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