Learning Outcomes

1. Compare and contrast the different steps

of the nursing process.
2. Identify health history questions to ask
during the assessment phase to
gather data that are pertinent to medication
administration.
3. Describe the three areas of concern that
are addressed during the diagnosis phase of
the nursing process as applied to
pharmacotherapy.
4. Identify the two main components of the
planning phase of the nursing process.
5. Discuss three key nursing interventions
required in the implementation phase of the
nursing process for patients receiving
medications.
6. Explain the importance of the evaluation
phase of the nursing process as applied to
pharmacotherapy.
 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 nurse’s notes.
 The patient’s Medication Administration Record lists two antiepileptic
medications that are due at 0900, but the patient is NPO for a barium
study. The nurse’s 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.
 Describe physiological changes during pregnancy that may
Describe affect the absorption, distribution, metabolism, and excretion of
drugs.

Describe Describe the placental transfer of drugs from mother to infant.

Learning
Outcomes Match Match the five FDA pregnancy risk categories with their
definitions.

Identify factors that influence the transfer of drugs into breast

Identify milk.

Identify techniques that the breast-feeding mother can use to

Identify reduce drug exposure to the newborn.

Explain how differences in pharmacokinetic variables can affect

Explain drug response in pediatric patients.

Discuss the nursing and pharmacologic implications associated

Discuss with each pediatric developmental age group.

Describe physiological and biochemical changes that occur in the

Describe older adult, and how these affect pharmacotherapy.

Develop nursing interventions that maximize

Develop pharmacotherapeutic outcomes in the older adult.
Life Span Considerations
Pregnancy

Breast-feeding

Neonatal

Pediatric

Geriatric
Pregnancy

First trimester is the period of greatest danger

for drug-induced developmental defects

Drugs diffuse across the placenta

FDA pregnancy safety categories

 Breast-fed infants are
Breast- at risk for exposure to
feeding drugs consumed by
the mother
Consider risk-to-
benefit ratio
 • Absorption
• Gastric pH less acidic
Pediatric • Gastric emptying is slowed
Considerations: • Topical absorption faster through the
skin
Pharmacokinetics • Intramuscular absorption faster and
irregular
Pediatric Considerations:
Pharmacokinetics (cont'd)
• Distribution
• TBW 70% to 80% in full-term infants, 85% in
premature newborns, 64% in children 1 to
12 years of age
• Greater TBW means fat content is lower
• Decreased level of protein binding
• Immature blood-brain barrier
 Pediatric • Metabolism
• Liver immature, does not produce
Considerations: enough microsomal enzymes
Pharmacokinetics • Older children may have increased
metabolism, requiring higher doses
(cont'd) • Other factors
• Excretion
Body weight
dosage
calculations

Body surface area

method
Step 1. Convert pounds to kg: 22 lb × 1 kg/2.2 lb = 10 kg

Step 2. Calculate the dose in 10 kg × 40 mg/kg/day = 400 mg/day

mg:

Step 3. Divide the dose by the 400 mg/day ÷ 2 (BID) = 200 mg/dose
frequency: BID

Step 4. Convert the mg dose 200 mg/dose ÷ 400 mg/5 mL = 2.5

to mL: mL BID
Step 1. Calculate 18 kg × 100
the dose in mg: mg/kg/day = 1800
mg/day
Step 2. Divide the 1800 mg/day ÷ 1
dose by the (daily) = 1800
frequency: mg/dose
Step 3. Convert the 1800 mg/dose ÷ 40
mg dose to mL: mg/mL = 45 mL once
daily
Step 1. Convert pounds to 37 lb × 1 kg/2.2 lb = 16.8 kg
kg:

2
Step 2. Calculate BSA: √16.8 kg × 97 cm/3600 = 0.67 m

2 2
Step 3. Calculate the dose 2 mg/m × 0.67 m = 1.34 mg
in mg:

Step 4. Calculate the dose 1.34 mg ÷ 1 mg/mL = 1.34 mL

in mL:
Geriatric Considerations
Geriatric: older than age 65

• Healthy People 2010: older than age 55

Polypharmacy

Use of OTC medications

 • Absorption
• Gastric pH less acidic
Geriatric • Slowed gastric emptying
Considerations: • Movement through GI tract slower
• Reduced blood flow to the GI tract
Pharmacokinetics • Reduced absorptive surface area due
to flattened intestinal villi
 Geriatric • Distribution
• TBW percentages lower
Considerations: • Fat content increased
Pharmacokinetics • Decreased production of proteins by
the liver, resulting in decreased
(cont'd) protein binding of drugs
 Geriatric • Metabolism
Considerations: • Aging liver produces less microsomal
Pharmacokinetics enzymes, affecting drug metabolism
(cont'd) • Reduced blood flow to the liver
Geriatric
• Excretion
Considerations:
• Decreased glomerular filtration rate
Pharmacokinetics • Decreased number of intact nephrons
(cont'd)
Analgesics

Geriatric
Anticoagulants
Considerations:
Problematic
Anticholinergics Medications

Antihypertensives

Digoxin

Sedatives and hypnotics

Thiazide diuretics
Legal, Ethical,
and Cultural
Considerations
U.S. Drug Legislation

Federal Food and Drug Act Harrison Narcotic Act

1912 1938

1906 1914

Sherley Amendment (to the Federal Food, Drug, and

Federal Food and Drug Act of Cosmetic Act (revision of 1906
1906) Act)
U.S. Drug Legislation (cont'd)

Durham-Humphrey Amendment (to

the 1938 act) Controlled Substance Act

1962

1951 1970

Kefauver-Harris Amendment (to the

1938 act)
U.S. Drug Legislation (cont'd)

Orphan Drug Act

1991

1983

Accelerated drug approval

New Drug Development
Investigational new drug (IND) application

Informed consent

Investigational drug studies

Expedited drug approval

U.S. FDA Preclinical investigational
drug studies
Drug
Approval Clinical phases of
Process investigational drug studies
• Phase I
• Phase II
• Phase III
• Phase IV
American Nurses
Association (ANA) Ethical Nursing
Code of Ethics for
Nurses Practice
Assess the influence of a patient’s
cultural beliefs, values, and customs
Cultural
Drug polymorphism Considerations

Compliance level with therapy

Environmental considerations

Genetic factors

Varying responses to specific agents

Cultural Assessment

Health beliefs and Past uses of

Folk remedies
practices medicine

Use of
nonprescription
Home remedies OTC treatments
drugs and herbal
remedies
Usual response to
treatment Cultural
Assessment
Responsiveness to (cont'd)
medical treatment

Religious practices and

beliefs

Dietary habits
Medication Misadventures

Medication errors (MEs)

Adverse drug events (ADEs)

Adverse drug reactions (ADRs)

Medication Misadventures (cont'd)

By definition, all ADRs are also ADEs

But all ADEs are not ADRs

Two types of ADRs

• Allergic reactions
• Idiosyncratic reactions
Medication Errors

Preventable

Common cause of adverse health care

outcomes

Effects can range from no significant effect

to directly causing disability or death
Preventing Medication Errors

Minimize List Avoid

Minimize verbal or List indication next Avoid medical

telephone orders to each order shorthand,
• Repeat order to including
prescriber abbreviations and
• Spell drug name aloud acronyms
• Speak slowly and
clearly
Preventing Medication Errors
(cont'd)

1 2 3
Never assume Do not hesitate to Do not try to
anything about question a decipher illegibly
items not specified medication order written orders;
in a drug order (i.e., for any reason when contact prescriber
route) in doubt for clarification
Preventing Medication Errors
(cont'd)
NEVER use “trailing zeros” with
medication orders

Do not use 1.0 mg; use 1 mg

1.0 mg could be misread as 10 mg,

resulting in a tenfold dose increase
Preventing Medication Errors
(cont'd)

ALWAYS use a “leading zero” for decimal dosages

Do not use .25 mg; use 0.25 mg

.25 mg may be misread as 25 mg

“.25” is sometimes called a “naked decimal”

Preventing Medication Errors
(cont'd)

Check medication order and what is

available while using the “5 rights”

Take time to learn special

administration techniques of certain
dosage forms
Preventing Medication Errors
(cont'd)

Always listen to and honor any concerns

expressed by patients regarding medications

Check patient allergies and identification

Medication Reconciliation
Medication Errors
Possible consequences to nurses

Reporting and responding to MEs

• ADE monitoring programs

• USPMERP (United States Pharmacopeia Medication Errors
Reporting Program)
• MedWatch, sponsored by the FDA
• Institute for Safe Medication Practices (ISMP)

Notification of patient regarding MEs

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