (central nervous system) • Hepatotoxicity (liver) • Nephrotoxicity (kidneys) • Ototoxicity (eighth cranial nerve) • Cardiotoxicity (heart) • Immunotoxicity (immune system)

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Neurotoxicity

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-Is a drug's ability to harm or poison a nerve cell or nerve tissue. - Signs and symptoms of neurotoxicity include drowsiness, auditory and visual disturbances, restlessness, nystagmus (involuntary cyclic movement of the eyeballs), and tonic-clonic (grand mal) seizures. -can occur after exposure to drugs and other chemicals and gases (e.g., alcohol, solvents, insecticides, industrial vapors, and pollutants).

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Hepatotoxicity

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-damage to the liver. -Manifestations of hepatotoxicity include hepatitis, jaundice, elevated liver enzyme levels, and fatty infiltration of the liver.

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nephrotoxicity

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-Damage to the kidneys -Decreased urinary output, elevated blood urea nitrogen, increased serum creatinine, altered acid-base balance, and electrolyte imbalances can all occur with kidney damage.

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Ototoxicity

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-damage to the eighth cranial nerve -Signs and symptoms of ototoxicity include tinnitus, which is a buzzing or ringing sound in the ear, and sensorineural hearing loss.

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cardiotoxicity

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Irregularities in cardiac rhythms and conduction, heart failure, and even damage to the myocardium

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immunotoxicity.

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When the immune system is significantly affected by drug therapy

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Drug Interactions

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• Drug interactions occur when one drug is affected in some way by another drug. •Absorption •Distribution •Metabolism •excretion

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Drug Interactions Affecting Pharmacodynamics

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-additive effect -synergistic effect -Potentiated effect -antagonistic effect

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additive effect

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occurs when two or more "like" drugs are combined, and the result is the sum of the drugs' effects.

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synergistic effect

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occurs when two or more "unlike" drugs are used together to produce a combined effect, and the outcome is a drug effect greater than either drug's activity alone.

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Potentiation

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best describes an interaction in which the effect of only one of the two drugs is increased. in other words, a drug that has a mild effect enhances the effect of a second drug.

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An antagonistic drug interaction

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is the opposite of a syner-gistic effect. It results in a therapeutic effect that is less than the effect of either drug alone because the second drug either diminishes or cancels the effects of the first drug

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Drug Incompatibilities

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• Chemical incompatibilities -Chemical incompatibilities between drugs change both the drug's structure and its pharmacologic properties. The alteration may be beneficial. For example, heparin and protamine sulfate (a heparin antagonist) form an ionic bond that lacks any anticoagulant activity. Conversely, the chemical incompatibility may also be harmful; for example, combining multi-vitamins and antibiotics in the same intravenous (IV) solution changes the solution's pH and inactivates the antibiotic. • Physical incompatibilities -Physical incompatibilities occur when two drugs are mixed together. The mixture results in the formation of a precipitate. Phenytoin and a diluent containing dextrose, for example, produce a cloudy, white precipitate. This kind of reaction usually interferes with the pharmacologic activity of one or both drugs.

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Assessment of Core Patient Variables

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• Health status - Concurrent medical conditions - A patient's chronic health condition • Life span and gender - A patient's age -older adults are more likely to be receiving polypharmacy • Lifestyle, diet, and habits • Environment • Culture and inherited traits - responses to drug therapy that are genetically determined in various ethnic and racial populations.

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Nursing Diagnoses and Outcomes

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• Risk for Infection related to drug-induced myelosuppression - Desired outcome: The patient will not develop infection while on drug therapy. • Imbalanced nutrition: Less Than Body Requirements related to drug-induced nausea, vomiting, anorexia, stomatitis - Desired outcome: Despite adverse effects, the patient will receive enough nourishment to meet physiologic needs. • Risk for Poisoning (Toxicity) related to use of drug with a narrow therapeutic index - Desired outcome: The patient will receive drug

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