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CHAPTER 2 APPLICATION OF PHARMACOLOGY IN NURSING PRACTICE

I. EVOLUTION OF NURSING RESPONSIBILITIES REGARDING DRUGS

A. 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. APPLICATION OF PHARMACOLOGY IN PATIENT CARE


- pharmacologic knowledge is applied in patient care and patient
education

A. PRE-ADMINISTRATION ASSESSMENT

1. Goals
a. collecting baseline data needed to evaluate therapeutic and adverse
responses
b. identifying high-risk patients
c. assessing the patient’s capacity for self care

B. COLLECTING BASELINE DATA


- baseline data are needed to evaluate drug responses, both therapeutic
and adverse

C. IDENTIFYING HIGH RISK PATIENTS


- predisposing factors are pathophysiology (especially liver and kidney
function), genetic factors, drug
allergies, pregnancy, old age, and extreme youth
- tools for identification are the patient history, physical examination and
laboratory tests - need to know what to look for: factors that
can increase the risk of severe reactions to the
drug in question

PRE-TEST ? What predisposing factor can make a patient high risk when giving
medications:
pathophysiological conditions
D. DOSAGE AND ADMINISTRATION

1. Read the medication order carefully. If the order is unclear, verify it with
the prescribing physician.
2. Verify the identity of the patient by comparing the name on the wristband
with the name on the drug
order or administration record.
3. Read the medication label carefully. Verify the identity of the drug, the
amount of drug (per tablet,
volume of liquid, etc.) and its suitability for administration by the
intended route.
4. Verify dosage calculations.
5. Implement any special handling the drug may require.
6. Don’t administer any drug if you don’t understand the reason for its use.
E. EVALUATING AND PROMOTING THERAPEUTIC EFFECTS

1. Evaluating Therapeutic Responses – 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
2. Promoting Compliance - drugs an be of great value to patients, but only
if they are taken correctly
3. Implementing Non-drug Measures – supportive measures directly,
through patient education, or by
coordinating the activities of other healthcare providers

F. MINIMIZING ADVERSE EFFECTS – all drugs have the potential to produce undesired
effects. In order to help reduce
adverse effects, you must know the following about the drugs you’re
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 minimize discomfort and harm

G. MINIMIZING 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

H. MAKING PRN DECISIONS – PRN medication order is one in which the nurse has
discretion regarding how much
drug to give and when to give it.
- PRN is an abbreviation that stands for pro re nata (Latin for as needed or
as the occasion arises)
- in order to implement a PRN order rationally, the reason for the drug use
and the patient’s medication
needs must be known

PRE-TEST ? What does PRN mean:


as needed

I. MANAGING TOXICITY – some adverse drug reactions are extremely dangerous; if


toxicity is not diagnosed early
and responded to quickly, irreversible injury or death can result.
- early signs of toxicity and the procedure for toxicity management must
be known

III. Application of Pharmacology in Patient Education


As a patient educator, you must give the patient the following information:
- drug name and therapeutic category - dosage size
- dosing schedule - route and technique of
administration
- duration of treatment - method of drug storage
- expected therapeutic response and when it should develop
- non-drug measures to enhance therapeutic responses
- symptoms of major adverse effects and measure to minimize
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. Drug Name – 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 realize
that two prescriptions that bear different names actually
contain the same medicine
2. Dosage Size and Schedule of Administration – patients need to be
told how much drug to take and
when to take it
3. Technique of Administration – patients must be taught how to
administer their drugs
4. Duration of Drug Use – just as patient must know when to take their
medicine, they must know when
to stop
5. Drug Storage – certain medications are chemically unstable and hence
deteriorate rapidly if stored
improperly. Patients must be taught how to store their medications
correctly. - all drugs should be stored where children cannot
reach them

B. PROMOTING THERAPEUTIC EFFECTS – patients must know the nature and time course of
expected beneficial
effects
- non-drug measures can complement drug therapy; teaching patients
about non-drug measures can
greatly increase the chances of success

C. MINIMIZING ADVERSE EFFECTS – knowledge of adverse drug effects will enable the
patient to avoid some adverse
effects and minimize others through early detection

D. MINIMIZING ADVERSE INTERACTIONS – patient education can help avoid hazardous


drug-drug and drug-food
interactions.

***IF IT’S NOT DOCUMENTED, IT’S NOT BEEN ADMINISTERED***

IV. APPLICATION OF NURSING PROCESS IN DRUG THERAPY

A. REVIEW OF NURSING PROCESS


1. Assessment – consists of collecting data about the patient
- methods of data collection are: patient interview
medical and drug use histories
physical examination
observation of the patient
laboratory tests

2. Analysis: Nursing Diagnosis – nurses analyze 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 qualified and licensed to treat
- consists of two statements that are usually separated by the
phrase related to:
a. statement of the patient’s actual or potential
health problem
b. statement of the problem’s probable cause or risk
factors
3. Planning – the nurse delineates specific interventions directed at solving
or preventing the problems
identified in analysis
- in the care plan, the nurse must define goals, set priorities, and
identify nursing interventions
performed by other healthcare providers
4. Implementation (Intervention) – begins with carrying out the
interventions identified during planning
- collaborative interventions – require a physician’s order
- independent interventions – do not require a physician’s
order
- involves coordinating actions of other members of the healthcare
team
- is completed by observing and recording the outcomes of
treatment
5. Evaluation – performed to determine the degree to which treatment has
succeeded
- accomplished by analyzing 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 maximum
benefit with minimum harm
- therapy must be individualized

1. Pre-administration Assessment – establishes the baseline data needed


to tailor drug therapy to the
individual

a. Basic Goals
i. 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
ii. 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
iii. 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 patient’s 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
extremely high risk versus
factors that put the patient at moderate or low risk
- contraindication – a pre-existing condition that
precludes use of
a particular drug under all but the most
desperate
circumstances
- precaution – a pre-existing condition that
significantly increases
the risk of an adverse reaction to a particular
drug, but not
to a degree that is life threatening
iv. assessment of the patient’s 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 dexterity
- limited intellectual ability - severe
mental illness
- inability to afford drugs
- individual and/or 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 examination - laboratory
tests
- patient’s medical history
- patient’s 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. Components of Drug History


i. Allergies to medications (OTC and prescribed) or food
***If there are more than 2 medications, BE AWARE***
ii. Habits
- dietary
- recreational drug usage (alcohol, tobacco, stimulants,
illicit drugs)
ask the patient “How much do you smoke?
drink?”
“What social drugs do you use?”
iii. Socioeconomic Status
- age - occupation
- education level - insurance coverage
iv. Life Style Beliefs
- marital status - childbearing status
- personal support system - utilization of health care
system
- typical pattern of daily activities
v. Sensory Deficit / Capacity for self-care
vi. Pre-existing conditions
vii. Prescription and OTC Drugs:
- reasons for use - knowledge of drugs
- frequency of dosage - effectiveness or
reaction
- pattern and route of administration

2. Analysis and Nursing Diagnosis

a.
Three objectives:
i. First, judge to appropriateness of the prescribed regimen
- the data collected during assessment must be analyzed
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
- patient’s prior responses to the drug
- presence of contraindications
- question the drug’s appropriateness:
- if the drug has no actions that are known to
benefit individuals with
the patient’s 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
ii. Second, identify potential health problems that the drug might
cause
- accomplished by synthesizing knowledge of the drug
under consideration
and the data collected during assessment
iii. Third, determine the patient’s capacity for self-care
- should indicate potential impediments to self-care
(visual impairment, reduced
manual dexterity, impaired cognitive function,
insufficient
understanding of the prescribed regimen)
- nursing diagnosis applicable to almost every patient is
“deficient knowledge
related to the drug regimen”

b. Planning – consists of defining goals, stabling priorities, identifying


specific interventions, and
establishing criteria for evaluating success

i. Defining Goals – the goal of drug therapy is to produce


maximum benefit with
minimum harm
- maximize therapeutic responses while preventing or
minimizing adverse
reactions and interactions
ii. Setting Priorities - highest priority is given to life
threatening conditions and reactions
that cause severe, acute discomfort and to reactions
that can result in long-
term harm
iii. Identifying Intervention – heart of planning
i. Major Groups:
- drug administration = must consider dosage size
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 minimize adverse effects and
interactions =
distinguish between reactions that develop
quickly and
reactions that are delayed
- patient education = well planned patient
education is central to
success
- address the following: - technique of
administration
- dosage size and timing
- duration of treatment
- method of drug storage
- measures to promote
therapeutic
effects
- measures to minimize
adverse
effects
iv. Establishing Criteria for Evaluation – 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

3. Implementation

a. Four Major Components:


i. drug administration ii. patient education
iii. interventions to promote therapeutic effects
iv. interventions to minimize adverse effects

4. Evaluation – over the course of drug therapy, the patient must be


evaluated for:

a. therapeutic responses
- how frequently evaluations are performed depends on the
expected time course of
therapeutic and adverse effects
- based on laboratory tests, observation of the patient,
physical examination and patient
interview
- to evaluate therapeutic responses, compare patient’s current
status with baseline data
- to evaluate treatment, know the reason for drug use, criteria
for success, and
expected time course of responses
b. 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
c. compliance (adhere to prescribed regimen)
- include measurement of plasma drug levels, interviewing
patient and counting pills
d. satisfaction with treatment
- satisfaction with drug therapy increases quality of life and
promotes compliance
- factors that can cause dissatisfaction include unacceptable
side effects, inconvenient
dosing schedule, difficulty of administration, and high
cost

C. USE OF A MODIFIED NURSING PROCESS FORMAT TO SUMMARIZE NURSING IMPLICATIONS

1. Pre-administration Assessment – summarizes the information you


should have before giving a drug
2. Implementation Administration – summarizes the routes of
administration guidelines for dosage
adjustment, and special considerations in administration
3. Implementation: Measures to Enhance Therapeutic Effects –
addresses issues such as diet
modification, measures to increase comfort and ways to promote
adherence to the prescribed
regimen
4. Ongoing Evaluation and Intervention – summarizes nursing
implications that relate to drug
responses, both therapeutic and undesired
a. Subsections:
i. summary of monitoring = summarizes the physiologic and
psychologic parameters that
must be monitored in order to evaluate therapeutic and
adverse responses
ii. evaluating therapeutic effects = summarizes criteria and
procedures for evaluating
therapeutic responses
iii. minimizing adverse effects = summarizes the major adverse
reactions that should be
monitored for and presents interventions to minimize
harm
iv. minimizing adverse interactions = summarizes the major drug
interactions to be alert for
and gives interventions to minimize them
v. managing toxicity – describes major symptoms of toxicity and
treatment

5. Patient Education

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