Chapter 2, 3, & 4 Notes

Factors Affecting Drug Therapy

  • Age:

    • Infants and geriatric patients are more sensitive to the effects of medications.

  • Body Weight:

    • Influences the required medication dose.
    • Increased body weight may necessitate a higher dose.
    • Decreased body weight may necessitate a lower dose.
    • Consider weight fluctuations in patients.
    • Medication dosage may be based on ideal body weight rather than actual weight.

  • Gender Differences:

    • Men and women respond differently to drugs.

  • Metabolic Rate:

    • A higher metabolic rate may require a higher medication dose.
    • A decreased metabolic rate may require a smaller medication dose.

  • Presence of Illnesses/Pathological Conditions:

    • May alter the rate of absorption, distribution, metabolism, and excretion of drugs.

  • Psychological Aspects:

    • Can play a major role in a patient's response to therapy.
      • Consider the placebo effect.
      • Consider the nocebo effect.
    • Ethical concerns exist for both the placebo and nocebo effects.
      • The American Pain Society and the Agency for Healthcare Research and Quality recommend avoiding the deceitful use of placebos, especially in pain management.

  • Tolerance and Dependence:

    • Tolerance: The need for a higher dose of medication to achieve the same desired effect after prolonged use.
    • Dependence: Habitual use of a medication where the person is unable to control their desire for using that medication because they like the way it makes them feel, may also be considered an addiction.

  • Cumulative Effect:

    • Occurs when a drug accumulates in the body because the next dose is given before the previous dose has been metabolized.
    • Can be positive for achieving a therapeutic range but can also lead to toxicity.

  • Other Factors Influencing Drug Actions:

    • Absorption, distribution, metabolism, and excretion of the medication.

Special Considerations for Pediatric and Older Adult Patients

  • Infants and the very old are the most sensitive to the effects of medications.

  • Intramuscular (IM) Injections:

    • Typically erratically absorbed in neonates and older adults, leading to unpredictable absorption.
    • Attributed to muscle mass, decreased blood flow, and muscle inactivity.

  • Topical and Transdermal Medications:

    • Affected differently in the very old and the very young.

Topical Administrations

  • Infants:

    • The outer layer of their skin has not been fully developed.
    • Skin is more hydrated.
    • Inflammation can impact absorption (e.g., diaper rash can increase absorption).

  • Elderly Patients:

    • Difficult to predict how topical medications will be absorbed.
    • Dermal thickness decreases with age, which may enhance absorption.
    • Thin, dry, wrinkly skin, and decreased hair follicles can decrease absorption.
    • Decreased cardiac output decreases blood flow, affecting absorption.

  • Gastrointestinal (GI) Absorption:

    • Influences drug absorption across the lifespan.
    • Differences between neonates and elderly can be attributed to gastric pH, gastric emptying time, enzymatic activity, and blood flow across the mucus lining of the intestines.

  • Other Factors Placing Older Adults at Risk:

    • Reduced renal and hepatic functions.
    • Polypharmacy.
    • Increased likelihood of being malnourished due to lack of income or secure food stores.

  • Nearly every body system for men and women are different to some degree.

  • Men and women perceive and experience disease processes differently.

  • The potential for toxicity due to medications, and slower absorption times, is higher in women than in men.

Drug Distribution

  • Depends on:

    • Body's pH
    • Body water concentration and content
    • Presence and quantity of fatty tissues
    • Protein binding
    • Cardiac output
    • Blood flow
    • Regional blood flow

  • Infants:

    • Have a much higher volume of water content.
    • Require higher doses.

  • With age, total body water content decreases and the amount of fat increases.

  • Infants have a lower percentage of body fat.

  • High fat soluble medications:

    • Take longer to act
    • Accumulate in fatty tissues, increasing the potential for toxicity.
    • Must be given in smaller doses to low birth weight babies because there is less fat there to bind with the drug.
    • Require a longer onset of action.
    • Prolongs their action.
    • Increases that potential for toxicity.

Protein Binding

  • Drugs that are relatively insoluble are transported in the circulation by binding to plasma proteins.

  • Protein binding is reduced in preterm infants due to decreased plasma protein concentration in their blood.

  • Drugs such as erythromycin, prednisolone, verapamil, diazepam, are metabolized faster in women than in men (refer to table 3.4).

Metabolites

  • Products of metabolism.

  • As the body ages, physiological changes occur in the kidneys:

    • Decreased renal blood flow caused by atherosclerosis and reduced cardiac output.
    • Decreased tubular function.

  • Metabolites of drugs (or the drug itself) are eventually excreted.

  • Preterm infants have about 15% of the adult renal capacity and function, which improves to full function by 9-12 months.

  • Renal function decreases with age in adulthood and the elderly.

  • No prediction of renal function can be based solely on age due to wide individual variations and changes.

  • Lifestyle factors and comorbidities greatly impact renal function.

  • The dosage and frequency of administration must often be adjusted to maintain therapeutic serum concentrations in the blood.

  • The timing of drug administration and specimen collection is crucial for accurate interpretation of data.

  • All medications have parameters (therapeutic actions, adverse effects, drug interactions); monitoring these levels and tests, considering the patient’s age is crucial.

Special Monitoring for Pediatric Patients

  • Infants and young children are more susceptible to dehydration.

  • Weight variation between ages significantly impacts drug dosage.

  • Accurate weight is essential, especially for medications dosed in mg/kg or mcg/kg.

  • Aspirin is never administered to children aged 12 or younger due to the risk of Reye syndrome.

    • Reye syndrome can cause swelling of the brain and fatty deposits in the liver, vomiting, diarrhea, and can be fatal.

  • Ibuprofen and acetaminophen are preferred for pain and fever management in children.

  • Allergic reactions can happen rapidly in children, especially with antibiotic use.

    • Teach parents what to monitor for in case of an allergic reaction.

  • Sometimes can do things for children that maybe aren't on that specific label of what a drug got approved for, and we consider this to be an off label use.

  • Ask patients and family about current medications and why they are being taken.

Special Monitoring for Geriatric Patients

  • Take a thorough drug history and nutritional assessment.

  • Know what kind of medications they take, including non-prescription medications and herbal remedies.

  • Determine if they can take medications on their own.

  • Identify new symptoms induced by medications.

  • Gradually taper dosages when discontinuing medications.

  • Taper up on dosages when initiating drug therapy (e.g., start with 1/3 or 1/2 of the normal dose and gradually increase).

  • Review medication regimen periodically.

    • Elderly patients may have multiple doctors and be confused by generic and brand names, leading to duplication.
    • Review the medication list, including non-prescription medications and herbal remedies.

  • Use calendars or pill boxes to avoid confusion.

  • Help patients destroy old medications and be mindful of expiration dates.

  • Expiration dates indicate when a drug may be less effective or when it may increase in potency, causing toxicity.

  • Additional teaching points:

    • Know what kind of medications they're taking, you know, specifically how they are formulated.
    • Is this medication that has an enteric coating?
    • What do we need to do when taking that medication?
    • Is it a controlled or an extended release medication?
    • And if so, we want to be sure that we communicate that, you know, that they should not open or crush or, you know, chew up those medications.
    • Is it a tablet that you swallow?
    • Is it sublingual?
    • You know, the sublingual that goes under your tongue so that it's absorbed properly.
      • Keep the medication regimen simple.
      • Review and discontinue medications when appropriate.
      • Assess their ability to pay for medications/find appropriate resources.
      • Polypharmacy and adverse effects of medications are more common.

  • Use medications like barbiturates, benzodiazepines, and narcotics in older adults only as a last resort. (refer to table 3.5).

Pediatrics: Question 1

  • Which patient has the greatest percentage of body water? (
  • Infant (74%), premature infant (83%).

Pediatrics: Question 2

  • Which type of topical drug is more readily absorbed by infants?
    • Water-soluble drugs due to the underdeveloped outer skin layer and higher hydration.

Pediatrics: Question 3

  • Which form of medication is more easily administered for a toddler requiring antibiotics?
    • Carefully measured liquids.

Pediatrics: Question 4

  • A drug level of 0.45 mg/mL is considered subtherapeutic if the therapeutic range is 0.5 to 2 mg/mL.

Pediatrics: Question 5

  • Due to decreased protein binding capacity in preterm infants, a higher dosage of protein-binding drugs may be needed to achieve a therapeutic effect/maintain levels.

Medications During Pregnancy

  • Pregnant women must avoid all medications, if possible, and use only medications recommended and monitored by their physician.

  • The stage (trimester) of pregnancy is important to be aware of because there are various effects that can happen, that are definitely dependent on, upon, you know, where the mom is in that stage of pregnancy.

  • Find out if the woman has just given birth or if she’s lactating because medications can pass through the placental barrier and breast milk.

  • Mom's history should include pregnancy, non-pharmacological treatments, and herbal medications.

  • Avoid drugs and tobacco because those can negatively impact the baby.

  • Specific drug classes are known to be tetrogenic. (refer to table 3.6)

  • TetraGEN drugs cause birth defects.

    • Category A: No risk for the fetus.
    • Category B: Studies show an adverse effect, but there is really no risk, to the fetus.
    • Category C: Really no adequate information to assess the risk for the fetus at this time in pregnancy.
    • Category D: Studies demonstrate a risk to the fetus.
    • Category X: Demonstrates positive fetal abnormalities. Absolutely contraindicated in pregnancy. Can't take it.

  • Category D and X require physician guidance due to the potential risk, the benefits of therapy could outweigh the potential risk and that might be something as to why the medications are still ordered for mom.

  • Legislation in the early 2000s limited the use of the categories for pregnant women but sought to acknowledge the impact medications can have on fertility, and also different genetic components related to your future offspring.
    * This applies to both males and females.

Breast Milk

  • For many drugs that are excreted in breast milk, no one knows with certainty what effect they will have on the baby. These include prescription, non-prescription, and even herbal products.

  • Refer to table 3.7.

Genetics and Drug Metabolism

  • Genetics: Studying how living organisms inherit the traits of their ancestors.

    • Includes metabolic pathways.

  • Genome: A complete package of genetic coding of an organism.

  • Pharmacogenetics: How a person responds to a particular drug in relation to their genes/genetics.

    • The FDA maintains a website that lists genomic biomarkers identified in research studies.

The Nursing Process & Pharmacology

The nursing process is the foundation for clinical practice of nursing. It involves assessment, nursing diagnosis, planning, nursing interventions, and also evaluation, you know, because we want to evaluate and we also want to record or document our therapeutic outcomes.

Assessment &

  • Nursing history (admission questions).
  • Physical examination & look at diagnostic tests.

Nursing Diagnosis

  • Different from the medical diagnosis.

Planning Evaluation

  • Assessment is ongoing from admission to discharge.
Obtaining Drug History
  • Obtain the current and past use of any over the counter medications.
  • Evaluate it to obtain the current and past use of any over the counter medications and also to help you to identify any sort of problems that this patient may be having that's related to the drug therapy.
  • 3 Sources:
    • Primary: Patient. The primary source is typically gonna be your patient as long as, again, they're they are that reliable historian.
    • Secondary: Significant others, relatives, medical records. Secondary sources are things like, you know, their significant others, relatives, medical records, things like that.
    • Tertiary: Includes literature, background information (diagnostic or lab test results). Tertiary sources include literature to provide background information like your diagnostic tests, and different things like that.

Nursing Diagnosis vs. Medical Diagnosis

  • Nursing: The nursing diagnosis is related to your clinical judgment of that individual, maybe their family, or even the community response to an actual or potential life problem or a process.
  • Medical:Tangible medical problem.
    • The medical diagnosis is something that the physician or that provider comes up with. It's a real tangible medical problem.
  • Nursing example: Your patient can have a medical diagnosis of Parkinson's disease, but you can have a nursing diagnosis of altered mobility that's related to the medical diagnosis of Parkinson's disease.

4 Types of Nursing Diagnoses

  • Actual: Based on human responses.
  • Risk: Patients who are more susceptible to a particular problem.
  • Health promotion: wellness diagnoses.
  • Syndrome: Predicts certain circumstances or events.
  • Problem + Etiology + Evidence = Diagnostic Statement
  • Acute pain is related to tissue ischemia, as evidenced by a pain rating of 8 out of 10.

Phases Of Planning

  • Setting priorities.
  • Developing measurable patient centered outcomes. SMART
    • Clear criterion to measure patient's progress towards a goal. So, you know, let's say that your patient with Parkinson's has that altered mobility that we were just talking about.
      • SPECIFIC
      • MEASURABLE
      • ATTAINABLE
      • REALISTIC
      • TIMERS.

Example: SMART goal would be, we want to be able to say that your patient has improved their mobility. So we might wanna say that they're able to increase their mobility in the hallway from 10 feet today to 20 feet by the end of the week.

Other Phases of Planning

  • Setting Priorities
  • Helping patients meet their hierarchy of needs.
  • Developing measurable goals.
  • Formulating nursing interventions, and anticipated outcomes.

Maslows Hierarchy of Needs

Setting Priorities we want to:

  • Help our patients meet what's within those hierarchy of needs
  • Basic needs need to met first.
    • Air, Waer, Food, and Shelter

Planning Relation Pharmacology

  • Identification of therapeutic intent of each prescribed medication.

  • Review drugs for adverse effects that can be alleviated or prevented by the actions of the nurse or the patient.

  • Confirm recommended dosages / Confirm those routes for our medications.

  • We wanna check the scheduling of the administration of that medication based on what the provider has ordered.

  • We wanna teach our patients to keep written response records

  • We should encourage patients with self administration, when appropriate

  • Instruct/educate patients on proper administration of medications.

Nursing Interventions

Nurses are action oriented

  • Implementing = interventions

  • We are doing what we planned todo.

  • Actions can be:

    • Dependent --Requires a providers order/prescription
    • Interdependent Action
    • Independent

  • Provide education in this phase.

Nursing Interventions in Pharmacology and Implementation

This step of the process includes preparing procedures and following protocols to ensure patient safety, medication administration and documentation.

  • Nurse prepares described medications using the procedures to ensure patient safety.
  • Collect data, like lab values.
  • Collect that appropriate data, you know, like our labs and assessment findings and things like that.

Evaluation-Final Step

  • You also want a record and Document
    *Did there occur good therapeutic outcomes from the overall drug therapy/care plan.

NCLEX Practice Questions About Nursing Process and Pharmacology

Question 1

  • What is an Independent Intervention?
    *Verifying you patient is getting the correct rote of adminstration is an independent intervention. Verifying that correct route of administration is an independent nursing action that is required as part of the seven rights of administration. Ordering drugs or labs or changing the route of administration, those things are not within the scope of practice for a nurse. Those all require a provider's order.

Question 2

What Assessment data is considered Subjective
What did the patient tell you about their pain level for example. So remember that a subjective finding is one, that, you know, the patient says. Okay? You know, you ask a patient a question like, you know, what's your pain level? And they tell you what it is. You know, they have told you, that information. An objective assessment is clearly measurable and it's consistently reported. It's something that you as a nurse observe from your patient.

Those are the domains for the Nurse.

Three Domains of Learning

Cognitive.

Involves learning and storing knowledge.
This is kinda like your memory bank. Right? So I'm learning new things here, and I'm gonna put it right here in my filing cabinet in my brain.

Affective

Involves feelings, needs, values, opinions. Okay? So this is kind of like your patient understands the value of managing their blood sugar because of the impact that it's gonna have on their organs. If they don't, excuse me. Sorry. If they don't, it's going to ultimately maybe result in dialysis and possibly burden on their family.

AFFECTIVE

You know, this is the doing domain. It involves actually learning new skills. Okay? It's not learning what my blood sugar is. This is me actually knowing how to draw up the insulin out of the vial with the syringe, the correct syringe, correct needle, and then how to inject it into my belly in the appropriate location and method and so on.

Principle of Learning For your Patient

Answer patient's questions first so they are focused on what you are saying / repeat information so they can master a concept / what is their level of learning. Why to let them ask questions and things like that is you're gonna know what their knowledge base is. You're gonna know where they are and where you need to go instead of starting way back over here where they already know this stuff and it's gonna be pointless to them and they're not gonna be really paying attention. You wanna know where they are and where we need to go.

  • Make sure the environment is quiet and well lit.
  • Encourage active participation.
  • We want patient to ask questions and give feedback
  • Consider patient education / literacy level.
    *Health literacy.
    We have to remember as nurses and as healthcare providers that those that are out in the general public don't have the same medical terminology and medical concepts as the rest of us. Okay?
  • Review what you have told them.
  • Motivational

What patient already knows prior to teaching?
Paceful learning. The pace that you teach at is going to depend on the learning style and a lot of times the age of the patient. Remember, not all patients are tech savvy to assess prior.

Asses patient adherence/ compliance - how likely the patient will to follow instruction once they leave your care.

Short hospital stays create challenges.

Communicate clearly , patient centered care, mutual goals, therapy, expectation and realistic discharge helps.

Refer to other community agencies for support or unmet needs.

Medication education, is to provide patient with to understand.
It help them manage healthcare related services. Patient are mandated education by j the joint commission.

Discharge teaching for you patients you are.

Printing statement at end of hospital stay

*State the patients
*Needs met/ unmet
*Further needs goal
*Teaching needs all.
*Includes referrals to medical teams to check back in with you. Needs to see if they need further
*This is a team that would call you to get in touch, it's going to identify potential collaborative problems that require further monitoring at discharge to document those patient outcomes.
*Also let you know you might to go for any follow up appointments.

Question 3 NCLEX Question #3 During Discharge.

Remember that discharge teaching, it's an ongoing process. Okay? We want the family, the need to learn how to care for them at home before discharge. And all the content needs to do it the right way because if you don't tell them what they doing the right way that patient will not.
Question 4 NCLEX Question #4 During Discharge.
Which is the best measure of educating your patinets.

  • Drug Summary Sheets for meds

Urban hospital new the new Nurse.

approach is best for the nurse to take in caring for these patients?

  • Develop a plan of care that is individualized to each patient's needs