1

The Nursing Process

and Drug Therapy
CHAPTER 1
2
The Nursing Process
A research-based organizational
framework for professional nursing
practice
Central to all nursing care
Encompasses all steps taken by the nurse
in caring for a patient
Flexibility is important
Requires critical thinking
Ongoing and constantly evolving process
3
The Nursing Process (contd)
Assessment
Nursing diagnosis
Planning
Goals
Outcome criteria
Implementation
Evaluation
4
The Nursing Process (contd)
Assessment
Data collection
Subjective, objective
Medication history
Prescriptions
Over-the-counter medications
Herbal therapies
Responses to medications (therapeutic and adverse)

5
The Nursing Process (contd)
Nursing diagnosis
Decision about the need/problem of the
patient (actual or at risk)
Critical thinking, creativity, and accurate
data collection
NANDA-I format
6
The Nursing Process (contd)
Nursing diagnosis
Three steps
Human response to illness (actual or at risk)
related to
as evidenced by
7
The Nursing Process (contd)
Planning
Identification of goals and outcome criteria
Must be specific and measurable
Must be patient-centered
Time frame
Prioritization
8
The Nursing Process (contd)
Goals
Objective, measurable, realistic
Time frame specified
Outcome criteria
Specific standard(s) of measure
Patient oriented
9
The Nursing Process (contd)
Implementation
Initiation and completion of the nursing
care plan as defined by the nursing
diagnoses and outcome criteria
Follow the Six Rights of medication
administration
10
The Role of Nurses in Relation to
Pharmacology
Nurses share information with other health care professionals to provide the
most effective medication regimen for the patient
Nurses have to follow the Six Rights of Medication Administration

Nurses play an active role in drug administration
Nurses contribute to the planning and modification of drug therapy from their
assessment of patient factors and evaluation of progress or problems
occurring during drug therapy
In addition to: the role in patient education and compliance
1. Right drug
2. Right dose
3. Right time
4.Right Route

5. Right Patient

6. Right Documentation
11
Evaluation
Ongoing part of the nursing process
Determining the status of the goals and
outcomes of care
Monitoring the patients response to drug
therapy
Expected and unexpected responses
Clear concise documentation
12


Pharmacologic
Principles

CHAPTER 2
13
Pharmacologic Principles
Drug
Any chemical that affects the physiologic
processes of a living organism
Pharmacology
Study or science of drugs


14
Drug Names
Chemical name
Describes the drugs chemical composition and
molecular structure
Generic name (nonproprietary name)
Name given by the United States Adopted Name
Council
Trade name (proprietary name)
The drug has a registered trademark; use
of the name is restricted by the drugs patent owner
(usually the manufacturer)
15
Pharmacologic Principles
Pharmaceutics
Pharmacokinetics
Pharmacodynamics
Pharmacotherapeutics
Pharmacognosy
16
Pharmaceutics
The study of how various drug forms
influence pharmacokinetic and
pharmacodynamic activities
17
Pharmacokinetics
The study of what the body does to the
drug
Absorption
Distribution
Metabolism
Excretion
18
Pharmacodynamics
The study of what the drug does to the
body
The mechanism of drug actions in living
tissues
19
Pharmacotherapeutics
The use of drugs and the clinical
indications for drugs to prevent and treat
diseases
Empirical therapeutics
Rational therapeutics
20
Pharmacognosy
The study of natural (plant and animal)
drug sources
21
Pharmaceutics
Dosage form design affects dissolution
22
23
Pharmacokinetics: Absorption
The rate at which a drug leaves its site
of administration, and the extent to
which absorption occurs
Bioavailability
Bioequivalency
24
Factors That Affect Absorption
Absorption characteristics vary according
to the dosage form and route
Food or fluids administered with the drug
Dosage formulation
Status of the absorptive surface
Rate of blood flow to the small intestine
Acidity of the stomach
Status of GI motility
25
Routes
A drugs route of administration affects
the rate and extent of absorption of that
drug
Enteral (GI tract)
Parenteral
Topical
26
Enteral Route
The drug is absorbed into the systemic
circulation through the oral or gastric
mucosa or the small intestine
Oral
Sublingual
Buccal
Rectal (can also be topical)
27
First-Pass Effect
The metabolism of a drug and its
passage from the liver into the
circulation
A drug given via the oral route may be
extensively metabolized by the liver before
reaching the systemic circulation (high
first-pass effect)
The same druggiven IVbypasses the
liver, preventing the first-pass effect from
taking place, and more drug reaches the
circulation
28
Parenteral Route
Intravenous (fastest delivery into the blood
circulation)
Intramuscular
Subcutaneous
Intradermal
Intraarterial
Intrathecal
Intraarticular
Transdermal also can be considered parenteral
29
Topical Route
Skin (including transdermal patches)
Eyes
Ears
Nose
Lungs (inhalation)
Rectum
Vagina
30
Distribution
The transport of a drug in the body by
the bloodstream to its site of action
Protein-binding
Water soluble vs. fat soluble
Blood-brain barrier
Areas of rapid distribution: heart, liver,
kidneys, brain
Areas of slow distribution: muscle, skin, fat
31
Metabolism/Biotransformation
The biochemical transformation of a drug
into an inactive metabolite, a more
soluble compound, or a more potent
metabolite
Liver (main organ)
Skeletal muscle
Kidneys
Lungs
Plasma
Intestinal mucosa
32

Metabolism/Biotransformation

Biologic transformation of a drug into:
An inactive metabolite
A more soluble compound
A more potent metabolite
33


Metabolism/Biotransformation
(contd)


Organs or body tissues
Liver (main)
Skeletal muscle
Kidneys
Lungs
Plasma
Intestinal mucosa

34
Metabolism/Biotransformation
(contd)
Factors that decrease metabolism
Cardiovascular dysfunction
Renal insufficiency
Starvation
Obstructive jaundice
Slow acetylator
Erythromycin or ketoconazole drug therapy
35
Metabolism/Biotransformation
(contd)
Factors that increase metabolism
Fast acetylator
Barbiturate therapy
Rifampin therapy
36
Metabolism/Biotransformation
(contd)
Delaying drug metabolism causes:
Accumulation of drugs
Prolonged action of the drugs drug toxicity
Stimulating drug metabolism causes:
Diminished pharmacologic effects
37
Excretion
The elimination of drugs from the body
Kidneys (main organ)
Liver
Bowel
Biliary excretion
Enterohepatic recirculation
38
Half-life
The time it takes for one half of the original
amount of a drug to be removed from the
body
A measure of the rate at which a drug is
removed from the body
Most drugs considered to be effectively
removed after about five half-lives
Steady state
39
The Movement of Drugs
Through the Body
Drug actions
The cellular processes involved in the
drug and cell interaction
Drug effect
The physiologic reaction of the body to
the drug
40
Onset, Peak, and Duration
Onset
The time it takes for the drug to elicit a
therapeutic response
Peak
The time it takes for a drug to reach its
maximum therapeutic response
Duration
The time a drug concentration is
sufficient to elicit a therapeutic response
41
42
Therapeutic Drug Monitoring
Peak level
Highest blood level
Trough level
Lowest blood level


43
Ways Drugs Produce
Therapeutic Effects

Once the drug is at the site of action, it can
modify the rate (increase or decrease) at
which the cells or tissues function
A drug cannot make a cell or tissue
perform a function it was not designed to
perform
44
Pharmacodynamics:
Mechanisms of Action
Receptor interactions
Enzyme interactions
Nonselective interactions
45
Pharmacotherapeutics:
Types of Therapies
Acute therapy
Maintenance therapy
Supplemental/replacement therapy
Palliative therapy
Supportive therapy
Prophylactic therapy
Empiric therapy
46
Contraindications
Any characteristic of the patient, especially
a disease state, that makes the use of a
given medication dangerous for the patient
It is important to assess for
contraindications!
47
Monitoring
The effectiveness of the drug therapy must
be evaluated
One must be familiar with the drugs:
Intended therapeutic action (beneficial)
Unintended but potential adverse effects
(predictable, adverse reactions)
48
Monitoring (contd)
Therapeutic index
Drug concentration
Patients condition
Tolerance and dependence
Interactions
Adverse drug effects
49
Monitoring (contd)
Therapeutic index
Ratio of a drugs toxic level to the level that
provides therapeutic benefits
Tolerance
Decreasing response to repeated drug doses
Dependence
Physiologic or psychological need for a drug

50
Monitoring (contd)
Interactions may occur with other drugs or
food
A drug interaction is the alteration of a drugs action by:
Other prescribed drugs
Over-the-counter medications
Herbal therapies
51
Monitoring (contd)
Drug interactions
Additive effect
Synergistic effect
Antagonistic effect
Incompatibility
52
Monitoring (contd)
Adverse drug events
Medication errors
Adverse drug reactions

53
Monitoring (contd)
Adverse drug reactions
Pharmacologic reactions, including adverse effects
Hypersensitivity (allergic) reaction
Idiosyncratic reaction
Drug interaction

54
Monitoring (contd)
Adverse effects
Predictable, well-known reactions that result in little or
no change in patient management
Predictable frequency
Occurrences are related to the size of the dose
Usually resolve when the drug is discontinued
55
Other Drug-Related Effects
Teratogenic
Mutagenic
Carcinogenic
56
Pharmacognosy
Four main sources for drugs
Plants
Animals
Minerals
Laboratory synthesis
57
Toxicology
The study of poisons and unwanted
responses to drugs and other
chemicals

58
59


Life Span Considerations
CHAPTER 3
60
Life Span Considerations
Pregnancy
Breast-feeding
Neonatal and pediatric
Elderly
61
Pregnancy
First trimester is the period of greatest
danger for drug-induced developmental
defects
Drugs cross the placenta by diffusion
During the last trimester, the greatest
percentage of maternally absorbed drug
gets to the fetus
FDA has implemented pregnancy safety
categories
62
63
Breast-feeding
Breast-fed infants are at risk for exposure
to drugs consumed by the mother
Consider risk-to-benefit ratio
64
65
Neonatal and Pediatric
Considerations:
Pharmacokinetics
Absorption
Gastric pH less acidic
Gastric emptying slowed
Intramuscular absorption faster and
irregular
66
Neonatal and Pediatric
Considerations:
Pharmacokinetics (contd)
Distribution
The younger the person, the greater the
percentage of total body water
Greater total body water means lower fat
content
Decreased level of protein binding
Immature blood-brain barriermore drugs
enter the brain
67
Neonatal and Pediatric
Considerations:
Pharmacokinetics (contd)
Metabolism
Liver immature, does not produce enough
microsomal enzymes
Older children may have increased
metabolism, requiring higher doses than
infants
Other factors
68
Neonatal and Pediatric
Considerations:
Pharmacokinetics (contd)
Excretion
Kidney immaturity affects glomerular
filtration rate and tubular secretion
Decreased perfusion rate of the kidneys
may reduce excretion of drugs
69
Factors Affecting Pediatric
Drug Dosages
Skin is thin and permeable
Stomach lacks acid to kill bacteria
Lungs have weaker mucus barriers
Body temperatures less well regulated,
and dehydration occurs easily
Liver and kidneys are immature,
impairing drug metabolism and
excretion
70
Methods of Dosage
Calculation for Pediatric
Patients
Body surface area method
Using the West nomogram
Always use weight in kilograms, not
pounds
Body weight dosage calculations
Using mg/kg (most commonly used)
71
72
The Elderly
Elderly: older than age 65
Use of over-the-counter medications
Increased incidence of chronic illnesses
Sensory and motor deficits
Polypharmacy
73
Physiologic Changes
in the Elderly Patient
Cardiovascular
Gastrointestinal
Hepatic
Renal

74
The Elderly:
Pharmacokinetics

Absorption
Gastric pH less acidic
Gastric emptying slowed
Movement through GI tract slowed
Blood flow to GI tract reduced
Use of laxatives may accelerate GI motility

75
The Elderly:
Pharmacokinetics (contd)
Distribution
Lower total body water percentages
Increased fat content
Decreased production of proteins by the
liver, resulting in decreased protein binding
of drugs (and increased circulation of free
drugs)

76
The Elderly:
Pharmacokinetics (contd)
Metabolism
Aging liver produces fewer microsomal
enzymes, affecting drug metabolism
Reduced blood flow to the liver

77
The Elderly:
Pharmacokinetics (contd)
Excretion
Decreased glomerular filtration rate
Decreased number of intact nephrons

78
The Elderly:
Problematic Medications
Analgesics, including NSAIDs and opioids
Anticoagulants
Anticholinergics
Antidepressants
Antihypertensives
Cardiac glycosides (digoxin)
Sedatives and hypnotics, CNS depressants
Thiazide diuretics
79
CHAPTER 4



Cultural, Legal, and Ethical
Considerations
80
New Drug Development
Investigational new drug (IND) application
Informed consent
U.S. FDA drug approval process
Preclinical testing
Clinical studies
Investigational drug studies
Expedited drug approval

81
U.S. FDA Drug Approval
Process
Preclinical investigational drug studies
Informed consent
Clinical phases of investigational drug
studies
Phase I
Phase II
Phase III
Phase IV

82
Ethical Nursing Practice
American Nurses Association (ANA) Code
of Ethics for Nurses
International Council of Nurses (ICN)
Code of Ethics for Nurses
83
Cultural Considerations
Assess the influence of a patients cultural
beliefs, values, and customs
Drug polymorphism
Compliance level with therapy
Environmental considerations
Genetic factors
Varying responses to specific drugs
84
Cultural Considerations (contd)
Changing national demographics
Influence of ethnicity and genetics
Rapid and slow acetylators
Examples of various ethnic groups found
in the U.S.
Asian
African American
Hispanic
Native American

85
Cultural Assessment
Health beliefs and practices
Past uses of medicine
Folk remedies
Home remedies
Over-the-counter drugs and treatment
Herbal remedies

86
Cultural Assessment (contd)
Usual response to illness
Responsiveness to medical treatment
Religious practices and beliefs
Dietary habits

87
Chapter 1
The Nursing Process
and Drug Therapy
88
1. The day shift charge nurse is making rounds. A patient tells the
nurse that the night shift nurse never gave him his medication,
which was due at 11 pm. What should the nurse do first to
determine whether the medication was given?

1. Call the night nurse at home.
2. Check the Medication Administration Record.
3. Call the pharmacy.
4. Review the nurses notes.
89
2. The nurse answers a patients call light and finds the patient
sitting up in bed and requesting pain medication. What should
the nurse do first?

1. Check the orders and give the patient the
requested pain medication.
2. Provide comfort measures to the patient.
3. Assess the patients pain and pain level.
4. Evaluate the effectiveness of previous pain
medications.
90
3. The patients Medication Administration Record lists two antiepileptic
medications that are due at 0900, but the patient is NPO for a barium
study. The nurses coworker suggests giving the medications via IV
because the patient is NPO. What should the nurse do?

1. Give the medications PO with a small sip of water.
2. Give the medications via the IV route because the
patient is NPO.
3. Hold the medications until after the test is
completed.
4. Call the physician to clarify the instructions.
91
4. The nurse goes into a patients room to give medications. The
patient is confused, and the nurse discovers that the patient is
not wearing an armband. How should the nurse identify the
patient?

1. Ask the patient to state his name.
2. Ask the visitor the patients name.
3. Ask the patient to state his birthday.
4. Check with the charge nurse to obtain an
armband.
92
Chapter 2
Pharmacologic
Principles
93
1. The nurse is giving a medication that has a high first-pass effect.
The physician has changed the route from IV to PO. The nurse
expects the oral dose to be:

1. higher because of the first-pass effect.
2. lower because of the first-pass effect.
3. the same as the IV dose.
4. unchanged.
94
2. A patient is complaining of severe pain and has orders for
morphine sulfate. The nurse knows that the route that would give
the slowest pain relief would be which route?

1. IV
2. IM
3. SC
4. PO
95
3. A patient is prescribed ibuprofen 200 mg PO every 4 hours as
needed for pain. The pharmacy sends up enteric-coated tablets,
but the patient refuses the tablets, stating that she cannot swallow
pills. What should the nurse do?

1. Crush the tablets and mix them with applesauce or pudding.
2. Call the pharmacy and ask for the liquid form of the
medication.
3. Call the pharmacy and ask for the IV form of the medication.
4. Encourage the patient to try to swallow the tablets.
96
4. When giving morning medications, the nurse is preparing to
administer a transdermal patch medication and finds that the
patient already has a medication patch on his right upper chest.
What should the nurse do?

1. Remove the old medication patch and notify the
physician.
2. Apply the new patch without removing the old one.
3. Remove the old patch and apply the new patch in the
same spot.
4. Remove the old patch and apply the new one to a
different, clean area.
97
5. Two drugs that are synergistic do not have a drug interaction
with each other.

1. True
2. False
98
Chapter 3
Life Span
Considerations
99
Most medications have been
extensively studied in a variety of
different populations and age groups.

1. True
2. False
100
2. A pregnant woman with liver disease is taking a
pregnancy category B medication for her illness.
Which statement is true in this situation?

1. The mothers liver disease will expose the fetus
to less of the medication.
2. The mothers liver disease will expose the fetus
to more of the medication.
3. Because the medication is pregnancy category
B, the medication is generally considered safe for
the fetus.
4. The liver of the fetus will protect the fetus from
the effects of the medication.
101
3. A mother calls the clinic to ask about giving
acetaminophen to her infant. She says she has used
the liquid form for her 5-year-old child, and she wants
to know how much to give to her infant, who has a
fever. The nurse should:

1. instruct the mother to give the infant the same
dose as the child.
2. instruct the mother to give the infant half the
dose that she would normally give the child.
3. assist the mother in calculating the dose for the
infant.
4. consult with a physician before instructing the
mother on giving the medication.
102
4. The elderly patient will experience
polypharmacy, but not much can be
done about it.

1. True
2. False
103
5. What percent of currently approved
drugs in the U.S. lack approval for
pediatric use?

1. 10%
2. 25%
3. 50%
4. 75%

104
Chapter 4
Cultural, Legal, and
Ethical
Considerations
105
A 20-year-old patient is receiving chemotherapy for
leukemia. Her parents are very involved in her care. The
patient has indicated that she would like to try alternative
therapies in addition to the chemotherapy. Her parents
disapprove of this and do not want their daughter to take
any wacky treatments. The nurses responsibility is to:

1. research the safety of combining the therapies.
2. agree with the parents as they are being more
reasonable.
3. work with the patient and physician to find
appropriate alternative therapies.
4. convince the patient that the chemotherapy is most
beneficial to her health.
106
2. Two 40-year-old patients, one of Asian
origin and one of European origin, are
taking the same drug. The same drug
may result in very different responses in
these individuals.

1. True
2. False
107


3. A nurse has been asked to participate in an
elective procedure that violates the nurses
personal ethical principles. The nurse should:

1. refuse to participate.
2. ask to switch assignments with another
nurse.
3. speak to the manager or supervisor.
4. perform the procedure.
108
4. A research group is conducting an investigational drug study
on a promising new drug for osteoporosis. It has been difficult
to find research subjects that meet the criteria. Just before the
conclusion of the study, four subjects approach the
researchers and express their desire to withdraw from the
study. The researcher should first:

1. inform them that they waited too long to withdraw from
the study.
2. explore with them the reasons for withdrawing from the
study.
3. acknowledge that they can withdraw at any time from
the study.
4. request that they try to remain with the study until it is
completed.
109


5. Which racial group is predicted to be
nearly one in three U.S. residents in
2050?

1. African American
2. Asian
3. Hispanic
4. White
110