Fundamentals from Taylor

HISTORICAL PERSPECTIVES ON NURSING Caregivers for the ill and injured have always been a part of history. The roles, settings, and responsibilities, however, have changed over time, as is summarized in the following section. Development of Nursing from Early Civilizations to the 16th Century Most early civilizations believed that illness had supernatural causes. The theory of animism attempted to explain the cause of mysterious changes in bodily functions. This theory was based on the belief that everything in nature was alive with invisible forces and endowed with power. Good spirits brought health; evil spirits brought sickness and death. In providing treatment, the roles of the health care provider and the nurse were separate and distinct. The health care provider was the medicine man who treated disease by chanting, inspiring fear, or opening the skull to release evil spirits. nurse usually was the mother who cared for her family during sickness by providing physical care and herbal remedies. This nurturing and caring role of the nurse has continued to the present. As ancient Greek civilizations grew, temples became the centers of medical care because of the belief that illness was caused by sin and the gods' displeasure (disease literally means "dis-ease"). During the same period, the ancient Hebrews developed rules through the Ten Commandments and the Mosaic Health Code for ethical human relationships, mental health, and disease control. Nurses cared for sick people in the home and the community and also practiced as nurse-midwives In the early Christian period, nursing began to have a formal and more clearly defined role in society. Led by the idea that love and caring for others were important, women called "deaconesses" made the first organized visits to sick people, and members of male religious orders gave nursing care and buried the dead. Both male and female nursing orders were founded during the Crusades (11th to 13th centuries). Hospitals were built for the enormous number of pilgrims needing health care, and nursing became a respected vocation. Although the early Middle Ages ended in chaos, nursing had developed purpose, direction, and leadership. At the beginning of the 16th century, many Western societies shifted from a religious orientation to an emphasis on warfare, exploration, and expansion of knowledge. Many monasteries and convents closed, leading to a tremendous shortage of people to care for the sick. To meet this need, women who were convicted of crimes were recruited into nursing in lieu of serving jail sentences. In addition to having a poor reputation, these nurses received low pay and worked long hours in unfavorable conditions. Florence Nightingale and the Birth of Modern Nursing From the middle of the 19th century to the 20th century, social reforms changed the roles of nurses and of women in general. It was during this time that nursing as we now know it began, based on many of the beliefs of Florence Nightingale. Born in 1820 to a wealthy family, she grew up in England, was well-educated, and traveled extensively. Despite strong opposition from her family, Nightingale began training as a nurse at the age of 31. The outbreak of the Crimean War and a request by the British to organize nursing care for a military hospital in Turkey gave Nightingale an opportunity for achievement. As she successfully overcame enormous difficulties, Nightingale challenged prejudices against women and elevated the status of all nurses. After the war, she returned to England, where she established the first training school for nurses and wrote books about health care and nursing education. Florence Nightingale's contributions include: Identifying the personal needs of the patient and the role of the nurse in meeting those needs Establishing standards for hospital management Establishing a respected occupation for women Establishing nursing education Recognizing the two components of nursing: health and illness Believing that nursing is separate and distinct from medicine Recognizing that nutrition is important to health Instituting occupational and recreational therapy for sick people Stressing the need for continuing education for nurses Maintaining accurate records, recognized as the beginnings of nursing research Florence Nightingale, other historically important nurses, and images of early nursing can be seen in Figure 1-1 (on page 8). People important to the development of nursing are listed in Table 1-1 (on page 9). A historical overview of the foundational documents for nursing is presented in Box 1-1 on page 10. Development of Nursing from the 19th to 21st Centuries Both the work of Florence Nightingale and the care provided for battle casualties during the Civil War focused attention on the need for educated nurses in the United States. Schools of nursing, founded in connection with hospitals, were established on the beliefs of Nightingale, but the training they provided was based more on apprenticeship than on educational principles. Hospitals saw an economic advantage in having their own schools, and most hospital schools were organized to provide more easily controlled and less expensive staff for the hospital. This resulted in a lack of clear guidelines separating nursing service and nursing education. As students and as graduates, female nurses were under the control of male hospital administrators and health care providers. The lack of educational standards, the male dominance in health care, and the pervading Victorian belief that women were subordinate to men combined to contribute to several decades of slow progress toward professionalism in nursing. World War II had an enormous effect on nursing. For the first time, as large numbers of women worked outside the home, they became more independent and assertive. These changes in women and in society led to an increased emphasis on education. The war itself had created a need for more nurses and resulted in a knowledge explosion in medicine and technology, which broadened the role of nurses. After World War II, efforts were directed at upgrading nursing education. Schools of nursing were based on educational objectives and were increasingly developed in university and college settings, leading to degrees in nursing for men, women, and minorities. Nursing achievement has broadened in all areas, including practice in a wide variety of health care settings, the development of a specific body of knowledge, the conduct and publication of nursing research, and the recognition of the role of nursing in promoting access to affordable quality health care. Increased emphasis on nursing knowledge as the foundation for evidence-based practice (EBP) has led to the growth of nursing as a professional discipline.

Nursing achievement has broadened in all areas, including practice in a wide variety of health care settings, the development of a specific body of knowledge, the conduct and publication of nursing research, and the recognition of the role of nursing in promoting access to affordable quality health care. Increased emphasis on nursing knowledge as the foundation for evidence-based practice (EBP) has led to the growth of nursing as a professional discipline. People Important to the Early Development of Nursing in North America 19th Century Florence Nightingale= Defined nursing as both an art and a science, differentiated nursing from medicine, created freestanding nursing education; published books about nursing and health care; is regarded as the founder of modern nursing (see text for further information) Clara Barton= Volunteered to care for wounds and feed Union soldiers during the Civil War; served as the supervisor of nurses for the Army of the James, organizing hospitals and nurses; established the Red Cross in the United States in 1882 Dorothea Dix= Served as superintendent of the Female Nurses of the Army during the Civil War; was given the authority and the responsibility for recruiting and equipping a corps of army nurses; was a pioneering crusader for the reform of the treatment of the mentally ill Mary Ann Bickerdyke= Organized diet kitchens, laundries, and an ambulance service, and supervised nursing staff during the Civil War Louise Schuyler= nurse during the Civil War; returned to New York and organized the New York Charities Aid Association to improve care of the sick in Bellevue Hospital; recommended standards for nursing education Linda Richards= Graduated in 1873 from the New England Hospital for Women and Children in Boston, Massachusetts, as the first trained nurse in the United States; became the night superintendent of Bellevue Hospital in 1874 and began the practice of keeping records and writing orders Jane Addams= provided social services within a neighborhood setting; a leader for women's rights; recipient of the 1931 Nobel Peace prize Lillian Wald= Established a neighborhood nursing service for the sick poor of the Lower East Side in New York City; the founder of public health nursing Mary Elizabeth Mahoney= Graduated from the New England Hospital for Women and Children in 1879 as America's first African American nurse Harriet Tubman= A nurse and an abolitionist; active in the underground railroad movement before joining the Union Army during the Civil War Nora Gertrude Livingston= Established a training program for nurses at the Montreal General Hospital (the first 3-year program in North America) Mary Agnes Snively= Director of the nursing school at Toronto General Hospital and one of the founders of the Canadian Nurses Association Sojourner Truth= Provided nursing care to soldiers during the Civil War and worked for the women's movement Isabel Hampton Robb= A leader in nursing and nursing education; organized the nursing school at Johns Hopkins Hospital; initiated policies that included limiting the number of hours in a day's work and wrote a textbook to help student learning; the first president of the Nurses Associated Alumnae of the United States and Canada (which later became the American Nurses Association) 20th Century Mary Adelaide Nutting= Became the first professor of nursing in the world as a faculty member of Teachers' College, Columbia University; with Lavinia Dock, published the four-volume History of Nursing Elizabeth Smellie= A member of the original Victorian Order of Nurses for Canada (a group that provided public health nursing); organized the Canadian Women's Army Corps during World War II Lavinia Dock= A nursing leader and women's rights activist; instrumental in the Constitutional amendment giving women the right to vote Mary Breckenridge= Established Frontier Nursing Service n one of the first midwifery schools in United States Margaret Sanger= Opened the first birth control clinic in the United States; founder of Planned Parenthood Federation The American Nurses Association (ANA) defines nursing as "the protection, promotion, and optimization of health and abilities, prevention of illness and injury, facilitation of healing, alleviation of suffering through the diagnosis and treatment of human response, and advocacy in the care of individuals, families, groups, communities, and populations" (ANA, 2015c). In addition to a definition of nursing, the ANA describes the social context of nursing, the knowledge base for nursing practice, the scope of nursing practice, standards of professional nursing practice, and the regulation of professional nursing in its Nursing's Social Policy Statement (2010). Within today's definitions of nursing we find all the elements of professional nursing. Nurses focus on human experiences and responses to birth, health, illness, and death within the context of people, families, groups, and communities. The knowledge base for nursing practice includes diagnosis, interventions, and evaluation of outcomes from an established care plan. In addition, the nurse integrates objective data with knowledge gained from an understanding of the patient's or group's subjective experience, applies scientific knowledge in the nursing process, and provides a caring relationship that facilitates health and healing.

Mechanisms of Drug Action Pharmacokinetics Pharmacokinetics is the effect the body has on a drug once the drug enters the body. It is the movement of drug molecules in the body in relation to the drug's absorption, distribution, metabolism, and excretion. ABSORPTION Absorption is the process by which a drug is transferred from its site of entry into the body to the bloodstream. Absorption of a drug is influenced by the following factors. Route of Administration The rate of absorption depends on the route of administration. Drugs given orally usually take the longest to be absorbed, with liquids that do not need to be dissolved having a faster absorption rate than capsules or tablets. Drugs injected intramuscularly or subcutaneously are usually absorbed more rapidly than oral medications. Drugs administered intravenously are placed directly into the bloodstream, thus technically are not absorbed and take effect quickly. Drugs administered through intact skin, unless formulated specifically for systemic absorption (transdermal patches), tend to have primarily local effects. However, drugs administered via a mucous membrane (oral mucosa, eye, nose, vagina, or rectum) are absorbed both locally and systemically, which means the drug acts right at the site of administration, but also passes directly into the bloodstream. The portion of a drug that reaches the systemic circulation and can act on the cells is called the drug's bioavailability (Frandsen & Pennington, 2018). Lipid Solubility Cell membranes have a fatty acid layer. A drug that is more lipid soluble can be absorbed more readily and pass more easily through the cell membrane. pH Acidic drugs are well absorbed in the stomach. Drugs that are basic remain ionized or insoluble in an acid environment. These drugs are not absorbed before reaching the small intestine. The concept of acid-base balance is further discussed in Chapter 40. Blood Flow Absorption is increased with increased blood flow. Patients with impaired circulatory function absorb drugs less rapidly than do patients with normal circulatory function. Local Conditions at the Site of Administration The more extensive the absorbing surface, the greater the absorption of the drug and the more rapid the effect. For example, a patient with burns would have poor absorption from an intramuscular injection because of the damage to the blood supply typically present in muscle. Food, especially fatty food that slows gastric emptying, can slow the rate of absorption of some drugs; but food may enhance the rate of absorption of poorly soluble drugs. Since most of the absorption in the gastrointestinal tract takes place in the small intestine, the length of time a drug is present in the intestinal tract (diarrhea or vomiting) affects absorption and drug bioavailability. Drug absorption can be manipulated with sustained-release preparations or enteric-coated preparations, which are primarily absorbed in the large intestine (Le, 2017). Enteric-coated preparations are resistant to the digestive action of the stomach. Drug Dosage When determining a drug dosage, providers consider absorption, distribution, metabolism, and elimination. The amount of a drug administered directly impacts its bioavailability. For example, a loading dose, or a larger than normal dose, is usually given when a patient is in acute distress and the maximum therapeutic effect is desired as quickly as possible. Serum drug levels (which require a blood-draw and laboratory analysis) help determine dosage by reflecting absorption, bioavailability, and drug half-life, as well as metabolic and excretory rates. Serum drug levels ultimately indicate the onset, peak, and duration of action (Frandsen & Pennington, 2018). These laboratory values become especially important when the margin of error between a therapeutic level and toxic level is narrow. If drug toxicity occurs, it can be detected quickly and treated in the controlled hospital environment. A maintenance dose is a lower dosage that becomes the usual or daily dosage. Patients who receive digoxin or phenobarbital, for example, may receive loading doses when therapy is initiated. The goal of drug dosing is to give a dose that achieves the desired therapeutic effect of the drug (pharmacotherapeutics) without causing other undesirable or adverse reactions (discussed later in this chapter). DISTRIBUTION Distribution occurs after a drug has been injected or absorbed into the bloodstream—the drug molecules are transported throughout the body to where they take action. Metabolism and excretion occur after distribution. Distribution depends on: (1) the adequacy of blood circulation; (2) protein binding, which affects the drug's ability to leave the bloodstream or storage areas (such as muscle, fat, or other tissues) and enter the cells; and (3) the selectively permeable blood-brain barrier that protects the central nervous system (CNS) with its capillary wall, but can also limit the passage of drugs intended to act on the CNS (Frandsen & Pennington, 2018). In the case of pregnancy and lactation, some drugs readily cross the placenta and/or enter breast milk. These factors must be considered when planning and implementing drug therapies. Any concern about the safe use of a medication during pregnancy can be identified in a pharmacology text, through consultation with a pharmacist, or from trusted computer programs and electronic databases. METABOLISM Metabolism, or biotransformation, is the change of an active drug from its original form to an inactivated or new form (Frandsen & Pennington, 2018). The liver is the primary site for drug metabolism. Various processes and enzymes are involved in metabolism. Most drugs are inactivated by the liver and transformed to inactive substances for excretion (discussed in the next section). Physiologic changes associated with aging, the presence of liver disease, or other factors that impair the functioning of the liver decrease its ability to metabolize drugs. Other tissues, such as those of the gastrointestinal tract, lungs, and kidney, also have a role in drug metabolism (Frandsen & Pennington, 2018). Drugs given orally move from the intestinal lumen to the liver by way of the portal vein. Some drugs are extensively metabolized in the liver and do not make it to the systemic circulation. This reduction in bioavailability is referred to as the first-pass effect or presystemic metabolism (Frandsen & Pennington, 2018). Drugs with extensive or variable first-pass effects, like nitroglycerin, are not given orally because most of the drug would be destroyed by the liver, with little or no drug left to work in the body. This is why nitroglycerin is only given via sublingual, transdermal, or intravenous routes (McCuistion, Vuljoin-DiMaggio, Winton, & Yeager, 2018). Some drugs are metabolized by the liver to an inactive form, reducing the amount of active drug left in the body. Other drugs do not undergo metabolism at all in the liver, and others may be metabolized to an active drug metabolite (another form), and may be more active than the original drug. Pharmacology texts provide more detailed explanations of the metabolism of drugs. EXCRETION After the drug is broken down to an inactive form, excretion of the drug occurs. Excretion is the process of removing a drug, or its metabolites (products of metabolism), from the body. The kidneys excrete most drugs through urine. The lungs are the primary route for the excretion of gaseous substances, such as inhalation anesthetics. Some drugs or their metabolites are excreted through bile—either directly through feces or returned to the liver and then eventually excreted by the kidney. The skin has minimal excretory function. Some medications may be contraindicated, or dosages may need to be adjusted, if renal excretion is impaired. Changes associated with aging, disease, or the presence of other factors that impair the functioning of the kidneys can decrease their ability to excrete drugs. Manufacturers are required by law to include specific information regarding implications for specific populations, including geriatric patients, on the package inserts of prescription drugs and biological products. Of particular concern are details concerning the excretion of these drugs in older adults whose renal function has declined. Pharmacodynamics Drugs act at the cellular level to achieve the desired effects. The process by which drugs act on target cells resulting in alterations in cellular reactions and functions is called pharmacodynamics. Pharmacodynamics represents what a drug does to the body. Drugs turn on, turn off, promote, or block responses that are part of the body's processes. One mechanism of drug action is a drug-receptor interaction, in which the drug interacts with one or more cellular structures to alter cell function. These specialized structures are called receptor sites. The drug fits the receptor just like a key fits a lock. Drugs may also combine with other molecules in the body to achieve their effect. For example, a drug may combine with an enzyme to achieve the desired effect, which is referred to as a drug-enzyme interaction. Other drugs achieve their effect by acting on the permeability of the cell membrane, or altering the cellular environment via neurohormones that regulate key physiologic processes Adverse Drug Reactions Although a therapeutic effect is the desired outcome in medication administration, sometimes secondary undesirable effects occur. Harmful effects that lead to injury are known as adverse effects or adverse drug reactions (ADRs) Some unintended, secondary effects are mild, predictable, and may be tolerated as part of the therapy. These are often referred to as side effects. For example, morphine, an opioid agonist, is used to treat moderate to severe and chronic pain. A known side effect of morphine is constipation. However, the benefit of pain relief usually outweighs the side effect of constipation, so that side effect is often accepted and managed with stool softeners and laxatives. On the other hand, adverse reactions can be severe and may require discontinuation of the drug, depending on whether the benefit of the drug outweighs the harm from the adverse effect. For example, should the morphine cause a sudden drop in blood pressure, this may be considered an ADR and require intervention and discontinuation of the morphine. Another example of an ADR is the development of an iatrogenic disorder caused unintentionally by drug therapy. Neutropenia caused by chemotherapy is an example of this. Other types of ADRs to be discussed include allergic effects, drug tolerance, toxic effects, idiosyncratic effects, and drug interactions. It is important for nurses and other health care professionals to monitor for ADRs. Serious ADRs, considered adverse events or sentinel events (discussed in Chapter 27), must be documented according to facility policy and should be reported to a national database, such as MedWatch. MedWatch is a safety information and voluntary adverse events reporting program, sponsored by the U.S. Food and Drug Administration (FDA, 2018b). This program provides nationwide tracking of all serious ADRs, along with up-to-date information about medication errors and potential or actual medical-product problems and errors. According to FDA criteria, a serious adverse drug event is defined as an action that is life threatening, requires intervention to prevent death or permanent impairment, and/or leads to death, hospitalization, disability, or congenital anomaly. Reporting of serious adverse effects is necessary for corrective action to take place to protect patients. This information is used to revise drug labels, add warnings for health care providers, create patient medication guides, or withdraw a drug from the market (FDA). One example of how this information is used is the addition of a Black Box Warning (BWW), a specific warning placed on the label of some prescription drugs (such as antidepressant drugs and immediate-release opioid analgesics), to indicate the risk for serious ADRs and safety information (Frandsen & Pennington, 2018; FDA). Additional information regarding reporting adverse events is discussed at the end of the chapter, in the section on Preventing and Responding to Medication Errors.

Allergic Effect An allergic effect is an immune system response that occurs when the body interprets the administered drug as a foreign substance and forms antibodies against the drug. Drug allergies can be manifested in a variety of symptoms ranging from minor to serious. The reaction can occur immediately after the patient receives the medication or be delayed for hours to days. Symptoms may become more severe each time the drug is introduced into the body. Some of the signs and symptoms of a drug allergy are rash, urticaria, fever, diarrhea, nausea, and vomiting. The most serious allergic effect is called an anaphylactic reaction (anaphylaxis). Anaphylaxis is life threatening and results in respiratory distress, sudden severe bronchospasm, and cardiovascular collapse. This reaction is treated with vasopressors, bronchodilators, corticosteroids, oxygen therapy, intravenous fluids, and antihistamines. Drug Tolerance Drug tolerance occurs when the body becomes accustomed to the effects of a particular drug over a period of time. Larger doses of the drug must be taken to produce the desired effect. For example, patients using morphine for an extended period of time become tolerant to the drug's therapeutic effects and eventually need higher and higher doses to control their pain. Toxic Effect Toxic effects (toxicities) are specific groups of symptoms related to drug therapy that carry risk for permanent damage or death (Frandsen & Pennington, 2018). The organ or system affected by the toxicity is used to name the toxicity, such as with nephrotoxicity, or damage to the kidney. Toxicities can occur from a cumulative effect. A cumulative effect occurs when the body cannot metabolize one dose of a drug before another dose is administered. The drug is taken in more frequently than it is excreted, and each new dose increases the total quantity in the body. Older adults are at risk for experiencing a cumulative effect, related to altered drug metabolism and elimination due to impaired hepatic metabolism and renal clearance related to normal changes with aging. Researchers are working to quantify this risk and develop risk prediction models to improve early detection and prevent progressive organ damage in this vulnerable population (Kane-Gill et al., 2015) Idiosyncratic Effect An idiosyncratic effect (sometimes called paradoxical effect) is any unusual or peculiar response to a drug that may manifest itself by overresponse, underresponse, or even the opposite of the expected response. Idiosyncratic effects are related to a patient's unique response to a drug and are thought to be the result of genetic enzyme deficiencies that lead to an abnormal mechanism of drug breakdown. This term may become obsolete as ADR reporting continues and the specific mechanisms of ADRs are discovered (Marsh, 2016). Older adults often have unpredictable or erratic responses to medications. Drug Interactions Drug interactions occur when one drug is affected in some way by another drug, a food, or another substance that is taken at the same time. Drug interactions may be advantageous when, for example, a medication is given to decrease the adverse effects of a drug or increase its therapeutic effects. Other drug interactions are not beneficial: for example, interactions that decrease the therapeutic effect and/or increase the adverse effects. In a drug-drug interaction, the combined effect of two or more drugs acting simultaneously can produce several effects (Frandsen & Pennington, 2018): Additive effect—drugs with similar pharmacologic actions; results in an increase in the overall effect Synergistic effect—drugs with different sites or MOA; results in greater effects when taken together (one drug potentiates the other) Antagonistic effect—combined drugs alter the overall sum effect or negate each other; results in an effect less than that of each drug alone Interference—one drug interferes with the metabolism of another; leads to the buildup of a medication (that cannot be metabolized) and can result in toxicity or ADR Displacement—one drug binds to protein-binding sites and forces another drug to be displaced; results in the released drug becoming pharmacologically active and can lead to an increase in the effect of the unbound drug Alcohol and barbiturates, for example, when taken together create an unbeneficial synergistic effect with the potential for significantly increased CNS depression. It is important to be knowledgeable about and watch for drug interactions and the effects of drug therapy. Dietary supplements and herbal and natural remedies are another potential problem area for drug interactions. Many patients do not consider dietary supplements, herbs, and natural remedies to be medications because they can purchase these items at a store selling nutritional products. However, many of these products have recognized pharmacologic effects, unexpected allergic reactions, and problematic drug-supplement interactions (Dudek, 2017; National Center for Complementary and Integrative Health, 2018). When asking patients if they are taking any medications, specifically ask if they are taking any herbal or natural supplements. Health care providers need to identify viable resources (Gregory, Jalloh, Abe, Hu, & Hein, 2015) and be aware of the intended benefits, possible adverse effects, potential drug interactions, and perioperative implications related to these types of supplements. Further information related to dietary supplements, and natural and herbal products can be found at the FDA's website Factors Affecting Drug Action Certain variables can influence the action or effect of a medication. These variables include developmental considerations, patient's body weight, patient's biological sex, genetic and cultural factors, psychological factors, pathology, environment, and timing of medication administration. Developmental Considerations During pregnancy, many drugs are contraindicated because of their possible adverse effects on the fetus. Certain drugs, referred to as teratogenic, are known to have the potential to cause developmental defects in the embryo or fetus and are definitely contraindicated. Examples of teratogenic drugs include cocaine, alcohol, phenytoin (an anticonvulsant), and isotretinoin (a medication used to treat severe acne). Some drugs cross into breast milk, putting breastfed infants at risk for adverse effects from drugs in the mother's circulation. Small body size, reduced weight, and reduced body water also alter distribution, as do decreases in cardiac output and organ perfusion. Therefore, a child's medication dose is smaller than an adult's dose. Infants are especially sensitive to medications because of the immaturity of their organs and immaturity of the blood-brain barrier. Older people are sensitive to medications because their bodies have experienced physiologic changes associated with the aging process, including decreased gastric motility, muscle mass, acid production, and blood flow, which affect drug absorption. They may also be more susceptible to certain adverse effects. Liver function declines with advancing age, and changes occur in the hepatic enzymes involved in drug metabolism. Blood flow to the liver decreases secondary to a decrease in cardiac output. Drugs are excreted more slowly from the body as a result of changes in kidney function. Receptor sensitivity is altered in older people, and their sensitivity to certain drugs increases. The physiologic changes in older people that increase drug susceptibility are summarized in the accompanying display, Focus on the Older Adult Weight Expected responses to drugs are based largely on the reactions that occur when the drugs are given to healthy adults (18 to 65 years of age, 150 lb [∼68 kg]). It is important to know the usual dose for a medication before administering it. Body surface area (BSA) is the area of the external surface of the body, expressed in square meters (m2). BSA is the initial factor considered when calculating the drug dose for infants, children, older adults, patients receiving oncologic medications, and patients with low body weight (Frandsen & Pennington, 2018). Drug doses for children are calculated by weight in kilograms or BSA. Biological Sex The difference in the distribution of body fat and fluids in men and women is a minor factor affecting the action of some drugs. To date, most research on drugs and their actions and effects has been conducted on men. Future clinical drug trials are expected to include more women to document the effects of hormonal fluctuations. Cultural and Genetic Factors Religious restrictions and beliefs or cultural practices may affect the patient's acceptance of, response to, and compliance with certain drug therapies. Health care providers need an understanding of a patient's cultural values, beliefs, and practices to provide culturally competent care (Giger, 2017). For example, Christian Scientists place their faith in a system of spiritual healing; therefore, they do not take medicine. A Christian Scientist would not participate in a childhood vaccination program or pharmaceutical therapy to manage disease (The Christian Science Board of Directors, 2018). Herbal treatments that are popular in some cultures may interfere with or counteract the action of prescribed medication. Ethnopharmacology is a relatively new field of study composed of several interrelated aspects. "Combining the approaches of medical anthropology, phytotherapy, and pharmaceutical science, this discipline examines medicinal plants in indigenous cultures, their bioactive compounds, and the sustainable development and production of nature-derived therapeutics" (Transcultural C.A.R.E. Associates, 2015, Ethno Pharmacology). Although standardized classification systems do not universally exist, discussions around ethnopharmacology and ethnomedicine involve cultural perceptions and values that impact medical systems, cross-cultural comparisons of terms and medicinal uses, and drug discovery (Staub, Geck, Weckerle, Casu, & Leonti, 2015). The more recent use of the term ethnopharmacology (or ethnic pharmacology) involves the study of the effect of ethnicity on responses to prescribed medication, especially drug absorption, metabolism, distribution, and excretion. This is often associated with pharmacogenetics where differences in the responses of patients receiving the same medication may result from genetic differences, such as genetic variations in certain enzymes, that may cause differing drug responses. Ethnicity and race influence responses to certain medications. Certain ethnic groups and races have more of these variations than do others (Muñoz & Hilgenberg, 2006; Woods, Mentes, Cadogan, & Phillips, 2017). Specifically, there may be important variations in the therapeutic dose and/or incidence of adverse effects. Some patients in certain groups obtain therapeutic responses at lower doses than those usually prescribed, while other patient groups experience less effect or more effect from prescribed medications than expected. For example, certain angiotensin-converting enzyme (ACE) inhibitors have been found to be less effective in Black patients. Alternately, certain thiazide diuretics appear to be better for controlling hypertension in Black patients. African American, Japanese, and Taiwanese patients may experience elevated serum drug levels when lithium is prescribed in the usual dosages, thus experiencing symptoms of drug toxicity. Care must be taken, however, to avoid making sweeping generalizations and assumptions. Ethnicity and race influence responses to certain medications, but no two people are alike. General and specific cultural knowledge allows the health care provider to ask the right questions when interacting with patients of varying backgrounds. Nurses who are aware of the specific needs and beliefs of culturally diverse patient populations are better able to communicate effectively and provide optimal culturally competent care. Box 29-1 gives guidelines for effective communication about medication with culturally diverse patients.

Key Terms absorption: process by which drugs are transferred from the site of entry into the body to the bloodstream adverse drug reactions (ADRs): undesirable effects other than the intended therapeutic effect of a drug allergic effect: immune system response that occurs when the body interprets an administered drug as a foreign substance and forms antibodies against the drug ampule: glass flask containing a single dose of medication for parenteral administration anaphylactic reaction: severe reaction occurring immediately after exposure to a drug; characterized by respiratory distress and vascular collapse anaphylaxis: severe reaction occurring immediately after exposure to a drug; characterized by respiratory distress and vascular collapse bioavailability: distribution: movement of drugs by the circulatory system to the site of action drug tolerance: tendency of the body to become accustomed to a drug over time; larger doses are required to produce the desired effects ethnopharmacology: study of the effect of ethnicity on responses to prescribed medication, especially drug absorption, metabolism, distribution, and excretion excretion: removal of a drug from the body generic name: name assigned by the manufacturer who first develops a drug; it is often derived from the chemical name half-life: the amount of time it takes for half a dose of a drug to be eliminated from the body idiosyncratic effect: unusual, unexpected response to a drug that may manifest itself by overresponse, underresponse, or response different from the expected outcome inhalation: (1) act of breathing in; synonym for inspiration; (2) administration of a drug in solution via the respiratory tract intradermal injection: injection placed just below the epidermis intramuscular injection: an injection into deep muscle tissue, usually of the buttock, thigh, or upper arm intravenous route: injection of a solution into the vein medication reconciliation: process of creating an accurate list of all medications a patient is taking, including drug name, dosage, frequency, and route, and comparing the list to the physician's admission, transfer, or discharge orders, with the goal of providing correct medications to the patient at all transition points within the hospital metabolism: (1) chemical changes in the body by which energy is provided; (2) breakdown of a drug to an inactive form; also referred to as biotransformation parenteral: outside of intestines or alimentary canal; popularly used to refer to injection routes peak level: highest plasma concentration of a drug pharmacodynamics: process by which drugs alter cell physiology and affect the body pharmacogenetics: the study of how genetic variation affects an individual's response to drugs pharmacokinetics: movement of drug molecules in the body in relation to the drug's absorption, distribution, metabolism, and excretion pharmacology: study of actions of chemicals on living organisms pharmacotherapeutics: dynamic that achieves the desired therapeutic effect of the drug without causing other undesirable effects piggyback delivery system: placebo: Latin word meaning, "I shall please"; an inactive substance that gives satisfaction to the person using it PRN order: "as needed" order for medication stat order: single order carried out immediately subcutaneous injection: injection into the subcutaneous tissue that lies between the epidermis and the muscle synergistic effect: combined effect of two or more drugs is greater than the effect of each drug alone teratogenic: known to have potential to cause developmental defects in the embryo or fetus therapeutic range: that concentration of drug in the blood serum that produces the desired effect without causing toxicity topical application: application of a substance directly to a body surface toxic effect: specific groups of symptoms related to drug therapy that carry risk for permanent damage or death trade name: drug name selected and trademarked by the company marketing the drug; also called brand name or proprietary name trough level: the point when a drug is at its lowest concentration vial: glass bottle with self-sealing stopper through which medication is removed; may be single or multiple dose Z-track technique: technique used to administer medications intramuscularly that ensures that the medication does not leak back along the needle track and into the subcutaneous tissue, reducing pain and discomfort

INTRODUCTION A drug or medication is any substance that modifies body functions when taken into the body. The study of drugs and their effect on the body's functioning is called pharmacology. A pharmacist is a person licensed to prepare and dispense drugs. Physicians, dentists, psychiatrists, podiatrists, physician assistants, and advanced practice nurses have prescriptive authority. Prescriptive authority for advanced practice nurses (clinical nurse specialists, nurse practitioners, certified nurse anesthetists, nurse midwives) and physician assistants varies in the degree of independence and the medications that may be prescribed from state to state. Nurses must be familiar with the laws relative to prescriptive authority in their state of practice. The prescriber conveys medication plans to others by an order called a prescription. In a hospital or other health care facility, after the pharmacist prepares the medication, the nurse administers the medication to the patient. This chain provides a check-and-balance system for medication administration. If an error is made when the order is written, the pharmacist or nurse administering the medication has the opportunity to note the discrepancy. If an error occurs when the pharmacy dispenses the medication, the administering nurse has the opportunity to note this discrepancy. See the accompanying Reflective Practice box for an example. Medication administration is a core nursing function that involves skillful technique and consideration of the patient's development, health status, and safety. The nurse administering medications needs to have knowledge of drugs, including drug names, preparations, classifications, adverse effects, and physiologic factors that affect drug action. Information about specific drugs is available in pharmacology texts and drug reference books. Computer programs and electronic databases are available for up-to-date medication information. Nurses must have sufficient knowledge about the drugs being administered to safely care for their patients. The Joint Commission has made several recommendations regarding safe practice when administering medications. Up-to-date information about these recommendations can be found at www.jointcommission.org/PatientSafety/NationalPatientSafetyGoals. The nursing process can be applied to medication administration. Assessment includes a comprehensive medication history, awareness of the patient's allergies, and patient assessment, as well as ongoing assessments of the patient's response during and after medication administration. Nursing diagnoses are developed from the assessment data. Patient-centered outcomes are evaluated after implementation of the plan of care and are tailored to the patient's needs. PRINCIPLES OF PHARMACOLOGY An overview of basic pharmacology includes drug nomenclature, types of drug preparations, drug classification, drug indication, mechanisms of drug action, adverse drug reactions, side effects, and factors affecting drug action, as well as drug blood level monitoring and pertinent U.S. drug legislation. Drug Nomenclature Drugs have several names, and are most commonly referred to by their generic and trade names. The generic name, which identifies the drug's active ingredient, is the name assigned by the manufacturer that first develops the drug. Often, the generic name is derived from the chemical name, which is a precise description of the drug's chemical composition that identifies the drug's atomic and molecular structure using exact chemical language and terminology. The generic name is not owned by any drug company and is universally accepted. The official name (also known as a monograph) is the name by which the drug is identified in publications such as the United States Pharmacopeia and National Formulary (USP-NF, 2018). The official name is typically the generic name. The trade name, also referred to as the brand name, is selected by the pharmaceutical company that sells the drug and is protected by trademark. A drug can have several trade names when produced by different manufacturers. Nurses should be familiar with both generic and trade names. For example, acetaminophen (generic name) has trade names such as Tylenol, Tempra, and Liquiprin. The generic name is universal and is not likely to change; however, the trade name will change depending on the specific company and manufacturer. Health care entities vary in their use of generic-only or both the generic and trade names. Electronic medication administration records (eMARs) typically default to the generic names, but may include both the generic and trade names. In conversations with interprofessional/intraprofessional teams and with patients, the trade name is often used because it is frequently easier than the generic name to articulate or spell. In drug literature and in clinical practice, trade names are capitalized and generic names are presented in lowercase unless they are in a list or used at the beginning of a sentence (Frandsen & Pennington, 2018). Developing a working knowledge of the generic and trade names of drugs is an important part of the nurse's responsibilities when transcribing orders and administering medication therapies.

NURSING'S AIMS AND COMPETENCIES Four broad aims of nursing practice can be identified in the definitions of nursing: To promote health To prevent illness To restore health To facilitate coping with disability or death To meet these aims, the nurse uses four blended competencies: cognitive, technical, interpersonal, and ethical/legal. More recently these competencies have been further specified as the Quality and Safety Education for Nurses (QSEN) project competencies: patient-centered care, teamwork and collaboration, quality improvement, safety, EBP, and informatics. These competencies are described in Chapter 13. The Reflective Practice Boxes that begin each chapter of this book offer examples of practical challenges to these competencies that actual nursing students have encountered. The primary role of the nurse as caregiver is given shape and substance by the interrelated roles of communicator, teacher, counselor, leader, researcher, advocate, and collaborator. These roles are described in Table 1-2 and throughout the text. The nurse carries out these roles in many different settings, with care increasingly provided in the home and in the community. Examples of settings for care are fully described in Unit II. Recall Roberto Pecorini, the 38-year-old patient with metastatic cancer. When providing care for Mr. Pecorini, the nurse assumes the role of competent, caring, and responsible caregiver, creates a respectful partnership while identifying best practices, maintains the patient's safety throughout, and appropriately educates the patient and advocates for the patient's rights. Promoting Health Health is a state of optimal functioning or well-being. As defined by the World Health Organization (WHO), a person's health includes physical, social, and mental components, and is not merely the absence of disease or infirmity. Health is often a subjective state: people medically diagnosed with an illness may still consider themselves healthy. Wellness, a term that is often associated with health, is an active state of being healthy by living a lifestyle that promotes good physical, mental, emotional, and spiritual health. Models of health and wellness are described in Chapter 3. Health is an essential part of each of the other aims of nursing. Nurses promote health by identifying, analyzing, and maximizing each patient's own individual strengths as components of preventing illness, restoring health, and facilitating coping with disability or death. When teaching Mr. Basshir, the patient described at the beginning of the chapter with risk factors for heart disease, the nurse would focus the teaching plan to rely on the patient's strengths. Although his statements reflect a reluctance to learn and change, emphasizing the patient's strengths would help the patient feel more in control of his health, and thus, hopefully, spur him to make the necessary changes. Health promotion is motivated by the desire to increase a person's well-being and health potential. A person's level of health is affected by many different interrelated factors that either promote health or increase the risk for illness. These factors include genetic inheritance, cognitive abilities, educational level, race and ethnicity, culture, age and biological sex, developmental level, lifestyle, environment, and socioeconomic status. A level of health or wellness is also strongly influenced by what is termed "health literacy." Health literacy, defined by the U.S. Department of Health and Human Services in the document Healthy People 2020, is the ability of people to obtain, process, and understand the basic information needed to make appropriate decisions about health. Examples of ways that nurses can promote health literacy are included throughout this text. Healthy People 2020 also establishes health promotion guidelines for the nation as a whole. The guidelines are focused on meeting four overarching goals: Attain high-quality, longer lives free of preventable disease, disability, injury, and premature death. Achieve health equity, eliminate disparities, and improve the health of all groups. Create social and physical environments that promote good health for all. Promote quality of life, healthy development, and healthy behaviors across all life stages. The guidelines also contain 12 Leading Health Indicators, which are used to measure the health of the nation over a 10-year period. The Healthy People 2020 Leading Health Indicators listed in Box 1-2 reflect the major health concerns in the United States at the beginning of the 21st century. They were selected on the basis of their ability to motivate action, availability to measure progress, and importance as public health issues. Patient-centered health promotion is the framework for nursing activities. The nurse considers the patient's self-awareness, health awareness, and use of resources while providing care. Through knowledge and skill, the nurse: Facilitates patients' decisions about lifestyle that enhance the quality of life and encourage acceptance of responsibility for their own health Increases patients' health awareness by assisting in the understanding that health is more than just not being ill, and by teaching that certain behaviors and factors can contribute to or diminish health Teaches self-care activities to maximize achievement of goals that are realistic and attainable Serves as a role model Encourages health promotion by providing information and referrals BOX 1-2 Healthy People 2020: Leading Health Indicators Access to health services Clinical preventive services Environmental quality Injury and violence Maternal, infant, and child health Mental health Nutrition, physical activity and obesity Oral health Reproductive and sexual health Social determinants Substance abuse Tobacco Source: From U.S. Department of Health and Human Services. Office of Disease Prevention and Health Promotion. Healthy People 2020. Washington, DC. Retrieved http://www.healthypeople.gov/2020. Recall Michelle Fine, the young mother with a new baby who calls the nursery for help with breastfeeding. Making a referral for home care follow-up before Michelle's discharge from the hospital would have been an appropriate intervention to offer support, guidance, and additional teaching. Preventing Illness The U.S. Department of Health and Human Service's Office of Disease Prevention and Health Promotion leads efforts to improve the health of all Americans. The objectives of disease prevention activities are to reduce the risk of illness, to promote good health habits, and to maintain optimal functioning. Nurses prevent illness primarily by teaching and by personal example. Examples include: Educational programs in areas such as prenatal care for pregnant women, smoking-cessation programs, and stress-reduction seminars Community programs and resources that encourage healthy lifestyles, such as aerobic exercise classes, "swimnastics," and physical fitness programs Literature, television, radio, or Internet information on a healthy diet, regular exercise, and the importance of good health habits Health assessments in institutions, clinics, and community settings that identify areas of strength and risks for illness Take time to check out Health.gov, the Office of Disease Prevention and Health Promotion's website, at https://health.gov, to familiarize yourself with many helpful resources that you can use for yourself, your family, and your patients. Think back to Ahmad Basshir, the 62-year-old man at risk for heart disease who was described at the beginning of the chapter. By addressing Mr. Basshir's resistance to change and teaching him the lifestyle modifications necessary to reduce his risk for developing heart disease, the nurse contributes to illness prevention by promoting healthier behavior. Restoring Health Activities to restore health encompass those traditionally considered to be the nurse's responsibility. These focus on the person with an illness, and range from early detection of a disease to rehabilitation and teaching during recovery. Such activities include: Performing assessments that detect an illness (e.g., taking blood pressure, measuring blood sugars) Referring questions and abnormal findings to other health care providers as appropriate Providing direct care of the person who is ill by such measures as giving physical care, administering medications, and carrying out procedures and treatments Collaborating with other health care providers in providing care Planning, teaching, and carrying out rehabilitation for illnesses such as heart attacks, arthritis, and strokes Working in mental health and chemical-dependency programs Facilitating Coping With Disability and Death Although the major goals of health care are promoting, maintaining, and restoring health, these goals cannot always be met. Nurses also facilitate patient and family coping with altered function, life crisis, and death. Altered function decreases a person's ability to carry out activities of daily living (ADLs) and expected roles. Nurses facilitate an optimal level of function through maximizing the person's strengths and potentials, through teaching, and through referral to community support systems. Nurses provide care to both patients and families at the end of life, and they do so in hospitals, long-term care facilities, hospices, and homes. Nurses are active in hospice programs, which assist patients and their families in multiple settings in preparing for death and in living as comfortably as possible until death occurs.

NURSING AS A PROFESSIONAL DISCIPLINE As definitions of nursing have expanded to describe more clearly the roles and actions of nurses, increased attention has been given to nursing as a professional discipline. Nursing uses existing and new knowledge to solve problems creatively and meet human needs within ever-changing boundaries. Nursing is recognized as a profession based on the following defining criteria: Well-defined body of specific and unique knowledge Strong service orientation Recognized authority by a professional group Code of ethics Professional organization that sets standards Ongoing research Autonomy and self-regulation Nursing involves specialized skills and application of knowledge based on an education that has both theoretical and clinical practice components. Nursing is guided by standards set by professional organizations and an established code of ethics. Nursing focuses on human responses to actual or potential health problems and is increasingly focused on wellness, an area of caring that encompasses nursing's unique knowledge and abilities. Nursing is increasingly recognized as scholarly, with academic qualifications, research, and publications specific to the profession that are widely accepted and respected. In addition, nursing interventions are focused on EBP, which is practice based on research and not intuition. Nursing has evolved through history from a technical service to a person-centered process that maximizes potential in all human dimensions. This has been an active development process, using lessons from the past to gain knowledge for practice in the present and in the future. EDUCATIONAL PREPARATION FOR NURSING PRACTICE Educational preparation for nursing practice involves several different types of programs that lead to licensure, or the legal authority to practice as a nursing professional. Students may choose to enter a practical nursing program and become a licensed practical nurse (LPN) or they may enter a diploma, an associate degree, or a baccalaureate program to be licensed as a registered nurse (RN). State laws in the United States recognize both the LPN and the RN as credentials to practice nursing. Increasingly, various levels of nursing education are providing programs for educational advancement. For example, the LPN can complete an associate degree and become an RN, and the RN prepared at the diploma or associate degree level can attain a bachelor of science in nursing (BSN) degree. There are also programs that provide RN-to-master's degrees, as well as BSN-to-DNP or PhD, and master's degree-to-DNP or PhD. Graduate programs in nursing provide master's and doctoral degrees. Educational preparation for the nurse has become a major issue in nursing; the multiple methods of preparation are confusing to employers, consumers of health care services, and nurses themselves. Nursing organizations are working hard to answer questions such as "What is technical nursing?" and "What is professional nursing?" as well as "Should graduates of different programs take the same licensing examination and have the same title?" These questions are likely to be resolved during your nursing career. The American Association of Colleges of Nursing (AACN) believes that baccalaureate education should be the minimum level required for entry into professional nursing practice in today's complex health care environment. The AACN's Essentials of Baccalaureate Education for Professional Nursing Practice notes that "nursing has been identified as having the potential for making the biggest impact on a transformation of health care delivery to a safer, higher quality, and more cost-effective system" (AACN, 2008). The Essentials document describes the outcomes expected of graduates of baccalaureate programs and emphasizes concepts such as patient-centered care, interprofessional teams, EBP, quality improvement, patient safety, informatics, clinical reasoning/critical thinking, genetics and genomics, cultural sensitivity, professionalism, and practice across the lifespan in an ever-changing and complex health care environment. The following sections discuss current education for LPNs and RNs, as well as graduate nursing education, continuing education for nurses, and in-service education. Practical and Vocational Nursing Education Practical (also labeled vocational) nursing programs were established to teach graduates to give bedside nursing care to patients. Schools for practical nursing programs are located in varied settings, such as high schools, technical or vocational schools, community colleges, and independent facilities. Most programs are 1 year in length, divided into one third classroom hours and two thirds clinical laboratory hours. On completion of the program, graduates can take the National Council Licensure Examination-Practical Nurse (NCLEX-PN) for licensure as an LPN. LPNs work under the direction of a health care provider or RN to give direct care to patients, focusing on meeting health care needs in hospitals, long-term care facilities, and home health facilities. Registered Nursing Education Three types of educational programs traditionally lead to licensure as an RN: (1) diploma, (2) associate degree, and (3) baccalaureate programs. Graduates of all three programs take the NCLEX-RN examination. Although it is a national examination, it is administered by—and the nurse is licensed in—the state in which the examination is taken and passed. It is illegal to practice nursing unless one has a license verifying completion of an accredited (by state) program in nursing and has passed the licensing examination. Nurses gain legal rights to practice nursing in another state by applying to that state's board of nursing and receiving reciprocal licensure. The U.S. Department of Labor, Bureau of Labor Statistics (BLS), annually collects and publishes data on employment and earnings for more than 800 occupations. As of June 2017, the BLS estimates that there were 2,751,000 RNs employed in various settings in the United States. See Figure 1-2 for a breakdown of where nurses are employed. Diploma in Nursing Many nurses practicing in the United States today received their basic nursing education in a 3-year, hospital-based diploma school of nursing. The first schools of nursing established to educate nurses were diploma programs; until the 1960s, they were the major source of graduates. In recent years, the number of diploma programs has decreased greatly. Graduates of diploma programs have a sound foundation in the biologic and social sciences, with a strong emphasis on clinical experience in direct patient care. Graduates work in acute, long-term, and ambulatory health care facilities. Associate Degree in Nursing Most associate degree in nursing (ADN) programs are offered by community or junior colleges. These 2-year educational programs attract more men, more minorities, and more nontraditional students than do the other types of programs. Associate degree education prepares nurses to give care to patients in various settings, including hospitals, long-term care facilities, and home health care and other community settings. Graduates are technically skilled and well prepared to carry out nursing roles and functions. As defined by the National League for Nursing (NLN), competencies of the ADN on entry into practice encompass the roles of provider of care, manager of care, and member of the discipline of nursing. Baccalaureate in Nursing The first baccalaureate nursing programs were established in the United States in the early 1900s. The number of programs and the number of enrolling students, however, did not increase markedly until the 1960s. Most graduates receive a BSN. Recommendations by national nursing organizations that the entry level for professional practice be at the baccalaureate level have resulted in increased numbers of these programs. Although BSN nurses practice in a wide variety of settings, the 4-year degree is required for many administrative, managerial, and community health positions. In BSN programs, the major in nursing is built on a general education base, with concentration on nursing at the upper level. Students acquire knowledge of theory and practice related to nursing and other disciplines, provide nursing care to individuals and groups, work with members of the health care team, use research to improve practice, and have a foundation for graduate study. Nurses who graduate from a diploma or associate degree program and wish to complete requirements for a BSN may choose to enroll in an on-campus, online, or external degree RN-to-BSN program. In addition, there are accelerated BSN programs for people who already have a degree in another area. Emerging Entry Points Beyond the traditional entry routes to a career as an RN, a number of additional pathways are emerging and proving effective at attracting new audiences into the nursing profession. These alternative routes include entry-level master's programs, accelerated programs for graduates of nonnursing disciplines, community college-based baccalaureate programs, and RN completion programs for LPNs and other allied health providers. Graduate Education in Nursing The two levels of graduate education in nursing are the master's and doctoral degrees. A master's degree prepares advanced practice nurses (APRNs) to function in educational settings, in managerial roles, as clinical specialists, and in various advanced practice areas, such as nurse-midwives and nurse practitioners (Table 1-3 on page 16). Many master's graduates gain national certification in their specialty area—for example, as family nurse practitioners (FNPs) or nurse midwives. The clinical nurse leader (CNL) is an emerging nursing role developed by the American Association of Colleges in Nursing (AACN, 2012) in collaboration with an array of leaders from the practice environment. The CNL, an advanced clinician with education at the master's degree level, puts EBP in to action to ensure that patients benefit from the latest innovations in care delivery. The CNL role is not one of administration or management. Nurses with doctoral degrees meet requirements for academic advancement and organizational management. They also are prepared to carry out research necessary to advance nursing theory and practice. The newest graduate nursing degree is the doctor of nursing practice (DNP). In 2004, the AACN, in consultation with a variety of stakeholder groups, called for moving the current level of preparation necessary for advanced practice from the master's degree to the DNP by the year 2015. According to their position statement, the DNP is designed for nurses seeking a terminal degree in nursing practice and offers an alternative approach to research-focused doctoral programs. DNP-prepared nurses are well equipped to fully implement the science developed by nurse researchers prepared in PhD, DNSc, and other research-focused doctorates. For more information on the AACN's position, refer to the AACN Fact Sheet on the DNP, available at http://www.aacn.nche.edu/media-relations/fact-sheets/dnp. It is a good idea as you begin clinical practice to talk with as many nurses with graduate degrees as you can to see if one of their roles might become your next goal. Continuing Education The ANA defines continuing education as those professional development experiences designed to enrich the nurse's contribution to health. Colleges, hospitals, voluntary facilities, and private groups offer formal continuing education through courses, seminars, and workshops. In many states, continuing education is required for an RN to maintain licensure. You will quickly learn that successful nurses are lifelong learners!

Principles of Medication Administration Medication Prescriptions and Orders Prescription and order both refer to the means by which a provider communicates information regarding medications (and other procedures and therapies) to the health care team. When considering medication administration, both terms refer to a prescription written or entered into the EHR by a provider with prescriptive rights. In health care, the word order is typically used in the inpatient setting, with prescription primarily used in the outpatient and community settings. No medication may be given to a patient without a medication order from a licensed practitioner. Each health facility has a policy specifying the manner in which the practitioner writes an order. In some instances, prescriptions are written on a form designed specifically for a primary care provider's order. This becomes part of a patient's permanent record. Prescribers are able to make use of electronic prescribing systems, sending medication prescriptions electronically to outpatient pharmacies. Most health care facilities are beginning to use computer provider order-entry (CPOE) systems. CPOE systems allow the prescribing provider to enter medication orders in a standard format. CPOE systems guide the prescriber in complete, accurate, and appropriate prescribing. The computer sends the prescription directly to the pharmacy and enters the prescription into the patient's permanent record. This prevents any guessing when handwriting is illegible or drug names are similar (Frandsen & Pennington, 2018). Some of the information this system provides includes recommended dosing of medications, drug-specific information, current patient information, laboratory tests that monitor the action of the drug, and potential interactions that may occur with other medications or food. A computerized order-entry system can make medication administration safer and reduce adverse drug events. Safe practice dictates that a nurse follows only a written or typed order, or an order entered into a computer order-entry system because these types of orders are less likely to result in error or misunderstanding. Under certain circumstances, such as in an emergency, a verbal order from the physician may be given to a registered nurse or a pharmacist. In most settings, a student nurse is not permitted to accept a verbal order from a physician. The legal implications for dispensing and administering an agent without a written order vary, and nurses must be familiar with the exact facility policy whenever called on to administer therapeutic agents. The legal implications of verbal orders are discussed in Chapter 7. Usual hospital policy dictates that when a patient is admitted, unless specific orders to the contrary are written, all drugs that may have been prescribed while the patient was at home are discontinued. To avoid the possibility of having the patient continue to take the home medications while receiving the same ones or others under new orders, all medications should be sent home with the family or removed from the patient's bedside. In some inpatient facilities, patients keep their medications at their bedside and learn, or continue, to administer them as they would at home. It is believed that this approach helps to promote patients' independence. This practice is also seen with drugs that are not available at a health care institution (such as oral contraceptives and certain antidiabetic agents). Careful labeling and adherence to institution-based policies and procedures must be ensured. Nurses continue to be involved with the medication self-administration process, verifying the medications are understood by the patient, are taken appropriately, and that the medications are documented in the patient's permanent record. When a patient has had surgery, is transferred to another clinical service, or is transferred to another health facility, it is general practice that all orders related to drugs are discontinued and new orders are written in the new setting. Medication reconciliation is a process used by the health care team where the current medication orders are compared to patient report, the patient's medical record, and prescriptions that may have been in place prior to the transition of care (Barnsteiner, 2008). Although most often a responsibility of the nurse, pharmacists and other members of the health care team play a valuable role in the medication reconciliation process (Shekelle et al., 2013). The Joint Commission (2018) includes medication reconciliation as part of the 2018 National Patient Safety Goals. Goal 3 identifies the collection of a patient's current medication list, informing patients of the importance of maintaining an accurate medication list, and comparison of medications taken with the newly prescribed medications to prevent duplications, omission, or interactions (The Joint Commission). Types of Orders There are several types of orders that a prescriber may write. A routine order is carried out as specified until it is canceled by another order. Many practitioners whose practices are limited to a particular clinical area have a specified set of written orders for all their hospitalized patients. These are also referred to as standing orders. A practitioner may write a routine or standing order with specified limitations; that is, the prescriber specifies that a certain order is to be carried out for a stated number of days or times. After the stated period has passed, the order is discontinued automatically. The prescriber may write a PRN order (as needed) for medication. The patient receives medication when it is requested or required, and when the specifics of the order (particularly clinical parameters or timing between doses) are met. PRN orders are commonly written for the treatment of symptoms. For example, medications used for pain relief, to relieve nausea, and for sleep aids are often written as a PRN or as-needed order. Another type of order is the one-time order. With this type of order, the directive is carried out only once, at a time specified by the prescriber. Medication to be administered immediately before surgery is an example of a single order. A stat order is also a single order, but it is carried out immediately. A stat order for a bronchodilator or an antihistamine would be carried out immediately for a patient who is experiencing an anaphylactic drug reaction. Parts of the Medication Order The medication order consists of seven parts: Patient's name and a secondary identifier (date of birth, medical record number) Date and time the order is written Name of drug to be administered Dosage of the drug Route by which the drug is to be administered Frequency of administration of the drug Signature of the prescribing provider Medication orders require the drug, dose, rate, route, frequency, and, when appropriate, duration to be explicit and specific to the needs of the patient in order to achieve the desired outcome. Although not to be used for identifying a patient, inpatient orders also contain information regarding the patient's location, such as unit and room number (Bowen, 2016). PATIENT'S NAME AND A SECONDARY IDENTIFIER (DATE OF BIRTH, MEDICAL RECORD NUMBER) The patient's full name is used. The middle name or initial should be included to avoid confusion with other patients. In facilities using paper records, the patient's full name, secondary identification number, and the primary care provider's name are labeled on all sheets on the patient's chart, including the medical order sheet. Be extremely careful when administering medications when there is more than one patient on the unit with the same last name. Not only can the nurse give the wrong patient the wrong medication, but a provider may enter an order in the wrong patient's medical record. A secondary identifier is used when verifying the patient's identity. DATE AND TIME THE ORDER IS WRITTEN The date and time the order is written are provided. Because the nursing staff in inpatient facilities changes several times during each 24-hour period, the date and time help to prevent errors of oversight as different nurses take charge of the patient's care. When an order is to be followed for a specified number of days, the date and time are important so that the discontinuation date and time can be determined accurately. State law determines the length of time an order for a narcotic remains valid, so the starting date and time must be clearly documented. Hospitals are utilizing many computer applications in patient care. Examples of such technology include a computer-generated database, computer-generated medication administration orders, and computer-generated flow sheets, as well as EHRs. This technology is helping to improve patient safety, but it also requires that nurses monitor the computer system for patient updates, including new medication orders. NAME OF DRUG TO BE ADMINISTERED The name of the drug is stated in the order, either by the trade (brand) name or by the generic name. Certain brand names are well known, but the practice of using the generic name is considered safest and is required by many health care facilities. A nurse unfamiliar with a drug can use several sources to obtain information. The United States Pharmacopeia and National Formulary (USP-NF, 2018) is the official source in the United States. Most other countries have similar references that describe official therapeutic agents. Most facilities also provide their own formulary, listing the drugs stocked by the facility. Health care facilities also provide access to online medication information sites. The Physicians' Desk Reference (PDR) is another source of information that is supplied by pharmaceutical companies. In addition, information about drugs can be obtained from the hospital pharmacist, the prescriber, and any of several texts written specifically for the nursing role in the management of drug therapy. Many of these nursing-specific texts are available as software and can be loaded onto handheld devices such as tablets and smartphones. DOSAGE OF THE DRUG The dosage of a drug can be stated in either the metric or the household system. These systems are described in the Dosage Calculations section. The metric system has been adopted internationally, is the most widely used, and is the safest measurement system for drug dosages. Self-administered drugs are commonly labeled in household measurements to facilitate administration for the patient. The household system of measurement may also be used in community settings, such as a person's home (McCuistion et al., 2018). It is important to be familiar with common equivalent measurements when using household equipment, such as teaspoons and tablespoons, because the home is usually not equipped with special measuring devices. However, instruct patients to use measuring spoons and not silverware, if administration equipment is not available, due to the variability of the amount silverware can hold. The most common equivalents are in Appendix B (found on ). Certain standard abbreviations are used to indicate drug amounts; it is important to know the common abbreviations before administering drugs. Refer to Box 19-3 in Chapter 19 for common abbreviations used in drug orders. Several abbreviations used in the past have been identified as having the potential to cause errors. The Joint Commission has identified an official do not use list of abbreviations. See Table 19-3 on page 463 for this list. The use of ambiguous medical abbreviations has been identified by the Institute for Safe Medication Practices (ISMP) and the FDA as one of the most common but preventable sources of medication errors (ISMP, 2017). Refer to the website for the ISMP at https://www.ismp.org/Tools/abbreviations for more information about their campaign to eliminate the use of error-prone abbreviations. In addition, the ISMP has identified a list of error-prone abbreviations, symbols, and dose designations that should never be used when communicating medical information (ISMP, 2017). See Table 19-2 for this list. ROUTE BY WHICH THE DRUG IS TO BE ADMINISTERED The route to be used when administering a medication is stated clearly because some drugs can be given in more than one way and others may be used safely through only one route. Table 29-2 describes common routes by which medications are administered. Refer to The Nursing Process for Administering Medications beginning on page 840 for guidelines on administering drugs by these routes. FREQUENCY OF ADMINISTRATION OF THE DRUG The time and frequency with which a drug is to be administered are usually stated in standard abbreviations in the medication order, although many abbreviations used in the past have been phased out due to error and safety concerns (see Table 19-3 on page 463). Common abbreviations used in writing prescriptions, including time and frequency, are listed in Box 19-3 on page 459. The nursing service, facility policy, and pharmacy departments of inpatient facilities usually determine the hours at which routine drugs are given. To lessen the risk for error, many health care facilities use the 24-hour clock (or military time), which designates midnight as 0000 hours and runs until 2400 hours. For example, an every-4-hour drug administration may be at the times of 1200, 1600, 2000, 0000, 0400, and 0800. Another facility may use the hours 1300, 1700, 1900, 0100, 0500, and 0900. If an administration order states that the drug is to be given before or after meals, the time of administration depends on the hours at which meals are served. It is a nursing and pharmacy responsibility to check that times for medication administration correspond to safe practice for that drug. If a drug is to be given only once or twice a day, the decision about which hours to use depends on the nature of the drug and the patient's plan of care, as well as the standard facility administration times. Whenever possible, consider the patient's choice of time. Administer drugs punctually, as ordered. A nurse administering drugs to several patients, however, cannot give all of the drugs exactly on the hour indicated. Facility policies vary, but a common one is that drugs should be administered within a half-hour before or after the indicated hour. Thus, a drug to be administered at 0900 can be administered any time between 0830 and 0930 using this policy. However, it is important to note that this policy does not apply to all drugs. A preoperative medication ordered to be given at 0730 should be administered at that hour because the time was planned in relation to the time that surgery is to begin. Preoperative medications may also be given when the nursing unit receives a call from the operating room to premedicate the surgical patient. This also holds true when patients are given drugs before certain diagnostic procedures and with stat orders.

Routes for Administering Drugs Oral route= Having patient swallow drug Enteral route= Administering drug through an enteral tube Sublingual administration= Placing drug under tongue Buccal administration= Placing drug between cheek and gum Parenteral route= Injecting drug into Subcutaneous injection= Subcutaneous tissue Intramuscular injection= Muscle tissue Intradermal injection= Corium (under epidermis) Intravenous injection= Vein Intra-arterial injection= Artery Intracardial injectio= Heart tissue Intraperitoneal injection= Peritoneal cavity Intraspinal injection= Spinal canal Intraosseous injection= Bone Topical route= Applying drug onto skin or mucous membrane Vaginal administration= Vagina Rectal administration= Rectum Inunction= Rubbing drug into skin Instillation= Placing drug into direct contact with mucous membrane Irrigation= Flushing mucous membrane with drug in solution Skin application= Applying transdermal patch Pulmonary route= Having patient inhale drug SIGNATURE OF THE PRESCRIBING PROVIDER Prescribers using a CPOE access the system using a unique username and password. The identifying information of the prescribing provider, such as name and title, is automatically recorded when the system is accessed, and a handwritten signature is not necessary. When it is necessary to handwrite a prescription, the signature and title of the person writing the prescription follows the order. Many facilities require prescribers to also print their name with the signature, to facilitate reading of the prescriber's name. This identifying information is important for legal reasons because the authority to prescribe drugs is defined by state laws. Also, if there is a question about the prescription, the identifying information indicates who should be contacted. Checking the Medication Order Facility policy specifies the manner in which the medication order is checked. Various systems are used; nurses should be familiar with the system used in the facility where they work and should use it as trained to minimize errors. The patient's medication record, often called an MAR (medication administration record) is a complete list of all medications prescribed for the patient. Increasing numbers of health care facilities are computerizing patient records, including medication records (eMARs [electronic medication administration record]). The nurse is responsible for checking that the medication order was transcribed correctly by comparing it with the original order, depending on the type of system in use. The nurse is also responsible for double-checking the dosage and appropriateness of the medication. Questioning the Medication Order Nurses are legally responsible for the drugs they administer. Therefore, it is important to question any drug order suspected to be in error. The suspected error may be in any part of the order. A study of neonatal nurses in Australia identified several things that impact on nurses questioning an order, including the working environment (whether positive or negative), their perceived responsibility to do the right thing, and their knowledge about medications (Aydon, Hauck, Zimmer, & Murdoch, 2016). When preparing to administer a medication, ask yourself why the patient is receiving the medication—is there a rationale you can provide as to why this medication has been prescribed? Do the therapeutic and pharmacologic classes link with your patient's condition(s)? If not, then ask the provider or pharmacist, and/or use an appropriate resource to further investigate. Perhaps the provider inadvertently ordered the wrong medication—the only way to be sure is to ask. Take the time to look up the medication, especially if it is one you do not use on a daily basis, and consider whether the dose, route, frequency, and prescribed use are within the range of what your resource lists. Once in practice, nurses tend to become familiar with medications used frequently with the patient populations they serve, but learning what is a reasonable dose takes time and experience. The legal implications are serious in a situation in which there is an error in a drug order and the nurse could be expected, based on knowledge and experience, to have noted and reported the error. Confusion over the placement of a decimal point can lead to a medication error. A zero should always precede a decimal point (e.g., 0.1 mg) for clarity. The use of a trailing zero (e.g., 1.0) is not considered good practice and has been included in The Joint Commission's Do not use list. See Table 19-3 on page 463 for additional abbreviations included in this list. A drug to which the patient is allergic may be prescribed inadvertently. In health care facilities, the allergy is listed in the chart/EHR, specifically on the MAR/eMAR, and may also be linked to the computerized medication dispensing system. The patient may wear a wristband (often red) that indicates specific allergies, so be sure to check for this when you first identify the patient. Before administering a medication, best practice is to question the patient about ever having received the medication and ask whether the patient is aware of any reaction to the medication. The patient may describe past adverse reactions with the drug. If the nurse suspects an undocumented allergy, the nurse should not give the drug and notify the provider. An allergic reaction can be life threatening to the patient. In addition, a drug may be prescribed that would potentially interact with another medication the patient is taking. It is important that nurses verify all medications that they are unfamiliar with before administration to avoid possible drug interactions. If a nurse has difficulty reading an order, guessing is gross carelessness; checking with the provider who wrote the order is the only safe procedure. Nurses have the right to refuse to administer any medication that, based on their knowledge and experience, may be harmful to the patient. Although this situation seldom occurs, it is important to understand that the patient's safety is a primary objective in the administration of medications. Always notify the primary care provider of the refusal to administer any medication. Document any concerns regarding medication orders in the patient's medical record, and note having contacted the primary care provider, the response of the primary care provider, and any related interventions. A standardized interprofessional approach to medication administration coupled with an emphasis on patient safety creates an environment that supports the nurse questioning an order, which may directly impact on patient outcomes. Medication Supply Systems Medications are supplied in a number of ways. Many facilities make use of one or more systems in conjunction with each other, or variations of systems. Unit dose dispensing on a patient-specific basis is now the standard of practice for most hospitals. Pharmaceutical manufacturers should also provide all medications in health systems in unit dose packages (American Society of Health-System Pharmacists [ASHP], 2009). Computerized automated dispensing cabinets are a technology based on stock supply of unit dose medications. A large cabinet containing stock medications for the unit is used. The nurse accesses the system with a user name and password, calling up a medication list for a specific patient or a list of available medications. In many systems, only medications entered for a specific patient are available for withdrawal at any one time. A computerized medication dispensing system is shown in Figure 29-1. With an individual unit dose supply system, each patient is supplied with the medication needed for a period of time. The nurse is responsible for accurately obtaining the prescribed medications from the patient's supply. In the unit dose system, the pharmacist simplifies medication preparation by packaging and labeling each dosage for a 24-hour period. Some nursing units use a medication cart for the administration of medications. The standard cart contains individual drawers into which the medications for each patient are placed. If computers are not standard in every patient room and an EHR is used, there may also be a computer attached to the cart that allows for ready access to the eMAR by the administering nurse. The nurse moves the cart from room to room when dispensing medications. Bar-code medication administration (BCMA) involves a computerized bar-coded administration system, where each patient and each nurse is identified by a unique bar code. Each drug is also packaged with a bar code that includes its unique National Drug Code number to identify the form and dosage. The nurse scans his or her own ID, the patient's ID, and each package of medication to be administered. The system confirms the nurse's dispensing authority and the patient's ID, matching the patient with his or her medication profile. If any of the information is incorrect or does not match, an alert message will appear on the screen notifying the nurse of the discrepancy. The system also records the medication administration and stores the information Technology Alert Bar-Code Medication Administration (BCMA) BCMA uses bar-code technology to provide a safeguard against human error. Although BCMA has contributed to a reduction in medication errors, work-arounds that deviate from institution policy and procedures need to be addressed. Identification of best practice workflow needs to be compared to actual bedside observed workflow using processes such as root cause analysis (see Chapter 27). Frontline nurses must be engaged in the process of identification and removal of best practice barriers for this valuable technology Dosage Calculations Systems of Measurement Nurses need to be proficient in the use of weights and measures as well as systems of measurement to calculate drug dosages and prepare medications for administration. Two systems of measurement are used in the United States for administering medications: the metric system and the household system. The apothecary system was used infrequently in the past and is no longer used for measurement of medications (McCuistion et al., 2018). The nurse may be called on to convert dosages from metric to household and household to metric. It is extremely important to be able to calculate commonly used equivalents, as listed in Appendix B (found on ). Practice the Medication Calculation Problems at the end of this chapter to develop your dose calculation skills. METRIC SYSTEM The metric system is the most widely accepted and convenient system of measurement. The basic units of measurement are the meter (linear), the liter (volume), and the gram (weight). The metric system is a decimal system, in which each unit can be divided into multiples of 10 (10, 100, 1,000). Calculations in the metric system often involve moving the decimal point to the right or left. In the preparation of medications, the following metric units are typically used: Weight 1 kilogram = 1,000 grams 1 gram = 1,000 milligrams 1 milligram = 1,000 micrograms Volume 1 liter = 1,000 milliliters or cubic centimeters It may be necessary to convert drug dosages to a different unit in the metric system. To convert a larger unit into a smaller unit, move the decimal point to the right (the new number is larger than the original). To convert a smaller unit into a larger unit, move the decimal point to the left (the new number is smaller than the original). Example 1: 0.5 g equals how many milligrams? Move the decimal point three places to right; the answer is 500 mg. Example 2: 900 mg equals how many grams? Move the decimal point three places to the left; the answer is 0.9 g. HOUSEHOLD SYSTEM The household system is not widely used except in some community settings, such as a person's home. Teaspoon and tablespoon are commonly used household measures. The household system is not as accurate as the metric system because of the lack of standardization of spoons, cups, and glasses. The measurements are approximate, so the National Council for Prescription Drug Programs (NCPDP, 2014) and other entities (American Academy of Pediatrics, 2015) advocate for the transition to the metric system in the United States for all dosing. Until this occurs, nurses need to reinforce that a teaspoon is considered to be equivalent to 5 mL. Three teaspoons equal one tablespoon. One ounce is considered to be equivalent to 30 mL. As discussed previously, teaspoon and tablespoon refer to measuring spoons, not silverware. Methods for Computing Drug Dosages Drugs are sometimes prepared and supplied in the amount ordered by the prescriber, and the nurse can see when checking the medication label that no calculation is necessary. At other times, drugs are not prepared and supplied in the exact quantities called for in the medication order, and the nurse must do a dosage calculation to determine what quantity of medication the patient is to receive. FORMULA METHODS Several formulas can be used to calculate drug dosages. One such formula consists of ratios to set up a proportion and can be used to calculate dosages for both solid and liquid preparations. A ratio shows the relation between numbers. A proportion contains two ratios. The nurse is usually seeking the quantity of on-hand medication that is equal to the desired dosage (the dosage ordered). The formula is as follows: The dosage must be in the same unit of measurement. This applies to the quantity as well. Dosages are on the top line of the proportion, quantities on the bottom line. After the numbers are placed in the proportion, cross-multiply to find the desired quantity. The benefit of this method is that it is predictable and easy to recall: "I have 250 mg in 5 mL and I need 625 mg in I-don't-know-how-many mL." However, it works best with simple calculations. Example: Amoxicillin, 625 mg PO, is ordered. It is supplied as a liquid preparation containing 250 mg in 5 mL. How much does the nurse administer? Example: Digoxin 0.125 mg PO daily is ordered. It is available as a liquid in a unit dose container labeled 500 mcg/10 mL. How many mL does the nurse the nurse administer? There are two systems of measurement in this problem and conversions cannot be built into this formula, so the conversion must take place before using the proportion method. The nurse knows that 1 mg is equal to 1,000 mcg; therefore, 0.125 mg equals 125 mcg. Another formula that can be used to calculate drug dosages is as follows: Using this formula, the previous example would be solved as: This formula can be used for both liquid dosages and fractions of tablets. However, this formula can lead to errors if the carrier (10 mL in the example above) is not 1. The proportion (above) and dimensional analysis (below) methods are recommended. DIMENSIONAL ANALYSIS Another method that is used to compute medication dosages is dimensional analysis. Dimensional analysis, also known as factor-labeled method, is a systematic, straightforward approach to setting up and solving problems that require conversions. It is an excellent way to approach medication math because it can be used with both simple and complex medication calculations. A standard approach in chemistry, dimensional analysis is a way of thinking about problems that can be used when conversions are needed to move from an order to a dose. When using dimensional analysis, the first numerator must be what you are solving for, with the remaining part of the equation working to cancel out all unnecessary content. For instance, in the amoxicillin example, you would set up the equation like this: Dimensional analysis can also encompass conversion factors all in the same formula. For instance, the nurse is to administer 50-mcg fentanyl. The pharmacy supplies the nurse with an ampule of fentanyl 0.1 mg/2 mL. How much should the nurse administer? To solve the problem, the mg needs to be converted to mcg. This can all be done in the same calculation with dimensional analysis. Here is an example of what the starting formula would look like in the more traditional chemistry format:

Types of Drug Preparations Drugs are available in many forms, or preparations. The form in which the drug is prepared may determine the route of administration. Drug preparations are available for oral, topical, and parenteral administration. Some drugs may be prepared in only one form to be administered by a certain route. Others may be supplied in several preparations, allowing them to be given through various routes. One type of preparation may be desirable in a given situation. For example, a liquid preparation of a medication would be indicated for a young child who cannot swallow solid preparations, such as tablets. A suppository may be indicated to deliver a medication for a patient who cannot take anything by mouth. Table 29-1 describes drug preparations commonly used by nurses. Common Types of Drug Preparations Capsule= Powder or gel form of an active drug enclosed in a gelatinous container; may also be called liquigel Elixir= Medication in a clear liquid containing water, alcohol, sweeteners, and flavor Enteric coated= A tablet or pill coated to prevent stomach irritation Extended release (ER)= Preparation of a medication that allows for slow and continuous release over a predetermined period; may also be referred to as CR or CRT (controlled release), SR (sustained or slow release), SA (sustained action), LA (long acting), or TR (timed release) Liniment= Medication mixed with alcohol, oil, or soap, which is rubbed on the skin Lotion= Drug particles in a solution for topical use Lozenge= Small oval, round, or oblong preparation containing a drug in a flavored or sweetened base, which dissolves in the mouth and releases the medication; also called troche Ointment= Semisolid preparation containing a drug to be applied externally; also called an unction Pill= Mixture of a powdered drug with a cohesive material; may be round or oval Powder= Single or mixture of finely ground drugs Solution= A drug dissolved in another substance (e.g., in an aqueous solution) Suppository= An easily melted medication preparation in a firm base such as gelatin that is inserted into the body (rectum, vagina, urethra) Suspension= Finely divided, undissolved particles in a liquid medium; should be shaken before use Syrup- Medication combined in a water and sugar solution Tablet= Small, solid dose of medication, compressed or molded; may be any color, size, or shape (e.g., caplets are elongated/oval in shape and are often coated); enteric-coated tablets are coated with a substance that is insoluble in gastric acids to reduce gastric irritation by the drug Transdermal patch= Unit dose of medication applied directly to skin for diffusion through skin and absorption into the bloodstream

Drug Classifications Drug classifications, or drug classes, refer to groups of drugs that share similar characteristics. Drugs are classified in two primary ways: pharmaceutical class and therapeutic class. The pharmaceutical class refers to the mechanism of action (MOA), physiologic effect (PE), and chemical structure (CS) of the drug (FDA, 2018). The therapeutic class refers to the clinical indication for the drug or therapeutic action (e.g., analgesic, antibiotic, or antihypertensive). General knowledge related to the class of drug can assist with understanding individual drugs in that same class. Drug Indications Pharmacotherapeutics is a subtopic of pharmacology that considers the "therapeutic uses and effects of drugs" (Pharmacotherapeutics, n.d.). It addresses why we administer a specific drug, which is more commonly known as the clinical indication(s). Understanding the desired outcome of administering a drug is an important part of nursing responsibilities related to medication administration. Nurses are legally responsible for understanding the pharmacotherapeutics of all drugs they administer. This knowledge is required to enable the nurse to assess the appropriateness of the medication, as well as provide appropriate and accurate patient education

Environment A patient's environment may influence that individual's response to medications. Sensory deprivation and overload may affect drug responses. The patient who receives pain medication or a sedative in an active, noisy environment may not be able to benefit fully from the medication's effects, whereas those receiving pain medication in a quiet environment and using an additional relaxation method, such as guided imagery, may have a longer benefit from the pain medication. The relative oxygen deprivation at high altitudes may increase sensitivity to some drugs. In addition, nutritional state can also affect the body's reaction to certain drugs. When dietary factors are altered, drug therapy may produce different effects in the body than would normally occur. For example, many drugs normally bind to proteins in the plasma. Lowered protein levels in the body means less drug bound to plasma proteins, leading to a higher concentration of free drug in the body. A higher drug concentration increases the drug's effect in the body and the risk for adverse effects (Frandsen & Pennington, 2018). Timing of Administration The presence of food in the stomach can delay the absorption of orally administered medications. Alternately, some medications should be given with food to prevent gastric irritation; the nurse should consider this when establishing a patient's medication schedule. Other medications may have enhanced absorption if taken with certain foods. Circadian rhythms and cycles may also influence drug action. Drug Dose and Serum Drug Levels Serum (blood) drug levels were reviewed earlier in this chapter in relation to drug dosage (see Absorption). The goal is to maintain a therapeutic level of a drug in the body. In addition to using serum drug levels to initiate and monitor drug therapy, they are also used to assess peak and trough levels of certain drugs, particularly antibiotics that are known to be toxic to the kidney (nephrotoxic). After a drug has been absorbed, its serum level can be monitored by drawing a blood specimen and measuring the level of the drug in the serum. A drug's therapeutic range is the concentration of drug in the blood serum that produces the desired effect without causing toxicity. The peak level, or highest plasma concentration, of the drug should be measured when absorption is complete. The peak level may be affected by factors that affect drug absorption as well as the route of administration. The peak level is typically drawn 1 hour after a drug has been administered (depending on the route). The trough level is the point when the drug is at its lowest concentration, indicating the rate of elimination. The trough level is typically drawn 30 minutes before the next dose is scheduled to be administered. The dosage schedule, as well as the half-life of the drug, can affect the trough level. A drug's half-life is the amount of time it takes for 50% of the serum concentration of a drug to be eliminated from the body. When a drug is given at a consistent dose, it takes four or five half-lives to achieve a steady concentration and develop balance between tissue and serum concentrations. This is when maximal therapeutic effects occur (Frandsen & Pennington, 2018). Monitoring these levels ensures that therapeutic ranges are obtained without reaching toxic levels.

Drug Legislation In 1906, the Pure Food and Drug Act designated the United States Pharmacopeia and National Formulary as the official drug standards in the United States (USP-NF, 2018), which set national standards for drug quality. This act also empowered the federal government to enforce these standards. This legislation was updated in 1938 by the Federal Food, Drug and Cosmetic Act, prohibiting adulterated or mislabeled drugs from being made available. The FDA enforces this law. Extensive testing of new drugs is required before they may be marketed for use. The Durham-Humphrey amendment to the Federal Food, Drug and Cosmetic Act in 1952 distinguished prescription drugs from nonprescription (over-the-counter [OTC]) drugs and provided directions for dispensing prescription drugs. The Kefauver-Harris Amendment of 1962 increased controls on drug safety, requiring tighter testing of drugs and written inclusion in the drug literature of adverse reactions and contraindications for approved drugs. The Comprehensive Drug Abuse Prevention and Control Act, also known as the Controlled Substances Act, was passed in 1970. This law regulates the distribution of narcotics and other drugs of abuse. Such drugs have been categorized according to their therapeutic usefulness and potential for abuse. Government programs for the prevention and treatment of drug abuse were established. In 1983, the Drug Enforcement Administration (DEA), a part of the Department of Justice, was identified as the nation's sole legal drug enforcement facility. More current drug-related legislation includes the Food and Drug Administration Modernization Act of 1997. This act provides for accelerated review and use of new drugs and approves drug testing in children before marketing. In addition, it necessitates the inclusion of clinical trial data for experimental drug use for serious or life-threatening health conditions and requires drug companies to provide information related to off-label drugs (drugs not approved by the FDA), including their uses and costs. The act provides that drug companies planning to discontinue drugs must inform health professionals and patients at least 6 months before stopping drug production In 2003, the Pediatric Research Equity Act was signed into legislation. This act authorizes the FDA to require testing by drug manufacturers of drugs and biologic products for their safety and effectiveness in children. Drug manufacturers must not assume that children are small adults (McCuistion et al., 2018). Also in 2003, Congress approved the Medicare Prescription Drug Improvement and Modernization Act (MMA). This legislation provides financial assistance to seniors to purchase needed prescription medications.

CHAPTER 1 Introduction to Nursing Roberto is a 38-year-old man diagnosed with metastatic colon cancer. Having undergone radiation treatments and chemotherapy, he is extremely weak and malnourished. He is receiving intravenous fluids via a central venous catheter. He has two pressure injuries on his sacrum, each approximately 2 cm in diameter, requiring wound care. He also has a colostomy that he cannot care for independently. Michelle, a 19-year-old first-time mother who was discharged with her healthy 7-lb 8-oz baby girl 2 days ago, calls the nursery. She reports, "My baby isn't taking to my breast and she hasn't had any real feeding for 24 hours." Michelle, a 19-year-old first-time mother who was discharged with her healthy 7-lb 8-oz baby girl 2 days ago, calls the nursery. She reports, "My baby isn't taking to my breast and she hasn't had any real feeding for 24 hours."

Learning Objectives Describe the historical background of nursing, definitions of nursing, and the status of nursing as a profession and as a discipline. Explain the aims of nursing as they interrelate to facilitate maximal health and quality of life for patients. Explain how nursing qualifies as a profession. Describe the various levels of educational preparation in nursing. Discuss the effects on nursing practice of nursing organizations, standards of nursing practice, nurse practice acts, and the nursing process. Identify current trends in nursing. Discuss the importance of self-care in relation to the demands of the nursing profession.

CHAPTER 29 - Medications Regina, a 73-year-old woman with a history of lymphoma, has presented to the emergency department with pain, swelling, and erythema (redness) of her left calf. She has been diagnosed with a left leg deep vein thrombosis (DVT). She is receiving intravenous heparin and oral warfarin. When she is discharged, she will need to have weekly blood testing to ensure therapeutic levels of the warfarin. Mildred, a 65-year-old woman with a history of arthritis and hypertension (high blood pressure), comes to the clinic for evaluation of her painful joints. She states, "I just saw this new medicine advertised on television that is supposed to be really helpful in relieving joint pain. What do you think? Is it something I should try?" François is an older adult with a wound infection requiring intravenous antibiotic therapy. He is scheduled to receive his next dose at 1000. The medication delivered by the pharmacy is labeled with the correct drug and dose, but with a different patient's name.

Learning Objectives Discuss drug legislation in the United States. Describe basic principles of pharmacology, including drug nomenclature and types of drug preparations. Develop an understanding of basic principles of pharmacology, including mechanisms of drug action, adverse drug reactions, and factors affecting drug action. Discuss principles of medication administration, including an understanding of medication orders, dosage calculations, and medication safety measures. Obtain patient information necessary to establish a medication history. Describe principles used to prepare and administer medications safely by the oral, parenteral, topical, and inhalation routes. Use the Nursing Process to safely administer medications. Develop teaching plans to meet patient needs specific to medication administration.

Expanded Educational and Career Roles of Nurses TITLEDESCRIPTION Clinical nurse specialist Examples: enterostomal therapist, geriatrics, infection control, medical-surgical, maternal-child, oncology, quality assurance, nursing process A nurse with an advanced degree, education, or experience who is considered to be an expert in a specialized area of nursing; carries out direct patient care; consultation; teaching of patients, families, and staff; and research Nurse practitioner= A nurse with an advanced degree, certified for a special area or age of patient care; works in a variety of health care settings or in independent practice to make health assessments and deliver primary care Nurse anesthetist= A nurse who completes a course of study in an anesthesia school; carries out preoperative visits and assessments; administers and monitors anesthesia during surgery; and evaluates postoperative status of patients Nurse-midwife= A nurse who completes a program in midwifery; provides prenatal and postnatal care; and delivers babies for women with uncomplicated pregnancies Clinical nurse leader= A nurse prepared at the graduate level who oversees the lateral integration of care for a distinct group of patients and who may actively provide direct patient care in complex situations. The CNL role is not one of administration or management. Nurse educator= A nurse, usually with an advanced degree, who teaches in educational or clinical settings; teaches theoretical knowledge and clinical skills; conducts research Nurse administrator= A nurse who functions at various levels of management in health care settings; is responsible for the management and administration of resources and personnel involved in giving patient care Nurse researcher= A nurse with an advanced degree who conducts research relevant to the definition and improvement of nursing practice and education Nurse entrepreneur= A nurse, usually with an advanced degree, who may manage a clinic or health-related business, conduct research, provide education, or serve as an adviser or consultant to institutions, political facilities, or businesses In-Service Education Many hospitals and health care facilities provide education and training for employees of their institution or organization, called in-service education. This is designed to increase the knowledge and skills of the nursing staff. Programs may involve learning, for example, a specific nursing skill or how to use new equipment.

PROFESSIONAL NURSING ORGANIZATIONS One of the criteria of a profession is having a professional organization that sets standards for practice and education. Nursing's professional organizations are concerned with current issues in nursing and health care, and influence health care policy and legislation. The benefits of belonging to a professional nursing organization include networking with colleagues, having a voice in legislation affecting nursing, and keeping current with trends and issues in nursing. International Nursing Organization The ICN, founded in 1899, was the first international organization of professional women. By sharing a commitment to maintaining high standards of nursing service and nursing education and by promoting ethics, the ICN provides a way for national nursing organizations to work together. National Nursing Organizations Professional nursing organizations in the United States include the ANA, the NLN, the AACN, and many other specialty organizations such as the Association of Critical Care Nurses. The National Student Nurses' Association (NSNA) prepares students to participate in professional nursing organizations. American Nurses Association The ANA is the professional organization for RNs in the United States. Founded in the late 1800s, its membership is comprised of the state nurses' associations to which individual nurses belong. Its primary mission is to advance the profession of nursing to improve health for all. It is the premier organization representing the interests of the 3.6 million RNs in the United States. It advances the nursing profession by fostering high standards of nursing practice, promoting a safe and ethical work environment, bolstering the health and wellness of nurses, and advocating on health care issues that affect nurses and the public. Publications of the ANA include the Code of Ethics for Nurses, American Nurse Today, The American Nurse, and OJIN: The Online Journal of Issues in Nursing. The website NurseBooks.org provides access to the publishing program of the ANA. ANA electronic newsletters include ANA SmartBrief, Nursing Insider, ANA ImmuNews, and Capitol Update. National League for Nurses The NLN is an organization open to all people interested in nursing, including nurses, nonnurses, and facilities. Established in 1952, its objective is to foster the development and improvement of all nursing services and nursing education. The NLN conducts one of the largest professional testing services in the United States, including pre-entrance testing for potential students and achievement testing to measure student progress. It also serves as the primary source of research data about nursing education, conducting annual surveys of schools and new RNs. The organization also provides voluntary accreditation for educational programs in nursing. American Association of Colleges of Nursing The AACN is the national voice for baccalaureate and higher-degree nursing education programs. The organization's goals focus on establishing quality educational standards, influencing the nursing profession to improve health care, and promoting public support of baccalaureate and graduate education, research, and nursing practice. National accreditation for collegiate nursing programs is provided (based on meeting standards) through the AACN by the Commission on Collegiate Nursing Education (CCNE). National Student Nurses Association Established in 1952 with the assistance of the ANA and the NLN, the NSNA is the national organization for students enrolled in nursing education programs. Through voluntary participation, students practice self-governance, advocate for student and patient rights, and take collective, responsible action on social and political issues. Specialty Practice and Special-Interest Nursing Organizations A wide variety of specialty practice and special-interest nursing organizations are available to nurses.

Psychological Factors The patient's expectations of the medication may affect the response to the medication. A placebo is a pharmacologically inactive substance. In clinical drug trials, one group of patients receives the active drug, whereas another group receives a placebo to study the drug's effects. Some patients appear to have the same response with the placebo as with the active drug-this is referred to as the placebo effect (McCuistion et al., 2018). Psychological factors such as attitudes and expectations of drug therapy also directly impact compliance, especially with long-term drug therapy (Frandsen & Pennington, 2018). Pathology The presence of disease can affect drug action. For example, the liver is the primary organ for drug breakdown, so pathologic conditions that involve the liver may slow metabolism and alter the dosage of the drug needed to reach a therapeutic level. Drugs taken orally may be impacted if a gastrointestinal disorder interferes with absorption. Cardiovascular disorders that affect blood flow potentially impact all pharmacokinetic processes. The kidneys excrete most drugs and their byproducts from the body. Pathologic conditions that involve the kidneys would change excretion and alter the dosage of the drug required to obtain a therapeutic level. Even the endocrine system, particularly thyroid disorders, has an effect on metabolism. These types of conditions also influence the presence of adverse effects, such as toxicities.

Tips for Communicating Effectively About Medication With Culturally Diverse Patients Encourage cultural sensitivity in health care workers in your particular setting. Acquire basic information about health beliefs and practices of various cultural groups in your health care setting. This provides a basis for assessing patient's beliefs and practices. Recognize, however, that within all cultures and ethnic groups, there are members who do not hold all the values of the group. Consider biological variations (e.g., color, body structure, pharmacogenetics) when performing a baseline assessment and administering medications. Be alert to atypical drug responses or unexpected adverse effects that may occur in certain ethnic groups. This knowledge helps you direct assessment questions as appropriate. Ask specifically about the use of folk or home remedies prescribed by a nontraditional healer. Ask specific questions about possible adverse effects, rather than asking general questions or waiting for the patient to voice concerns. For example, do not ask, "Are you having any problems with your medicine?" Instead, ask, "Have you noticed any unusual, involuntary movements?" Consider individual cultural health practices, values, and definitions of health and illness when teaching patients and families. Ask, "What do you think caused your health problem?" and "What treatment do you think will help?" Include culturally sensitive information in all basic health teaching. For example, consider the patient's perception of time and space when teaching. Consider the impact of their social organization and roles when presenting information. Involve the family and other members of the community as appropriate. Determine the patient's language preferences for spoken and written communication. Use trained medical interpreters as needed. Use printed or audiovisual information that is in the language spoken by your patients. Recognize that diversity exists within cultural groups. For example, the Hispanic population includes Mexicans, Cubans, Puerto Ricans, and other Latino groups. Help culturally diverse patients to value and understand the importance of communicating concerns and asking questions about prescribed medications. Patients and families need to know how to identify major adverse effects of the medications they are taking and the appropriate person(s) to contact if these effects are noted.

Key Terms burnout: (1) cumulative state of frustration with the work environment that develops over a long time; (2) behaviors exhibited as the result of prolonged occupational stress compassion fatigue: loss of satisfaction from providing good pt care health: state of optimal functioning or well-being licensure: to be given a license to practice nursing in a state or province after successfully meeting requirements mindfulness: capacity to intentionally bring awareness to present-moment experience with an attitude of openness and curiosity; mindfulness promotes healing as you pause, focus on the present, and listen nurse practice act: law established to regulate nursing practice nursing: profession that focuses on the holistic person receiving health care services and provides a unique contribution to the prevention of illness and maintenance of health nursing process: five-step systematic method for giving patient care; involves assessing, diagnosing, planning, implementing, and evaluating profession: an occupation that meets specific criteria including a well-defined body of specific and unique knowledge, a code of ethics and standards, ongoing research, and autonomy reciprocity: process allowing a nurse to apply for and be endorsed as a registered nurse by another state secondary traumatic stress: feeling of despair caused by the transfer of emotional distress from a victim to a caregiver, which often develops suddenly standards: rules or guidelines that allow nurses to carry out professional roles, serving as protection for the nurse, the patient, and the institution where health care is given

What is nursing? Consider the following examples of who nurses are and what they do: Delton Nix, RN, graduated from an associate degree nursing program 3 years ago. He is now working full-time as a staff nurse in a hospital medical unit while attending school part-time toward a baccalaureate degree in nursing; his goal is to become a nurse anesthetist. Jeiping Wu, RN, MSN, FNP, specializes as an advanced practice family nurse practitioner. She has an independent practice in a rural primary health clinic. Samuel Cohen, LPN, decided to follow his life's dream to become a nurse after 20 years as a postal worker. After examining all his options and goals, he completed a practical nursing program and is now a member of an emergency ambulance crew in a large city. Amy Orlando, RN, BSN, graduated 2 years ago and recently began a new job in an urban community health service. Ed Neill, RN, DNP, is the Chief Nursing Informatics Officer at a large health system. Roxanne McDaniel, RN, PhD, with a doctorate in nursing, teaches and conducts research on moral distress at a large university. These examples show how difficult it is to describe nursing simply. If everyone in your class were asked to complete the sentence, "Nursing is...," there would be many different responses, because each person would answer based on his or her own personal experience and knowledge of nursing. As you progress toward graduation and as you practice nursing after graduation, your own definition will reflect changes as you learn about and experience nursing. Nursing is a profession focused on assisting people, families, and communities to attain, recover, and maintain optimum health and function from birth to old age. Nurses act as a bridge between an often extremely vulnerable public and the health care resources that can literally make the difference between life and death, health and disease or disability, and well-being and discomfort. Yale School of Nursing faculty member and philosopher Mark Lazenby, PhD, APRN, FAAN, describes nursing as a "profoundly radical profession that calls society to equality and justice, to trustworthiness, and to openness. The profession is also radically political: it imagines a world in which the conditions necessary for health are enjoyed by all people". According to an annual Gallup survey, the public has rated nursing as the most honest and ethical profession in America for 14 years straight. The only exception was 2001 when firefighters following the attacks on September 11 were named the most honest and ethical. Nursing care involves a wide range of activities, from carrying out complicated technical procedures to something as seemingly simple as holding a hand. Nursing is a blend of science and art. The science of nursing is the knowledge base for the care that is given, and the art of nursing is the skilled application of that knowledge to help others achieve maximum health and quality of life. Today, 3.6 million nurses in the United States practice in over 200 different specialties, such as anesthesia, mental health, school nursing, cardiac care, pediatrics, surgery, oncology, obstetrics, and geriatrics. They are caregivers, administrators, innovators, and policy makers. Nursing is the largest of the health professions and the foundation of the nation's health care workforce (www.nursingworld.org). This chapter introduces you to nursing, including a brief history of nursing from its beginnings to the present, and provides the definitions and aims of nursing. The educational preparation for professional nursing, professional nursing organizations, and guidelines for professional nursing practice are discussed to help you better understand what nursing as a profession is and how it is organized. (For an example demonstrating the importance of licensure to nursing practice and responsibilities, see the Reflective Practice box on the next page.) Because nursing is a part of an ever-changing society, current trends in nursing also are discussed.