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theory test

Theory exam

Modules 7-12

What is patient-centered care?

Patient-centered care is defined as:

Providing care that is respectful of and to, individual patient preferences, needs, and values, and ensuring that patient values guide all clinical decisions.

Institution Of Medicine

The Institute of Medicine, which is made up of doctors in the country, decided that we really have to start looking at individual patient preference needs and values to make sure that they are guiding our clinical decisions.

Patients should be partners with us in every decision that we are making for our patients. Continue reading the following subsections for some of the reasons for this.

Changes in health care are happening rapidly:

Older, more diverse US population: Our patient population is now older and more diverse. How you're going to care for someone who's in their 80s and their needs might be very different than someone who's in their 30s.

Focus shift to chronic and preventive care: The way we are educating or helping patients who are in their 30s and haven't been sick at all yet, or haven't had any health illnesses should be different. It's going to focus more on prevention. Whereas for someone who already has a disorder like diabetes, we need to come up with a very different treatment plan.

Growing self-management of care: More and more patients are capable of self-care management.

Growing concerns regarding access, cost, quality, and outcomes of care: Patient-centered care is going to address this as well. If patients are compliant, it means they understand their treatment plan, they're able to take their medications and take care of themselves at home (which in the long run is going to save money), and they're going to have a better quality of life.

Continuous Health Relationships

This means that patients need to be seeing the same doctor or the same nurses, and they need to have the same health care team. If they get admitted to a hospital, they should be going to the same hospital and seeing the same doctor.

In primary care, patients should be seeing the same doctor to make sure that they have one doctor and one group of nurses who are familiar with their health care needs.

Customized (Individually Planned) Care

Someone who has diabetes takes the same medications, like insulin, and they have the same diet and treatment plan.

Now, we're looking at those individual needs, such as if the patient even wants to take medication, is capable of taking pills, or would rather take the insulin themselves. If we could give them weekly insulin versus three times a day, based on their needs as a patient, or if they are working and it's harder for them to take medication three times a day.

Patient Control, Shared Knowledge

We believe in autonomy and patient control. Patients should be part of this plan. They should be helping to make these decisions.

That wasn't always the case. For a long time in the United States, doctors came up with the treatment plan, and patients were just supposed to follow it.

Part of that patient control is we have to share knowledge with them. We have to give them all the information and resources and let them choose.

Free Flow of Information

Because of patient control and how we're developing the plan with the patient, there has to be a free flow of information.

We have to educate them about their disorder and their treatment options, and they need to be sharing with us what their preferences are, and what their daily life is like. What are their barriers? Can they afford the medication? That type of information is important to obtain to help guide patient-centered care.

Theory of Goal Attainment (1964)

Imogene King defined a person as a personal system that interacts with interpersonal and social systems. She looked at it as a whole person that is not broken down into parts and said it's all about social systems.

The environment is a context within each person that allows them to grow, develop, and perform daily activities. It is where you are performing your daily activities. She said that there's an internal environment within people that has this transformational energy that enables them to adjust to constant external environmental changes.

Health is all about being a dynamic life experience of a person. It's constantly changing due to different stressors in the internal and external environment, and people need to use their resources to achieve maximum potential for their daily living.

She said, nursing is a process of human interaction, so nurses are not performing skills. We're not giving blood pressure medication, we're not doing any type of dressing changes. It's all about human interaction, and the goal of nursing is to help patients achieve their goals. The patient needs to be setting goals about how they want to live, and what their daily life should look like, and our job as nurses is just to help them achieve those goals.

Imogene King said that nursing is all about communicating information, and how we teach our patients how to get better in their own lives.

It's about helping them set goals and then taking out actions, or interventions to help them achieve goals.

She said, there are some different factors that can influence attaining a goal. What's going to prevent patients from being able to be as successful as they can be? Why do some patients not achieve the goals that they set for themselves? 

Roles—Our patients aren't just our patients. A lot of times they have multiple roles. They might be a mother or a sister. One person can have multiple roles going on in their life. Because they have so many different roles that they're trying to focus on, they might not be able to focus on their role as a patient or on getting better.

Stress—Sometimes there's a lot of stress in people's lives because of those roles.

Space—Some people aren't getting better because they're not in the right space or environment. Are they in the hospital, or are they at home?

Time—It takes time to achieve a goal. When we're talking about smart goals, they need to be timed and realistic. Sometimes a patient might want to be able to walk again. Well, that's not going to happen in a week or in one nursing shift, it might take months before that goal is going to be able to be achieved.

Imogene King said that patients need information on how to prevent illnesses. Then once they do get sick care, they are unable to help themselves. How do we prevent illnesses? Then once you're sick, how do you get better? She had three different systems.

Personal: She said there's a personal system. This is a person's own perception of self, growth, and development.

Interpersonal: Interactions that happen every day with other people. It's important to look at that communication, those interactions, roles, and even the stress that those interpersonal relationships could be causing.

Social System: King said everyone has social systems, such as organizations, powers, status, and decision-making that are outside of their control.

Sister Callista Roy's Adaptive Model

Adaptive model is an important model and it can be the one theory that you will be using in all of your clinicals from here on out.

Sister Callista Roy developed this model in 1976. She assumed that people are constantly interacting with their environment. Much like Florence Nightingale, she said there is no way to separate us from our environment. We are always acting on it, and it is always acting on us. She said the goal of nursing is to help patients adapt. Once they develop any type of health care disorder or illness, they have to be able to adapt to that and adapt to their new environment. She did talk about four different adaptive modes. This theory is used a lot to help define health, quality of life, and even people who are dying. She said that our job as nurses is to assess their adaptive abilities and then help create interventions that affect the environment that is around them.

The goal of nursing, according to Roy, is to foster successful adaptation.

Adaptation is the process and outcomes where thinking and feeling are central. This theory is applicable to individuals or groups. It is essential to be consciously aware and choose to create human–environment interactions. The environment must be adapted to the patient, whether they are an individual or a group.

Adaptation can:

lead to optimum health and well-being

improve patients' quality of life

help them die with dignity if that is the final outcome

Person: Roy defined the person as a whole with many different parts that need to function together as one unit.

Environment: Environments are both internal and external, encompassing everything around and within a person. The world within and around people constitutes adaptive systems.

Health: Health is defined as a state and process of being and becoming an integrated and whole person.

Nursing: Nursing involves manipulating stimuli to foster successful adaptation.

A person is a whole with many parts, and the environment needs to be adapted to the individual. It is the nurse's job to facilitate this adaptation.

Roy came up with six different steps that she called the nursing process, about how to adapt our environments to our patients.

Assessment: patient's behaviors

Assessment: patient’s stimuli

Diagnose patient: after we assess our patient, the next step is to come up with some diagnoses for our patient and these are nursing diagnoses. Not medical diagnoses like diabetes, but things like pain-impaired nutrition.

Set goals: Once we come up with a diagnosis, we need to set some goals for the patient with the patient. They are helping us with the assessment portion by giving us information. They should be helping us come up with a diagnosis.

Intervention to meet goals: After we set these goals, we need to start coming up with interventions and actually carrying out interventions to meet those goals.

Evaluate to see if the goal is met: Lastly, we need to circle back to evaluate and see if the goals have actually been met. Has our patient been able to adapt to their new situation, and are they getting better because of it?

Basic Principles of Nursing (1966)

The unique function of the nurse is to assist the individual, sick or well, in the performance of those activities contributing to health or its recovery (or to a peaceful death) that he would perform unaided if he had the necessary strength, will, or knowledge, and to do this in such a way as to help him gain independence as rapidly as possible.

Henderson, 1966

Person: Recipient of nursing care who is composed of biological, psychological, sociological, and spiritual components

Environment: External environment

Health: Based upon the patients ability to function independently

Nursing: Assist the person, sick or well, in the performance of activities

Henderson’s 14 Basic Care Needs

Henderson’s 14 Basic Care Needs

1

Breathe normally!

2

Eat and drink adequately!

3

Eliminate bodily wastes!

4

Move and maintain postures!

5

Sleep and rest!

6

Dress and undress!

7

Maintain body temperature within normal range!

8

Keep body clean and protect integument!

9

Avoid dangers!

10

Communicate with others!

11

Worship according to one’s faith!

12

Work!

(We need a sense of accomplishment.)

13

Participate in recreation!

14

Learn and discover leading to normal development and health, and use health facilities!

Theory of Human Caring (1997)

Humans cannot be treated as objects and that humans cannot be separated from self, other, nature, and the larger workforce.

Watson, 1997

It wasn't until 1997 that the nursing profession actually came up with the theory that said one of our jobs as a nurse is to care for our patients. Before that, it was all just physical things. But Watson said, "Humans cannot be treated as objects, and that humans cannot be separated from self, others, nature, and the larger workforce."

Person: Watson defined a person as being open, more than, and different than, the sum of its parts. One of our theorists, Roy, said that you look at the whole person and they're broken down into parts. Watson is saying that people are more than just those individual parts. They are a whole person, they are a whole being. When you put those parts together, they actually become even more.

Environment: She said that these parts are constantly acting on the environment, and they're making ultimate choices for them, and they have to bear responsibility for those choices. She says the environment is a mutual process with a person. Again, we're constantly acting on our surroundings and they're constantly acting on us.

Health: She said health is continuously changing. It is a process of becoming. One day you might be sicker, one day you might be better.

Nursing: She said nursing is truly just about fostering care and helping that person become the ultimate being.

Theory of Caring: Nursing Is Caring

Watson came up with nine different ways that we care for our patients.

Theory of Caring: Nursing Is Caring

Accessible Interactive Instructions: This activity is arranged as a simple one-direction flow chart with 1 track that is revealed in stages. The item for each track in each stage connects to the items for the same track in the previous and next stages. Activate the Next button to reveal each stage in the sequence.

Stage 1, Track 1

Embrace: other’s values and practices

Stage 2, Track 1

Inspire: faith and hope

Stage 3, Track 1

Trust: self and others

Stage 4, Track 1

Nurture: helping, caring relationships

Stage 5, Track 1

Forgive and accept positive and negative feelings

Stage 6, Track 1

Balance: teaching and learning needs, with readiness and learning styles

Stage 7, Track 1

Cocreate: healing environment

Stage 8, Track 1

Minister: spiritual needs

Stage 9, Track 1

Open: to mysteries and miracles

Dorothea Orem’s General Theory of Nursing

In 1959, Dorothea Orem created what she called the general theory of nursing. But later, we had a lot of other theories on nursing. Today, we call this the self-care deficit theory of nursing. Her theory is actually composed of three different theories.

She wrote the theory of self-care, the theory of self-care deficit, and then the theory of nursing systems. She wrote three separate theories and then combined them into this general theory.

Theory of Self-Care: Things the Individual Does Independently - She said that there are things individuals need to be able to do independently. Going back to Virginia Henderson, we dress ourselves, we bathe ourselves, and we get ourselves up and ready to go to work.

Theory of Self-Care Deficit: Role of the Nurse - The role of the nurse is doing things for patients, guiding them, supporting them, teaching them, and helping them manage their environment. If someone is not able to dress themselves, we need to be teaching them how to do those things. We need to be guiding them on how to do those things, and changing their environment so they can do those things independently.

Theory of Nursing Systems: Relationship With Patient –

Our job as nurses is to do things for our patients, such as guiding, supporting, and teaching them when they are not able to do these things for themselves.

It can be wholly compensated, partially compensated, or it could just be support.

For example, if our patient is a newly diagnosed diabetic and I am teaching them how to give their own insulin, that would be considered supportive or educational, since I'm just teaching them and they're going to go home and do it on their own.

If I am partially doing it, if I'm guiding them through it and telling them how to do it, saying, "Here's how you open the syringe, here's how you draw up the insulin," that could be considered partially compensated.

If I'm just doing it for them, that would be wholly compensated. If I'm the one who's checking their blood sugar, drawing up their insulin, injecting their insulin, that's wholly compensated.

The patient relationship could be three different things, depending on the actual tasks that the nurse is performing for the patient. But with Orem, we want them to be able to do as much as they can for themselves.

A lot of times nurses get caught up in the compensated one, where in the hospital, patients are capable of bathing themselves, but you'll see the aides and the nurses just doing it for them. We want to be in that supportive, educational role as much as possible and not take on the wholly role unless it is completely necessary. As much as possible, our patients should be encouraged to do things for themselves.

Elizabeth Kubler-Ross: Death and Dying

Elizabeth Kubler-Ross originally called her theory the theory of death and dying. She was not a nurse, but this is a theory that nursing has really adapted and brought into our profession.

She actually met with people and interviewed them when they had terminal illnesses and started noticing that a lot of them had very similar experiences. A lot of them were crying. They had headaches. They had difficulty sleeping. They started feeling detached from the world, and they would actually start to detach themselves from their friends and families. They became very isolated, very worried, and very anxious.

Elizabeth Kubler-Ross Five Stages of Grief (1969)

She came up with the five stages of death and dying. It has since been renamed the five stages of grief. It used to be that we recognize these five stages are happening just in people who are dying. But today, we realize that it's not just people that are dying that can experience these. Anytime someone is going through a major life change, or is grieving, they can also go through these five stages. For example, someone who is newly diagnosed with diabetes, that is a major life change. The person they were before that diagnosis is essentially dead, and they're becoming a new person. So they can also go through these stages. The first four stages, denial, anger, bargaining, and depression, can happen in any order. But the last stage is always going to be acceptance.

Module 8

Martha Rodgers

Martha Rodgers created the unitary human being nursing theory. Martha Rodgers wrote her theory back in the 1920s. She was definitely a woman before her time. We had Florence Nightingale in the 1800s, but one of the next main nursing theories we had was from Martha Rodgers.

One of the things that Martha Rodgers is most famous for is saying that nursing is both an art and a science.

Martha Rodger's Unitary Human Beings Theory​

Nursing as an Art

Martha Rogers believed that nursing is an art, emphasizing the need for individualized patient care. Nurses must tailor their actions to each patient's unique needs, creating a personalized approach to care.

Nursing as a Science

Rogers asserted that nursing is also a science, grounded in research and theory. Her theories, like many others, are based on scientific principles and evidence-based practice.

Openness

Rogers' theory posits that humans have an openness, with no boundaries between themselves and their environment. This openness means that the environment continually affects our energy fields, impacting our health positively or negatively.

Energy Field

Rogers' theory highlights the importance of energy fields, which she believed are present in all living and nonliving things. Nurses can manipulate these energy fields through positive interactions, helping to heal patients by transferring uplifting energy to them.

Madeleine Leininger

Madeleine wrote her theory in the 1960s. She had the opportunity to travel to Papa New Guinea, islands in the Pacific Ocean, and found that what they believed as far as what cured or caused their illnesses was vastly different than what we believed here in the United States. Because they believed that spirits were causing their illnesses, it really affected the way that they went about treatment.

Madeleine Leininger's Theory​

Variations among Diverse Groups

Madeleine wrote her theory, just addressing the fact that we as nurses really need to consider our patients' spiritual and cultural beliefs when it comes to treating their health care needs because those beliefs are really going to impact their health and their health outcomes.

Variation is Biologic, Social, Environmental, and Communication

Variation is biological, social, environmental, and communication

Education, Practice, and Research Issues

Education, health practices, research, all of these issues can really influence someone's culture, which in turn is going to impact their ideas of health.

Health disparities. We know that currently in the United States, life expectancy for Caucasians is still around 78 years. For African Americans, it's around 73 years. The minority that actually has the highest life expectancy is Asians. Asians typically live into their 90s, 100s. Most common causes of death for minority groups, cancer. Hispanics actually have the highest rate of cancer among any of the races, cardiovascular disease and stroke. That would be highest among African Americans. We know that biologically African Americans typically have higher rates of high blood pressure and heart attacks. Chemical dependency. This is actually highest among Hispanics and Native Americans. Same with diabetes. Native Americans actually have the highest rates of diabetes, and then second would be Hispanics. Homicide and accidents, we're going to look at ethnicity, so African American. But we also know that this happens in more urban settings than rural. Happens more in cities than it does out in the country. Then also looking at ages. We know that children usually have more homicides and accidents than the elderly. That's part of our culture as well. If you start thinking about your grandparents versus you versus your parents, and even maybe your children, that's part of our culture. Culture from me growing up a certain time period versus my grandparents growing up in the 30s and 40s is very different. Then we have infant mortality. We know that African Americans, they have infant mortality rates two times higher than Caucasians. Again, when we're talking about culture, we're also talking about different areas. Franklin County, which is where Columbus, Ohio, the state capital of Ohio is located. People living in that county, they have infant mortality rates that are just as high as some of the Third World countries.

Federally Defined Minorities

The United States Federal government has defined different minority groups:

African Americans​

Hispanic​ ​Americans

Indian or Alaskan Native​s

Asian and Pacific Islanders

Marginalized Populations

Marginalized populations are people whom we tend to keep on the outside. They have a harder time accessing health care resources.

This would be people who are:

gays

lesbians

older adults

recent immigrants to our country, people from Afghanistan, Iraq, or Somalia

joblessness​

homelessness​

poverty​

For example, there's a large Nepali population now. A lot of times these people have difficulty accessing our health care system because it is vastly different than the health care system and their country of origin. Because these people are marginalized and viewed as outsiders within the health care world, their lives and health care are often kept secretive. They feel like they're voiceless. They feel like health care workers just don't understand their needs.

American Values vs Other Cultures

Change vs Tradition

In the United States, there is a strong belief in change, always wanting the newest, the latest, and the best, whether it's cell phones, technology, or health care. Typically in Western medicine, there is a focus on change, seeking the best and latest drugs and treatments. In contrast, Eastern medicine and Asian cultures usually rely more on tradition, preferring what has always been.

Human Equality vs Hierarchy, Rank, and Status

In the United States, there is a belief in human equality, treating all people the same, as opposed to a system of hierarchy, rank, and status. In places like India, there is a hierarchical system where the class you are born into determines your social standing for life. Historically in Europe, there were monarchs such as kings and queens, who held status and titles.

Individualism vs Group Welfare

In the United States, there is a strong belief in individualism, where everyone is acting on their own behalf and looking out for themselves. This is in contrast to cultures, mainly in Asia, where there is a focus on group welfare and everyone helping each other.

Self-Help vs Cooperation

In the United States, there is a significant emphasis on self-help, with the prevalence of resources like Dr. Google and numerous self-help books. People often try to diagnose and treat themselves, reflecting the individualistic mindset of looking out for oneself. This contrasts with a focus on cooperation and helping everyone else, which is more common in other cultures.

Environment Control vs Forces of Nature

Here in the United States, we strongly believe that we have control over our own environment. We can change things and manipulate things, but that is not true in other cultures. Other cultures sometimes believe that they are subject to nature, this is the belief that one has little or no control over what happens. Whatever is meant to happen, whatever is going to happen, is just going to happen. There's no point in trying to change it, we can't change it. This can have many implications for treatment.

One that immediately comes to my mind here in Ohio is the Amish community. Being very religious, they believe that it's God's will, whatever is going to happen is going to happen, so there's no point in taking antibiotics and going through with treatment because it's not going to change the outcome anyways.

Other groups that we typically see in this category are African Americans and Mexican Americans.

On the opposite side of that mastery over nature, this would be the belief that one can overcome the natural forces of nature. This would be Caucasian Americans. We only anticipate good results, especially from medicine. We believe that we can change things. Doing that chemo, that radiation, I am going to cure my cancer, I can do it.

Harmony with Nature

People or groups that believe that illness represents disharmony with nature. They rely mostly on naturalistic remedies because they see medicine as relieving symptoms. If I am sick, I am sick because me and nature are out of sync. If I get back in sync with nature, my symptoms, and my illness will go away. This tends to be Asian Americans and American Indians or Native Americans, that would fall into this category.

Time (Present, Past, and Future)

Present-oriented: I am only worried about the here and now, what is happening today.

Past-oriented: I believe that illness is caused by things that my ancestors might have done.

Future-oriented: I am only concerned about what's going to be happening next.

Past-oriented, we would see people like Asian Americans or Native Americans. They tend to be more interested in their ancestors, and what happened before them. Here in the United States, we tend to be more present or future-oriented, not so concerned with what's happening now but what's going to be happening in the future, so future-oriented. Biological Variations

We know that based on our race, genes, and genetics, we are different.

Body build and structure​

With bodybuilding structure, we know that African Americans and Caucasians tend to be taller.

African Americans tend to have denser bones and larger teeth than white people. Because they have denser bones, they tend to not have things like osteoporosis. Whereas Asian Americans or Asians, because they tend to be shorter and their bones tend to be thinner, they do tend to suffer more from things like osteoporosis.

Genetic variations

African Americans tend to have lower sodium cholesterol, but they do tend to have higher rates of high blood pressure and cardiovascular diseases.

Skin variations

Caucasians and Asian Americans tend to be lighter skinned and more prone to things like skin cancer.

As you are going through your Medical-Surgical 1, 2, and 3 courses, and you start to learn about risk factors for each disease, one of the risk factors can be our race, not ethnicity. Remember that's something that was learned, that's our culture, but our race is just our genes and what we were born with.

Susceptibility to Diseases

American Indians or Native Americans tend to have a higher incidence of strep throat and gastrointestinal issues and they also have a higher incidence of diabetes. Part of this is our race, our biology. Part of this is also our ethnicity, our culture. What foods do we tend to eat within specific races?

Native Americans and Mexican Americans tend to have more GI issues, stomach ulcers, and heartburn, because of the foods that they eat, things like spicy foods. We find that people in the southern part of the United States have higher rates of diabetes and heart disease. Why? Well, in the South, they eat more fried foods than we do up here in the North. It is part of their ethnicity and culture, and what they eat is also leading to some of these health disparities.

Japanese Americans tend to have lower incidences of cardiovascular disease and renal disease. Again, part of it is their genetics. Part of it is also their diet. They tend to eat more seafood and less fried food, which is healthier but they do have higher rates of stress-related diseases. A lot of Asian Americans tend to suffer from a lot of anxiety and stress. Again, part of it could be genetic, but part of it is their culture, which is their ethnicity.

Mexican Americans have higher rates of diabetes and obesity, and they usually use less preventative care.

Native Americans and Mexican Americans tend to not come into the health care system, or go to the doctor until they are really sick.

Social Organization

Part of our culture is going to be the way that it is organized.

We're talking about the nuclear family, we're talking about mom, dad, and kids, it's typically two parents, mom and dad, and children living in the home. Single-parent families, typically in the United States, just have one parent in the household. Extended family is anyone besides mom, dad, and the kids who are living in the family or in the household. It could be grandparents, aunts, uncles, or friends of the family.

We tend to see this in non-Caucasian families.

African, Asian, and Hispanic Americans tend to have multiple generations living in one house. Part of the extended family that we need to be aware of is who's making decisions.

African Americans tend to look towards mothers and grandmothers for decision-making in Mexican-Hispanic households. It tends to be the oldest male in the family. It might not be the parent. It could be the grandparent or the great-grandparent who's making decisions. Knowing about those roles and responsibilities within the family can help guide nurses in patient care.

When we're talking about the Amish community, it's not even the family members within the household that are making decisions, it's the elders within the church that are making the decisions. Just be aware of who's making decisions for your patient because it might not be the patient.

Communication

Part of our ethnicity is going to be communication styles.

Typically, here in the United States, when you are talking to someone, you should be making direct eye contact. However, there are certain cultures that find direct eye contact to be offensive. Some people who are from Europe, Native Americans, and African Americans find this rude. They will not be looking you in the eye. They might be looking at the ceiling, looking at the floor, and it's not that they're ignoring you, or trying to be disrespectful, that's their way of showing respect.

People who speak English as a second language, their language tends to be more formal because that's how they learned it in school. There is a difference between an interpreter and a translator. Translators are going to translate word for word, exactly what you are saying to the patient, while interpreters are just giving the gist of what you are saying.

Whenever we are assessing a patient or we are asking for medical consent, we need to make sure we are using a translator.

There are many different ways to have translators in the hospital nowadays. One is called Marty. It's a computer that we put in front of the patient, and the translator will come on and they will translate back and forth for us. There are also different hotlines that we can call. If we're just needing interpretation, is the family member hungry? Are they thirsty? We can have family members interpret that for them. But again, if we are asking for medical consent, anything formal, it needs to be a non-family member who is translating for that patient.

Space

Part of our ethnicity is going to be space. Cultures are going to vary greatly on comfort level when it comes to social distancing and how comfortable we are with people being near us.

Here in the United States, we typically say three feet. An arm's length away is what most people are comfortable with, however, not every culture is the same. Asian Americans believe touching strangers is inappropriate. Mexican Americans tend to be more comfortable with less space. They might be standing closer to you than that three feet because that is what they feel is appropriate.

Be aware that when it comes to things like spacing, how close you stand, and whether or not it's appropriate to touch a patient is going to vary based on their ethnicity.

Module 9

Hildegard Peplau

The nursing theorist who is related most to communication is Hildegard Peplau.

Hildegard was actually a psychiatric nurse. You will talk more about Hildegard in your psych mental health nursing class. Hildegard strongly believed that the main action of nursing was communication and building what's known as a therapeutic relationship with their patients. She believed one of the best ways we could help heal patients was through communication.

She said that when we're looking at this nurse-patient relationship, there are three different phases: orientation, working, and termination.

Orientation

This is when we're first introducing ourselves to our clients or patients.

We communicate caring and acceptance.

We want to be genuine.

We want to be open so that way our patients will learn to trust us and share information with us.

We want to be nonjudgmental.

We want to establish a trusting relationship: The best way we can start to establish this trusting relationship is to make sure that we follow through on anything that we say we're going to do. If we say that we are going to come back in 10 minutes, any promises we make, any appointments we make, we need to make sure we are doing those things.

During the orientation phase, that first interaction with our patient is also when we start to identify and set goals for what we want to accomplish throughout the rest of the relationship.

Working

The next phase is the working phase.

This is where we're going to be implementing the plan and working towards the goals that we established in the orientation phase with the patient.

It's important that when we're in this working phase, we do set boundaries with our patients. It's not uncommon for patients to start to get attached to us, and for us as nurses to start to get really attached to our clients. We want to make sure that we're keeping this relationship professional.

Termination

We've achieved the goals that we set out to achieve in the orientation phase, and so at this point, the relationship is going to end.

It's important to realize that this relationship can take a couple of hours or it could last for months or even years. But regardless of the time frame, the orientation phase is always going to be where we're setting goals and getting to know the patient, the working phase is when we're working to achieve those goals, and the termination phase is going to be when the relationship is over.

For example, when you guys are doing clinicals, the orientation phase when you first meet your patient might just be a few minutes when you first introduce yourself and decide what you're going to be doing for the rest of the shift. Over the next eight, 10 hours, the length of the shift, you're going to be working on those goals, and then your termination phase is just going to be a few minutes at the end, where you go in, let them know that you're leaving for the day and someone else is taking over. On the other hand, if you're working in the community as a community health nurse, those stages can look very different as far as the timeframe. It might take you weeks to get to know your patient and to build up that trusting relationship in that orientation phase while making the goals.

You could spend years working with the patient, trying to achieve those goals, and then terminate the relationship years from then.

Nonverbal Communication

Nonverbal communication is anything that is not spoken. This can be the facial expressions that we give. Think about emojis, and pictures of people, you can tell just by their facial expressions if they're happy or if they're sad. Things like eye contact are important.

Many factors confirm or deny the spoken word​

Facial expression​

Presence or absence of eye contact, posture, and body movement​

Indirect nonverbal messages influence communication​

dressing style​

lifestyle​

material possessions

Using Touch​

Individuals generally have a well-defined sense of personal space​.

Nurse should be sensitive to each patient’s preferences in terms of touch​.

A gentle touch for some can demonstrate genuine interest and concern.

Written Communication

It is accurate. ​

Pays attention to detail​.

It is​ thorough​.

It is concise.

Computer-Based Communication

Includes email, text messages, attachments, and chat rooms​.

It lacks nonverbal cues to aid in communication​.

Beware: Communication via computer can often be retrieved even after it has been deleted​.

Clarification: It is important to ensure that the correct message is received.

There are five elements of communication:

Who relays the message​

What is the message​

In what way is the message relayed​

To whom is the message relayed​

With what effect is the message relayed

There are three primary components:

sender

receiver

message

A dynamic, cyclic process whereby the receiver becomes the sender when responding to the message (feedback); this is followed by repeated alternating of roles.

Professional Communications

We will be talking and communicating with other disciplines, whether it's the providers, physicians, nurse practitioners, PT, or OT. There are a ton of different disciplines that are all going to have their own perception and theories on how to care for the patient. It's important that we really listen and identify the intended message when we're talking to these other professions.

A variety of disciplines have unique perspectives on the theories and therapies of the varied professions.

Listening is essential for identifying the intended message.

Frequent clarification and a sense of “safety” are paramount.

The fundamental goal of all health care professionals: provide quality patient care.

Team Communication

When we are all working on the same patient at the same time, especially if there's an event, something like a patient coding, our communication is going to change a little bit. During a code, we use something called a closed-loop communication system. What that means is that everything that's said, you repeat back to them. If the doctor says, "I want you to give an amp of EP," you need to repeat back, "I'm giving an amp of EP," just to make sure that there are no miscommunications.

Debriefing

One of the things we might do after a situation like that is called debriefing. We just talk about what happened, the good and the bad. What could we improve, what could we have done better?

Assertiveness

It's very important in those situations that we're assertive. In a little bit, we're going to talk about delegation, and that's another time when we really need to be assertive. "I need you to go wash the patient," is a nice way of not asking but telling someone what to do.

Listening

Then understanding that even within team communication, there can be some barriers to listening. Why might my coworkers, my fellow nurses, and my aides not be listening to me?

Anxiety: Part of it can be anxiety. As new students who are out on the units, I'm sure you've experienced being nervous about being on a new unit, being with a new instructor, or being around new nurses, and you're so focused on your anxiety and not messing up that you're not really able to listen and take everything in.

Distractions: On every hospital unit, we have alarms. We have multiple patients and other people who are trying to talk to us. It's very easy to get distracted and not be listening to someone who's trying to talk to you.

Fatigue: Sometimes we're tired, and 12-hour shifts can be very long. As the day goes on, it's not uncommon for us just to be tired and not really want to listen. Just because all we can think about is how tired we are.

Anger: It is not uncommon for people who are in an argument or in a disagreement to focus so much on what they're going to say next and how the other person is wrong, that they're not able to actually listen and focus on what the person is actually saying.

Confusing Messages: One doctor says this, while another doctor says that, and I'm not really sure what I'm supposed to be doing is also a barrier to listening.

One way that we communicate professionally is known as SBAR. SBAR was actually developed by the military.

SBAR stands for situation, background assessment, and recommendation.

At clinical, you will see the nurses give bedside or shift reports. Most of the time now they are following the SBAR pattern.

For situation, why is the patient here?

What brought them into the hospital is the background. Anything that is important to know about the patient's past medical history, family history, and socioeconomic history.

Assessment is your head-to-toe assessment. How are their lung sounds and their heart sounds? How are they as far as cognition?

The next section is recommendations. What are things that the next shift needs to be doing? What are our nursing goals? How are we working for those nursing goals?

When we're calling the doctor on the phone, we are going to give an abbreviated version of the SBAR.

The situation: why I am calling.

Background is going to be why the patient is here and any pertinent past medical history.

Still giving pertinent, so important assessment information,

The recommendation means just telling the doctor what you want him to do.

EHR System Uses

Why do we use electronic health records? Well, many years ago, the Federal government passed HIPAA, the Health Information Privacy and Portability Act. We’ve covered privacy already, now we’ll discuss the Portability Act. Paper records were not very portable. When a patient wanted to switch doctors or needed to see a doctor in another hospital system, all their paper records had to be copied and carried from one place to another. It costs a lot of extra money to duplicate records. If patients could not or did not receive copies of their records, one doctor might redo expensive tests that another practitioner had already ordered. The switch from paper to electronic health records was made to save money and improve the consistency and effectiveness of care for patients.

Benefits

Capture data: Every piece of information about the patient can be put into the electronic health record.

Storage: The government requires medical records to be kept for seven years. We used to store paper records in storage facilities. With EHRs, we can store these records in data banks. They are in the Cloud, and it's there forever.

Information processing: If a facility needs to do any type of quality improvement, it can process records information a lot faster.

Information communication: Communication between interdisciplinary care team members is faster, as is communication between members of outside facilities. When hospital systems use the same EMR system, like Epic, records are easily shared between facilities. This saves time and money. With these systems, patients can message doctors directly instead of having to call the office, wait on hold, leave a message, and have the message relayed to the doctor, who will eventually get back to the patient.

Security: Electronic health records are accessed on password-protected computers that are associated with a system that is itself password-protected. This limits who has access to the information.

EHR Security

Privacy is the patient's right to keep things private, even from their health care providers. Confidentiality is the provider's responsibility to not share the patient's information. They may not share information with other health care providers, with a patient’s family members, or concerned citizens who call into the office. Security are the physical barriers and things that we do to keep people out of EHRs. The biggest barrier is a password. Every person granted access to the EHR must have a password. Once a person logs in with that password, their activity in the EHR is tracked—which relates back to confidentiality.

You should only ever be in the medical records of your patients. If it is not a patient that is assigned to you, and you do not have a legitimate reason for being in there, accessing the medical records of someone who is not your patient is a violation of privacy and confidentiality. It may result in termination.

Quality and Safety Measures

Modified Early Warning System (MEWS)

The modified early warning system supports our clinical decision-making. Once nurses enter a patient’s vitals and other assessment data, the EHR analyzes the information and will return alerts for the nurse to consider. For example, based on my patient's vital signs, the reason why they're there, and some of their labs like their white blood count, the EHR might return an alert that the patient is at risk for sepsis. It will prompt me to follow the sepsis protocol. When doctors log in, those same flags for them will appear. So they're going to know immediately that this patient might be turning septic.

The EHR also alerts us about critical lab results. The EHR does a fantastic job of saying, "This is important, you need to do something about this right now to help protect the patient."

Automatic Reminders

The EHR reminds patients and providers when preventive health measures, like vaccines and colonoscopies, are due. It also analyzes a patient’s medications for potential drug interactions and reviews dosages for safety. Doctors may choose to override the alerts.

Data Interpretation and Clinical Decision-Making

Most EHRs will automatically alert you about abnormal lab values. These systems also have built-in resources on medications. For example, if I'm not sure what a medication does, I can click on it to review the route and the mechanism of action.

Computer Provider Order Entry (CPOE)

Doctors used to handwrite their orders and sometimes it was very, very hard to read. Or they would just give a verbal order that did not provide all the necessary information. Now, the expectation is that the physician is going to put the orders into the computer themselves. This process has eliminated a lot of lost orders, we no longer have to worry about poor handwriting, and the system will not let them save the order until every piece of information that we need is in there. It also helps them with decision-making. Again, if two medications are going to interact, it will not let them save it, or if they do save it, they have to give a reason why they think it's safe, and they should still be given.

Meaningful Use

One of the big reasons the federal government decided to pass a law implementing these EHRs was because of something called meaningful use. We saw that these EHRs could improve quality, safety, and efficiency within the health care system and we have to be able to show that.

The EHR provides more privacy and security for our patients.

Through MyChart, patients now have immediate access to their health care information. They can also easily take this information from one doctor's office to another.

MyChart also supports patient education. We can send and store information on their medications and disorders in MyChart.

The EHR improves care coordination. Providers can all look at the same record and know what's going on with patients at different places.

The EHR improves population and public health efforts. Since all this information is stored in the EHR, it is simple for the Center for Disease Control to mine this data.

The system provides reminders when preventative health measures are due.

CPOEs have helped to eliminate errors in physicians’ orders.

We have immediate access to lab results and support interpreting the results.

The EHR improves communication between team members and members of different facilities.

Opportunities and Barriers

There's been a lot of opportunities out there, but there are some barriers and problems to these EHRs. They're not perfect.

Opportunities

These systems are very expensive. The upgrades are very expensive, even just going and training staff on how to use these systems can be very costly. Initially, the federal government did give out financial incentives. They paid a certain percentage for each facility to start implementing this usage.

The EHR is improving care, quality, safety, and efficiency. It helps with the continuation of care as patients move from one place to the next, and their information follows them.

Barriers

Meeting guidelines can be very strenuous and costly. We must make sure we have all the required security measures in place. We must implement them. We must do system upgrades. All of that costs money.

Within some facilities, there is a lack of interoperability. For example, I know that there are some hospitals where the emergency room and the inpatient EHR do not talk to each other.

Every facility is also allowed to choose their own EHR and these systems do not talk to each other. In these instances, one facility might have to copy or send records to another.

Point of Care Technologies

Point of care technology is what we use at the patient's bedside that provides us with patient data immediately. This is paramount to delivering safe, effective, and quality patient care.

Examples

Electronic or automatic blood pressure cuffs are an excellent example. If I put a blood pressure cuff on and hit start, I will get the patient's blood pressure within a minute. We can also put a blood pressure cuff on and set it to take the patient's blood pressure every 15 minutes. Then, from outside the patient's room, I can see all their vital signs and immediately download them. I do not have to go back in and type anything.

The glucose monitor is another fantastic example. With most labs, I have to draw blood, send it to the lab, and wait for the results. The lab might not give me results for another day or two. With the glucometers, I can check my patient's blood sugar, draw their blood, and within a matter of seconds, right at their bedside, I know what their blood sugar is.

Other examples of point-of-care technology are handheld computers. The smartphone, laptop, and tablet that you take into the patient's room would all be considered point-of-care technology.

Telehealth

Telehealth is communication technology we can use with our patients to help provide them with care, even though there might be some distance between the patient and the provider. Telehealth has been around for many years but for the most part, patients and providers like being in the same room at the same time when providing care. However, it became very popular during the Covid pandemic when we were asking patients to not come to the hospitals and doctor's offices.

Telehealth platforms must be secure. We have to use apps or technology that cannot be hacked. There is a version of Zoom that cannot be hacked. We have to make sure that we're using it so a third party can not come in and listen to my meeting with my patient.

Telehome

With the rise of Telehome, we are using different devices to be able to improve our Telehealth. Patients can use automatic blood pressure cuffs and glucometers that sync to their EMR. This allows providers to review results and adjust medications without needing to meet with patients. There are also home health stations that we can give patients. Patients can sit down at the station, type in how they are feeling that day, and get their blood pressure and weight taken. The home health station collects all that information and sends it to the doctor's office. Again, the doctor can make adjustments based on all of this information that these home health care stations are giving us.

The Nurse's Role in Telehealth

Triage: There are some hospitals now, especially their emergency rooms (ERs) that are employing nurses to be that first level of triage. Instead of coming to the ER right away, a patient can call these nursing hotlines first. The nurse can ask questions and determine if the patient should come to the ER.

Interventions: When people call a doctor's office or an ER, we can provide them with some basic interventions. For example, if a patient has a low-grade fever, we can recommend that they try taking some Tylenol first, and if their fever doesn't come down, then come to an ER.

Consultations: We provide patients with information on where they need to go and what they need to do for their immediate health concerns.

Surveillance and follow-up: If a patient has just been discharged from the hospital for uncontrolled diabetes or heart failure, nurses can call them to see how they are doing. They do not have to return to the hospital or the doctor's office.

Robotics

An emerging area of health care informatics is robotics. Now we can do surgery with patients and not even have to be in the room with them. This is an extreme form of Telehealth. A medical expert in California can treat a patient in Massachusetts who needs the surgery that only this doctor in California can perform.

Medical Devices

Medical devices are also considered informatics. Two examples of medical devices are pacemakers and artificial hearts.

Pacemakers are small electronic devices that are put into the patient's chest. These devices have reduced the mortality rates of people who have heart problems. Over the last 60 years, this device has saved millions and millions of lives.

The artificial heart is an emerging technology for cardiac patients. This electronic heart will pump the patient's blood through their body until we are able to give them the heart transplant that they need to save their lives. For patients who will never get a heart transplant, they can live for years with an artificial heart.

Evaluation of Internet Websites

Module 11

Community Health Nursing

Community health nursing is everything outside of the hospital. This includes doctor's offices and urgent cares. It also encompasses schools, job sites, nursing homes, long-term care facilities, and the health department. The health department is one of the primary providers of community health nursing.

Services

Self-management: People take care of themselves in their own homes. Thanks to informatics and telehealth, we can take care of patients in their homes and patients are advocating for themselves.

Health education and literacy is one of the big areas of community health.

Case management: Patients in the hospital or those with chronic illnesses are assigned a case manager. These are nurses who have a lot of experience, usually eight or more years of experience in health care. Their job is to help patients navigate the healthcare system.

Occupational health: Some employers pay to have a health care provider on-site for their employees.

School health: Every school district has at least one district nurse. These nurses provide patient education for students or help students when they do get injured in the classroom or on the school site.

Home health: These nurses are assigned a block of patients and they visit each patient once or twice a week in their home to provide services like wound dressing changes and medication management.

Long-term care: A nursing home is just the name of a building. It doesn't tell you what services they offer. It could have long-term care, rehabilitation, assisted living, or end-of-life care.

Community

The people and the relationships that emerge among them as they develop and use common agencies and institutions and share a physical environment. When we're talking about community health, we're not talking about one individual, we're talking about a group of people. A community can be broken down in a variety of ways. The only criterion is that members have to share some common elements; again, it could be a physical environment. For example, Cleveland, Ohio could be considered a community. Even within Cleveland, we could talk about the Cleveland State University population, which would be very different from Ohio State’s population, or the Western Reserve community.

Population

A collection of people who share one or more personal and/or environmental characteristics. Again, we've got the Cleveland State population, and within the Cleveland State community, we have the nursing student population, which is different than the engineering population.

Family

Two or more individuals who depend on each other for support. This can be a caregiver and the recipient of that care. It does not have to be mom, dad, and siblings. It is any two individuals who live together and provide support for each other. It could be friends or it could be siblings. It could be married individuals, as long as it is at least two people.

Community Health

When we're talking about the community, we start to talk about community health. Whenever we're looking at the health of a given population, we want to assess for safety, access, infrastructure, and environment.

Safety: In the community, one of the biggest causes of injuries and illness is not having a safe environment. 

Treatment availability: How quickly could you get treatment if you needed it?

Infrastructure: This refers to the actual buildings. How safe are they? Are they accessible to different populations? Do they have elevators and ramps for people who might have disabilities?

Environment: This includes air quality, pollution, and access to food.

MAP-IT

Mobilize resources that are available to the public.

Assess safety, access available treatments, infrastructure, and environment.

Plan our interventions.

Implement interventions.

Track the progress.

Key Terms

Continuum of care: Effort to decrease fragmentation and cost that happens when people go from one place to another.

Continuity of care: A patient’s care is provided by the same people, which allows relationships to be built and supports information management.

Disease Prevention

One of the big focuses of community health is disease prevention. This encompasses the interventions used to stop diseases from developing in the first place or to treat and prevent diseases from getting worse. There are primary, secondary, and tertiary interventions.

Primary Interventions help maintain health to make sure people never get sick in the first place. This includes health literacy and health education. We want to teach community members about eating healthy, exercising, hand-washing, and getting vaccines.

Secondary interventions include screenings to detect illnesses as soon as possible. This includes mental health screenings, mammograms, and colonoscopies. These are primarily done in doctor's offices. If a disorder is detected early, the patient may or may not need to go to the hospital to receive acute care.

Tertiary interventions help patients maintain or improve their functioning so that they do not end up with complications from a disorder. For example, after receiving acute care in the hospital, a stroke patient is referred to rehab in their community.

Health Promotion and Disease Prevention

The focus of health promotion is on making lifestyle changes to maximize health. How do we get people to be as healthy as possible? With any disorder, there are risk factors, some are modifiable and some are unmodifiable. Unmodifiable risk factors are things you can not change. This includes age, gender, and ethnicity. Other risk factors, such as exercise, diet, and wearing sunscreen, are all modifiable. We really want to help people modify their modifiable risk factors. This includes helping people to eat healthier, exercise, wear sunscreen, and stay out of the sun as much as possible.

Pender's Model

Nola Pender developed the health promotion model. According to Pender, when we're looking to change and see behavior modification, there are some personal factors that make people more likely to change. These include personal factors such as age, race, and education. For example, people who are middle-aged or younger are usually more likely to start to make some changes; while people who are older are usually more stuck in their ways and less likely to do this. If people do not think that changing their behavior will help them, they will not do it. This is known as the perceived benefit of the action. People have to think and believe that changing their diet, activity level, or other behaviors will actually benefit them. The context of the situation matters. There are situational influences on people’s willingness to change. For example, many years ago, the State of Ohio passed a law saying people could no longer smoke inside public spaces. A lot of people quit smoking just because they were not going to go outside a restaurant or their dorm to smoke. There are also interpersonal influences on a person. For example, my sister who smokes just got cancer. I do not want to get cancer, so I'm going to quit smoking. Ultimately, the person has to commit to the plan of action to make that change.

Health and Illness

One of the largest organizations that looks at community health is the World Health Organization (WHO). Health, as defined by the WHO, is not the absence of disease. Just because someone is not sick does not mean that they are healthy. The WHO states that health is the highest attainable standard for any single person living anywhere in the world. The organization also claims that the health of all people is fundamental to peace and security.

Acute and Chronic Illness

Illness can be either acute or chronic. An acute illness is self-limiting. It occurs over a very short period of time (less than three months), and the person will get better, and once they get better, they no longer have that disorder. A chronic illness is a disease where there is no cure. Once you get it, you have it for the rest of your life. The best we can do is control the symptoms. For example, the flu is an acute illness. It is very short, and it is self-limiting. Diabetes, on the other hand, is a chronic illness. There is no cure.

There is also something called acute on chronic. This is an exacerbation of a chronic illness. For example, a person with COPD has it every day. If their COPD gets worse suddenly and they end up in the hospital, that is considered acute on chronic.

Some acute illnesses can turn into chronic illnesses. For most people, COVID-19 was self-limiting; for other people, it turned into a chronic illness. People still have respiratory issues and problems related to the COVID that they had a year ago.

Department of Health and Human Services

Now we're going to start looking at community health within the government. At the Federal level, we have the Department of Health and Human Services. The director of this department is part of the President’s Cabinet. This department is comprised of about 20 different organizations. These organizations include the Centers for Disease Control (CDC), the Food and Drug Administration (FDA), the Center for Medicaid and Medicare Services (CMS), and the National Institute of Health (NIH). At the state level, there is the Health Department. The Ohio Department of Health controls all health departments within the State of Ohio. Every county in the state has its own health department that reports to the state’s Health Department. County health departments offer all kinds of resources and services, from vaccines to WIC, which stands for women, infants, and children.

Click on the following link to open it.

Healthy People

In 1979, the Health and Human Services Department developed national health goals, which are called Healthy People. We are now looking at Healthy People 2030. Every 10 years, based on census data and information from the CDC, the Federal government and the HHS establish new goals. Financial resources are then allocated based on these goals. Common themes of these goals include chronic diseases, injury and violence, mental health, oral health, tobacco use, substance abuse, nutrition, physical activity, and obesity.

Improving access to health care is a significant focus of the Healthy People goals. While cost is a prominent barrier to access, people’s physical location is another. It is easier to access health care in urban areas than in rural settings. How can we improve or eliminate physical barriers to health care?

Another goal is to eliminate health disparities. Health disparities are inequalities or gaps that exist between two or more groups of people. Some groups, unfortunately, do get better care here in the United States, compared to others, and it's usually based on their social determinants of health. The social determinants of health include:

Economic stability: Employment, income, expenses, debt, medical bills, and support

Neighborhood and physical environment: Housing, transportation, safety, parks, playgrounds, walkability, zip code, and geography.

Education: Literacy, language, early childhood education, vocational training, and higher education

Food: Hunger, access to healthy options

Community and social context: Social integration, support systems, community engagement, discrimination, and stress

Health care system: Health coverage, provider availability, provider linguistic and cultural competency, and quality of care

One approach to improving access is to offer wraparound services. We are trying to make sure that people have access to affordable health care and have a provider that can care for them across the lifespan, from infancy all the way up to older age.

Important Concepts

In the final section of this lesson, we will briefly discuss three important concepts of community health.

Vulnerable Populations

A vulnerable population is a group of people who are at risk for developing health problems. These individuals have trouble accessing health care when and where they need it. Examples of vulnerable populations include children; the elderly; people with chronic illnesses, who tend to be a vulnerable population, especially if it is a chronic illness; immigrants and illegal aliens; people in rural areas; people experiencing homelessness; victims of any type of abuse; pregnant adolescents; and people who are HIV positive.

Emergency Preparedness

Hospitals are required to have plans of what they would do in the event of an emergency. Hospitals train and plan for mass casualty events. If there were to be a plane crash or a bus crash, what do we do when we get a lot of people coming in? The Health Department really focuses on what to do in the event of a natural disaster, such as a tornado, hurricane, or blizzard. They have to plan what they would do in these different situations, even if they're unlikely to happen.

Changing Nature of Community Health

Violence is on the rise, especially within families, in our Ohio community.

Ohio is third in the nation when it comes to opioid overdoses and deaths.

Health Care Organization (HCO)

There are different types of health care organizations that we would consider providers of acute care. Hospital systems are the largest providers. There is also something called LTACH, a long-term acute care hospital. Patients who are in the hospital can not stay in the hospital forever. For example, a patient has COVID and is in the ICU. They end up on a ventilator. Once they are stable, it can take 30 days or more to wean somebody who is dependent on a vent off of it. They cannot stay in the hospital that long, so they will go to a long-term acute care hospital, like a nursing home. These facilities will provide round-the-clock care. They can take more advanced patients, such as those on vents and pick lines.

There are also urgent care facilities and same-day surgeries. Urgent care facilities could be considered acute. Same-day surgeries are health care organizations that provide surgery out in the community. As such, they would usually be considered community medicine. These surgery centers may perform knee replacements, hip replacements, and eye surgeries.

Medicare and Medicaid

The United States government has two different insurance plans: Medicare and Medicaid.

Medicare is the federal health program for people who are over the age of 65. Sometimes people with disabilities who are under the age of 65 can qualify, but typically, they end up on Medicaid.

There are four different parts to Medicare.

Part A is for hospitalizations. At 65, everyone automatically gets Part A. It pays for 30 days of inpatient hospitalization. If it is not related to the hospital, it is not covered under Part A. This is the only part that everyone automatically gets for free.

People can then opt in and pay for Parts B or C, and D. Part B is for primary care. So is C, but C pertains to health maintenance organizations (HMOs). For all intents and purposes, they are the same thing. I can enroll in Medicare at 65 and look at different plans, such as Humana, Aetna, and Blue Cross. I can choose to pay for doctor's visits and preventative care. Part D is for drugs. Again, I can opt in and choose to pay a premium, which is a monthly fee, to cover medications. Many of the plans under Part B now also cover medications, so people are not opting into that as much. None of these options cover long-term care. If someone needs rehabilitation, it might be covered under Part B. However, if they need to stay at the nursing home, Medicare does not cover that. That expense would be out of pocket.

Medicaid is a federal program for people of lower income. The states receive money from the federal government to fund Medicaid. Access to Medicare is based on the income levels of each individual state. What is considered low income in one state is different than in the other 49 states. Children and people with disabilities also qualify for Medicaid. Every year, people who qualify for Medicare are re-evaluated to make sure that they are still considered low-income or disabled by Medicaid.

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Otic Drugs

Anatomy, Physiology, and Pathophysiology Overview 

The ear is made up of four parts: the external, outer, middle, and inner ears. The external ear is composed of the pinna and the external auditory meatus or opening of the ear canal. 

The term outer ear refers primarily to the external auditory canal, the space between the external auditory meatus and the tympanic membrane. The middle ear is composed of the tympanic cavity, the space that begins with the tympanic membrane and ends with the oval window. The middle ear has three bony structures of the mastoid bone—the malleus (“hammer”), incus (“anvil”), and stapes (“stirrup”)—as well as the auditory or Eustachian tube. The inner ear includes the cochlea and semicircular canals. 

External ear disorders are generally the result of physical trauma to the ear and consist of lacerations or scrapes to the skin and localized infection of the hair follicles, which often causes the development of a boil. These tend to be self-limiting and heal with time. 

Other examples of external ear disorders are contact dermatitis, seborrhea, and psoriasis, as evidenced by itching, local redness, inflammation, weeping, or drainage. These conditions usually respond to the same topical medications used for any other local skin disorders. 

Symptoms such as drainage, pain, and dizziness are sometimes also the first signs of a more serious underlying condition (e.g., head trauma, meningitis) and warrant prompt medical evaluation. 

The most common disorders affecting the outer and middle ear are bacterial and fungal infections, inflammation, and earwax accumulation. Such disorders of the ear are self-limiting to a degree, but appropriate treatment is important to prevent complications to the ear and/or systemic complications, such as a decrease in or loss of hearing. 

If problems persist or are untreated, more serious problems such as hearing loss may result. 

Infections in the ear canal are otitis externa; those in the middle ear are otitis media (OM). 

OM is common in infancy and early childhood, often preceded by upper respiratory tract infection. 

In adults, otitis externa is more likely, involving the ear canal and/or external tympanic membrane. 

If the condition is left untreated, tinnitus (ringing in the ears), nausea, vertigo, mastoiditis, and even temporary or permanent hearing deficits may occur. 

In 2013, the American Academy of Pediatrics updated its clinical practice guidelines on acute OM, with more stringent diagnostic criteria. The guidelines recommend antibiotics for severe symptoms with unilateral or bilateral OM and for bilateral nonsevere OM. Patients with nonsevere unilateral OM are either observed or can be placed on antibiotics. They also recommend that a pain assessment and pneumococcal and influenza vaccines be given. The guidelines no longer recommend prophylactic antibiotics. 

https://bb-csuohio.blackboard.com/bbcswebdav/pid-7116346-dt-content-rid-80386079_1/xid-80386079_1

Pharmacology Overview  

Treatment of Ear Disorders 

Drugs that treat ear conditions are known as otic drugs, and most are used topically in the ear canal. There are usually no drug interactions. Adverse effects are rare; localized irritation may occur. 

Otic drugs may include the following ingredients, either by themselves or mixed together (depending on the prescriber’s order): steroids, antibacterials, antifungals, antiinflammatories, and wax-emulsifying compounds. 

Many of the antiinfective drugs are combined with steroids (in solution) to take advantage of the additional anti-inflammatory, antipruritic, and antiallergic drug effects of the steroids. 

Some ear infections require additional drug therapy with systemic dosage forms of corticosteroids, antibiotics, antifungals, and anti-inflammatory drugs, so remind the patient of oral and other dosage forms. 

Some disorders of the ear are self-limiting to a degree, but appropriate treatment is important to prevent complications to the ear and/or systemic complications. If left untreated, ear infections or disorders may lead to a decrease in or loss of hearing. 

Antibacterial and Antifungal Otic Drugs 

Cortisporin (and other brands) is a three-drug combination that includes hydrocortisone and two antimicrobials, neomycin (an aminoglycoside), and polymyxin B. 

Hydrocortisone is the corticosteroid most commonly used in otic drugs, although there is one preparation (Ciprodex) that contains ciprofloxacin and dexamethasone. The steroid component is for the reduction of inflammation and itching associated with ear infections. 

All of these products are used for the treatment of bacterial otitis externa or OM caused by susceptible bacteria such as Staphylococcus aureus, Escherichia coli, Klebsiella species, and others. 

With some otic drugs, it is recommended to saturate a retrievable cotton or tissue wick and let this wick soak inside the ear canal, as a means of dosing the drug. 

Antifungal otic drugs are used primarily for otitis externa and may also have antibacterial and antiviral properties. Two commonly used preparations are Cortic and Acetasol HC. Cortic, also available as Otomar, Aero Otic HC, and Mediotic HC, is composed of hydrocortisone (a steroid), pramoxine (a local anesthetic), chloroxylenol (an antiseptic antifungal), propylene glycol diacetate (an emulsifying drug), and benzalkonium chloride (antiseptic preservative). 

Earwax Emulsifiers 

Wax, or cerumen, is a natural product of the ear and is normally produced by modified sweat glands in the auditory canal. It can build up and become impacted, which results in pain and partial temporary deafness. 

Emulsifying otic drugs (such as carbamide peroxide) loosen and aid in the ease of removal of wax. Earwax emulsifiers loosen impacted cerumen, which allows it to be flushed out of the ear canal through irrigation (with water). 

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Nursing Process 

Before administering any of the otic preparations, assess baseline hearing or auditory status, if deemed appropriate, and document the findings. 

Single drugs and combination drug products are used to treat many ear conditions, and it is important to know the indications for and specific information about these drugs to ensure their safe use. 

Perforated eardrums are usually a contraindication to the use of otic drugs. Neomycin, polymyxin B, and hydrocortisone otic preparations are contraindicated in patients with a perforated eardrum. Ciprofloxacin and ofloxacin can be used with perforated eardrums. 

Instill eardrops only after the ear has been thoroughly cleansed, all cerumen (earwax) has been removed (by irrigation if necessary, or as ordered), and the dropper has been cleansed. 

Store eardrops, solutions, and ointments at room temperature before installation. Administration of solutions that are too cold may cause a vestibular-type reaction with vomiting and dizziness. 

Gentle massage to the tragus area of the ear may also help to increase coverage of the medication after the solution is given. 

Therapeutic effects of otic drugs include less pain, redness, and swelling in the ear; a reduction in fever; and resolution of any other signs and symptoms associated with the ear disorder. Improvement in hearing may also be an anticipated therapeutic effect. 

Monitor the ear canal for the occurrence of rash and/or any signs of local irritation, such as redness and heat at the site. Evaluate the patient for adverse effects with each application or installation, and report the unusual appearance of the outer ear and ear canal immediately. 

The Institute for Safe Medication Practices has reported several instances of eardrops being used in the eyes, which may be related to the similarities between the words “otic” (meaning ear) and “optic” (meaning eye). Patients who receive eardrops in the eyes will immediately complain of burning and stinging; redness and swelling may develop later. 

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Ophthalmic

Anatomy, Physiology, and Pathophysiology Overview 

The eye is the organ responsible for the sense of sight. 

The exposed anterior portion of the eye is covered by three layers: the protective external layer (cornea and sclera), a vascular middle layer known as the uvea (includes the choroid, iris, and ciliary body), and the internal layer, known as the retina. All of these layers are protected by the eyelid, which serves as an external protective tissue. 

Each eye is held in place and moved by six muscles that are controlled by cranial nerves. These muscles include the rectus and oblique muscles. There are four types of rectus muscles: inferior, superior, medial, and lateral. There are two types of oblique muscles: inferior and superior. 

Lacrimal Glands 

The lacrimal glands produce tears that bathe and cleanse the exposed anterior portion of the eye. Tears are composed of an isotonic, aqueous solution that contains an enzyme called lysozyme, which acts as an antibacterial to help prevent eye infections. Tears drain into the nasal cavity through the lacrimal ducts. 

Layers of the Eye 

The fibrous outer layer of the eye has two parts that are continuous with each other: the sclera and the cornea. The sclera is a tough, fibrous layer that protects and maintains the shape of the eye. The cornea is a nonvascular transparent portion of the outer layer that allows light to enter the eye. It obtains nutrition from the aqueous humor, the clear watery fluid that circulates in the anterior and posterior chambers of the eye. 

The vascular middle layer of the eye is composed of the iris (to the anterior), ciliary body, and choroid (to the posterior), collectively called the uvea. The iris gives color to the eye and has an adjustable opening in the center called the pupil. The main function of the iris is to regulate the amount of light that enters the eye by causing the size of the pupil to vary. Pupil size is controlled by the sphincter pupillae muscle and by a radial smooth muscle called the dilator muscle. 

Aqueous humor contributes, along with vitreous humor, to the intraocular pressure of the eye. 

The lens is the transparent crystalline structure of the eye, located behind the iris and the pupil. It has a biconvex shape and is held in place by ligaments attached to the ciliary muscle. 

The larger chamber behind the lens is filled with a jellylike fluid called the vitreous body. 

The lens is transparent to allow light to pass through easily. A loss of lens transparency results in a visual condition called a cataract. 

The elasticity of the lens enables it to change its shape and focusing power (accommodation), facilitated by the ciliary body. Paralysis of accommodation is called cycloplegia. 

Mydriatics are drugs that dilate the pupil (e.g., apraclonidine). Drugs that constrict the pupil are called miotics (e.g., acetylcholine, pilocarpine). Drugs that paralyze the ciliary body are called cycloplegics, but they also have mydriatic properties (e.g., atropine, cyclopentolate). 

The third and inner layer of the eye is a thin delicate layer known as the retina. It contains light-sensitive photoreceptors called rods and cones. The basic function of the retina is to receive the light image formed by the lens and to convert it into the neural signals that support vision. 

Pathophysiology of Glaucoma 

Glaucoma is a disorder of the eye caused by inhibition of the normal flow and drainage of aqueous humor, and treatment helps to reduce intraocular pressure either by increasing the drainage of aqueous humor or decreasing its production. 

Drugs that increase aqueous humor drainage are direct cholinergics, indirect cholinergics, sympathomimetics, and beta-blockers. 

Two major types of glaucoma are angle-closure glaucoma and open-angle glaucoma. 

Glaucoma can be a primary illness or it can be secondary to another eye condition or injury (e.g., posttraumatic glaucoma). Congenital glaucoma can also occur in infants. 

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Pharmacology Overview  

Medications used to treat disorders of the eye can be divided into several major drug groups: antiglaucoma drugs, antimicrobials, anti-inflammatory drugs, topical anesthetics, diagnostic drugs, antiallergic drugs, and lubricants and moisturizers. 

 Antiglaucoma Drugs 

Treatment of glaucoma involves reducing intraocular pressure by either increasing the drainage of aqueous humor or decreasing its production. Some drugs may do both. 

Drug classes used to reduce intraocular pressure include direct-acting cholinergics (also called miotics and parasympathomimetic drugs), indirect-acting cholinergics (also called miotics, cholinesterase inhibitors, and parasympathomimetic drugs), adrenergics (also called mydriatics and sympathomimetic drugs), antiadrenergics (beta-blockers; also called sympatholytic drugs), carbonic anhydrase inhibitors, osmotic diuretics, and prostaglandin agonists. 

The newest class of drugs used to treat glaucoma is the prostaglandin agonists. The most commonly used drugs in this class include latanoprost (Xalatan), travoprost (Travatan-Z), bimatoprost (Lumigan), and tafluprost (Zioptan). 

Cholinergic Drugs (Miotics) 

Direct-acting cholinergics include acetylcholine, carbachol, and pilocarpine. 

Indirect-acting drugs, which are also called cholinesterase inhibitors, include echothiophate, the only available drug. Since the primary effect is pupillary constriction or miosis, they are also commonly called miotics. 

Acetylcholine is the neurochemical mediator of nerve impulses in the parasympathetic nervous system, stimulating parasympathetic or cholinergic receptors resulting in several effects on the eye: miosis, vasodilation of blood vessels in and around the eye, contraction of ciliary muscles, drainage of aqueous humor, and reduced intraocular pressure. 

Ciliary muscle contraction promotes aqueous humor drainage by widening the space where the drainage occurs. Miosis promotes aqueous humor drainage by causing the iris to stretch, which also serves to widen this space. 

Direct- and indirect-acting miotics have effects similar to those of acetylcholine, but their actions are more prolonged. 

The direct- and indirect-acting miotics are used for the treatment of open-angle glaucoma, angle-closure glaucoma, and convergent strabismus (“cross-eye”) and in ocular surgery. 

Most adverse effects from the use of cholinergics and cholinergic inhibitors are local and limited. Adverse effects are more likely with indirect-acting miotics because they are longer-lasting. Effects include blurred vision, drug-induced myopia (nearsightedness), and accommodative spasms. 

Sympathomimetics (Mydriatics) 

Sympathomimetic drugs are used for the treatment of glaucoma and ocular hypertension. These drugs include alpha receptor agonists brimonidine (Alphagan P) and apraclonidine (Iopidine), and alpha and beta receptor agonists epinephryl (Epinal) and dipivefrin (Propine). 

Sympathomimetic drugs mimic the neurotransmitters norepinephrine and epinephrine, stimulating dilator muscle contraction by alpha and/or beta receptor interaction resulting in mydriasis. 

Both epinephrine and dipivefrin are used to reduce elevated intraocular pressure in the treatment of chronic open-angle glaucoma, either as initial therapy or as long-term therapy. Increases in intraocular pressure during surgery are usually mediated via increased catecholamine stimulation. 

Adverse effects of the sympathomimetic mydriatics are primarily limited to temporary ocular effects and include burning, eye pain, and lacrimation.  

Beta-Adrenergic Blockers 

The antiglaucoma beta-adrenergic blockers that reduce intraocular pressure include the beta1-selective drugs betaxolol and levobetaxolol. 

The ophthalmic beta blockers reduce both elevated and normal intraocular pressure. They reduce intraocular pressure by reducing aqueous humor formation. 

Ophthalmic beta-blockers are used to reduce elevated intraocular pressure in chronic open-angle glaucoma and ocular hypertension. They may also be used alone or in combination with a topical miotic, which may have an additive intraocular pressure-lowering effect. 

Adverse effects of beta blockers include transient burning and discomfort, blurred vision, pain, photophobia, lacrimation, blepharitis, keratitis, and decreased corneal sensitivity.  

Carbonic Anhydrase Inhibitors 

Ophthalmic carbonic anhydrase inhibitors include brinzolamide (Azopt) and dorzolamide (Trusopt). These two drugs are available only in topical ophthalmic form. Both drugs are also sulfonamides and are chemically related to the sulfonamide antibiotics. They should be used with caution in patients who are allergic to sulfa antibiotics. 

Carbonic anhydrase inhibitors work by inhibiting the enzyme carbonic anhydrase, which results in decreased intraocular pressure by reduction of aqueous humor formation. 

Ocular carbonic anhydrase inhibitors are used primarily for the management of glaucoma, both open-angle and angle-closure types, and may be used preoperatively to control intraocular pressure. 

Patients with sulfa allergies may develop cross-sensitivities to carbonic anhydrase inhibitors.  

Osmotic Diuretics 

Osmotic drugs may be administered either intravenously, orally, or topically to reduce intraocular pressure; glycerin and mannitol are most commonly used. 

Osmotic diuretics reduce ocular hypertension by causing the blood to become hypertonic, creating an osmotic gradient that pulls water from the aqueous and vitreous humors into the bloodstream, causing reduced volume of intraocular fluid and decreased intraocular pressure. 

Osmotic diuretics are used for acute glaucoma episodes and reduction of intraocular pressure before or after ocular surgery. Glycerin is used first; if unsuccessful, mannitol is tried. 

Osmotic diuretics are contraindicated with allergy, anuria, acute pulmonary edema, cardiac decompensation, and severe dehydration because they can worsen all of these conditions. 

The most frequent reactions to osmotic diuretics are nausea, vomiting, and headache. The most significant adverse effects are fluid and electrolyte imbalances. 

Prostaglandin Agonists 

The newest class of drugs used to treat glaucoma is the prostaglandin agonists. The most commonly used drugs in this class include latanoprost (Xalatan), travoprost (Travatan-Z), bimatoprost (Lumigan), tafluprost (Zioptan), and latanoprostene bunod (Vyzulta). 

In late 2017, the FDA approved netarsudil (Rhopressa) which is a Rho-kinase inhibitor, also known as a ROCK Inhibitor. 

Prostaglandins reduce intraocular pressure in glaucoma by increasing the outflow of aqueous humor between the uvea and sclera as well as through the trabecular meshwork. 

Prostaglandin agonists are well tolerated. Adverse effects include foreign body sensation, punctate epithelial keratopathy (dotted appearance of the cornea), stinging, conjunctival hyperemia, blurred vision, itching, and burning. Systemic effects occur infrequently. 

In some people with hazel, green, or bluish-brown eye color, eye color will turn permanently brown, even after the medication is discontinued. 

Concurrent administration of prostaglandin agonists with any other eye drops containing the preservative thimerosal may result in precipitation. 

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Antimicrobials 

A variety of infections can occur in the eye; many are self-limiting. Topical antimicrobials used to treat ocular infections include antibacterial, antifungal, and antiviral drugs. 

Topical antimicrobials used to treat infections of the eye work to destroy the invading organism; actions are similar to those described for systemically administered drugs. 

Ocular antimicrobials are used for known or suspected infection with one or more specific microorganisms. Empirical treatment is based on clinical evaluation of presenting symptoms. 

The most common adverse effects of ocular antibiotics are local and transient inflammation, burning, stinging, urticaria, dermatitis, angioedema, and drug hypersensitivity. 

Concurrent use of antibiotics and corticosteroids may interact. Corticosteroids have immunosuppressive effects that may impede the therapeutic effects of ocular antimicrobials. 

A large proportion of the inflammatory diseases of the eye are caused by viruses, and many ocular antimicrobials are available to treat bacterial, viral, and fungal infections of the eye. Common infections include conjunctivitis, hordeolum, keratitis, uveitis, and endophthalmitis. 

Antiinflammatory Drugs 

A large proportion of the inflammatory diseases of the eye are caused by viruses, and many ocular antimicrobials are available to treat bacterial, viral, and fungal infections of the eye. Common ocular infections include conjunctivitis, hordeolum (sty), keratitis, uveitis, and endophthalmitis. 

Antiinflammatory ophthalmic drugs include corticosteroids and are used to inhibit inflammatory responses to mechanical forces, chemicals, and immunologic reactions. 

Antiinflammatory drugs used systemically may also be used ophthalmically to treat various ocular inflammatory disorders and ocular surgery-related pain and inflammation. These drugs include both nonsteroidal anti-inflammatory drugs (NSAIDs) and corticosteroids. 

There are several NSAID eye drops, including bromfenac, ketorolac, flurbiprofen, and diclofenac, which can be used to decrease ocular inflammation following eye surgery or for seasonal conjunctivitis. 

Corticosteroids and NSAIDs are applied topically for symptomatic relief of many ophthalmic inflammatory conditions and may be used to treat corneal, conjunctival, and scleral injuries from chemical, radiation, or thermal burns or from penetration of foreign bodies during acute phases of the injury to prevent fibrosis and scarring, which result in visual impairment. 

The most common adverse effect of corticosteroids is transient burning or stinging. Extended use may result in cataracts, increased intraocular pressure, and optic nerve damage. 

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Topical Anesthetics 

Topical anesthetics are used to prevent pain in the eye and are beneficial during surgery, ophthalmic examinations, and removal of foreign bodies. The two currently available topical anesthetics used for ophthalmic purposes are proparacaine and tetracaine. 

Application of topical anesthetic drugs results in local anesthesia in less than 30 seconds; they are used to produce ocular anesthesia for short corneal and conjunctival procedures. 

Adverse effects are rare with ophthalmic anesthetic drugs and are limited to local effects such as stinging, burning, redness, lacrimation, and blurred vision. 

Diagnostic Drugs 

Atropine sulfate solution and ointment are used as mydriatic and cycloplegic drugs. It is used to assist in eye examination or to treat uveal tract inflammatory states. 

Cyclopentolate solution (Cyclogyl) is used as a diagnostic mydriatic and cycloplegic drug. 

Fluorescein is a diagnostic dye used to identify corneal defects and foreign objects.  

Antiallergic Drugs 

Olopatadine (Patanol) is an ocular antihistamine used for allergic conjunctivitis (hay fever), which can be seasonal or nonseasonal. It works by competing at receptor sites for histamine, which produces ocular symptoms such as itching and tearing. Other ocular antihistamines include azelastine (Optivar), emedastine (Emadine), ketotifen (Zaditor, others), cetirizine (Zerivate), and epinastine (Elestat). 

Cromolyn sodium (Crolom), an antiallergic drug that inhibits the release of inflammation-producing mediators from sensitized inflammatory cells, is used to treat vernal keratoconjunctivitis. 

Tetrahydrozoline is an ocular decongestant, promoting vasoconstriction of blood vessels in and around the eye to reduce the edema associated with allergic and inflammatory processes. It is specifically indicated to control redness, burning, and other minor irritations. 

An array of products is available over the counter to provide lubrication or moisture for the eyes. This is helpful to patients with dry or otherwise irritated eyes. 

The newest drug approved for dry eyes is Lifitegrast (Xiidra). Lifitegrast is the first in a new class called lymphocyte function-associated antigen 1 (LFA-1) antagonist. 

The American Academy of Ophthalmology recommends that the FDA continue to use a uniform color-coding system for caps and labels of all topical ocular medications. 

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Nursing Process 

Document any redness, swelling, pain, excessive tearing, eye drainage or discharge, decrease in visual acuity, or other unusual symptoms. 

Focus the nursing history on past or present systemic disease processes and exposure to any chemicals that could be topical irritants to the eye, skin, or mucous membranes, including past or present occupational and environmental exposures. 

Always check for any potential drug interaction associated with the ophthalmic medications.   

Always inspect the solution, and administer only clear, unexpired products (e.g., drops, ointments, solutions) to the eye. 

Administer all ophthalmic preparations exactly as ordered. Always apply to the conjunctival sac. Safe and accurate application or instillation technique also includes avoiding contact with the eyedropper or tube to the eye to prevent contamination of the drug. 

Applying pressure to the inner canthus after the instillation of medication is needed to prevent or decrease systemic absorption and subsequent systemic adverse effects. 

With abrasion or injury to the eye and appropriate medications, patching the affected eye is used to prevent further injury resulting from loss of blink reflex due to topical anesthetic. 

Advise patients to report to the prescriber immediately any increase in symptoms, such as eye pain or drainage and fever. 

Therapeutic responses to miotics include decreased aqueous humor of the eye with resultant decreased intraocular pressure and signs, symptoms, and long-term effects of glaucoma. 

Beta-adrenergic blockers are therapeutic if intraocular pressure decreases. Adverse effects include weakness, eye irritation, rash, bradycardia, hypotension, and dysrhythmias. 

Therapeutic responses to antibiotic, antifungal, and antiviral ophthalmic drugs include elimination of infection or condition and complications and resolution of symptoms. 

Therapeutic responses to ophthalmic anesthetics include prevention or relief of pain. 

Adverse effects may include central nervous system (CNS) excitation (e.g., dizziness, tremors, restlessness, nervousness) if the drug is systemically absorbed. Antiinflammatory ophthalmic solutions result in a decrease in allergic reactions with a decrease in itching, tearing, redness, and eye discharge. Potential complications of these solutions include swelling of the conjunctiva (chemosis). 

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Dermatologic

Anatomy, Physiology, and Pathophysiology Overview 

The skin is the largest organ of the body. It covers the body and serves several functions, including protection, sensation, temperature regulation, excretion, absorption, and metabolism. It acts as a protective barrier for the internal organs. 

The skin is made up of two layers: the dermis and the epidermis. The outer skin layer, or epidermis, is itself composed of four layers. From the outermost to innermost, these are the stratum corneum, stratum lucidum, stratum granulosum, and stratum germinativum. 

Traversing the dermis is a rich supply of blood vessels, nerves, lymphatic tissue, elastic tissue, and connective tissue, which provide extra support and nourishment to the skin. Also contained in the dermis are the exocrine glands—the eccrine, apocrine, and sebaceous glands—and the hair follicles. 

A dermatosis is any abnormal skin condition. Dermatoses include a variety of types of dermatitis (skin inflammation). Among these are conditions such as atopic dermatitis, eczema, and psoriasis. In addition, there are also a variety of skin cancers, including basal cell carcinoma, squamous cell carcinoma, and melanoma. 

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Pharmacology Overview 

Drugs administered directly to the skin are called topical dermatologic drugs and are available in a variety of formulations with each having specific characteristics that make them beneficial for certain uses. 

Systemically administered drugs (transdermal) are also used to treat several skin disorders. 

Some of the more common therapeutic categories of dermatologic drugs include the following: antibacterial, antifungal, anti-inflammatory, antineoplastic, antipruritic, antiviral, keratolytic, and topical vasodilators. Other categories include dermatologic drugs used as emollients, debriding, local anesthetics, and for treating burns. 

Antimicrobials 

Topical antimicrobials are antibacterial, antifungal, and antiviral drugs that are applied topically. Although they have many of the same properties as the systemic forms, there are differences in terms of their absorption, distribution, toxicities, and adverse effects.  

General Antibacterial Drugs 

Bacterial skin disorders include folliculitis, impetigo, furuncles, carbuncles, and cellulitis. The bacteria responsible are most commonly Streptococcus pyogenes and Staphylococcus aureus. Dermatologic antibacterial drugs, such as bacitracin, polymyxin, and neomycin, are used to treat or prevent these skin infections. Unfortunately, due to the high incidence of infection with methicillin-resistant S. aureus (MRSA), mupirocin is now also

Antiacne Drugs 

Acne vulgaris is the most common skin infection. Likely causative factors include heredity, stress, drug reactions, hormones, and bacterial infections. Common bacterial causes include Staphylococcus species (spp.) and Propionibacterium acnes. 

Some of the most commonly used antiacne drugs are benzoyl peroxide, clindamycin, erythromycin, tetracycline, isotretinoin, and the vitamin A acid known as retinoic acid. Other drugs are used, such as systemic formulations of minocycline, doxycycline, and tetracycline. 

Retinoids are used in the treatment of stable plaque psoriasis and mild to moderately severe facial acne.  

 Antifungal Drugs 

A few fungi produce keratinolytic enzymes, which allow them to live on the skin. Topical fungal infections are primarily caused by Candida spp. (candidiasis), dermatophytes, and Malassezia furfur (tinea versicolor). These fungi are found in moist, warm environments, especially in dark areas such as the feet or groin. 

Candidal infections are most commonly caused by Candida albicans, a yeastlike opportunistic fungus present in the normal flora of the mouth, vagina, and intestinal tract. 

Two significant factors that commonly predispose a person to a candidal infection are broad-spectrum antibiotic therapy, which promotes an overgrowth of nonsusceptible organisms in the natural body flora, and immunodeficiency disorders. 

Dermatophytes are a group of three closely related genera consisting of Epidermophyton spp., Microsporum spp., and Trichophyton spp. that use the keratin found on the skin to feed their growth. They produce superficial mycotic (fungal) infections of keratinized tissue (hair, skin, and nails). Infections caused by dermatophytes are called tinea, or ringworm, infections. The name ringworm comes from the fact that the infection sometimes assumes a circular pattern at the site of infection. 

Tinea infections are further identified by the body location where they occur: tinea pedis (foot), tinea cruris (groin), tinea corporis (body), and tinea capitis (scalp). Tinea infections of the foot are also known as athlete’s foot and those of the groin as jock itch. 

Antifungal therapy may be required for periods ranging from several weeks to as long as 1 year. Many topical antifungal drugs are available for the treatment of both dermatophytic infections and those caused by yeast and yeastlike fungi. Systemically administered antifungal drugs are sometimes used to treat skin conditions as well. 

Efinaconazole (Jublia) was the newest topical antifungal approved in 2014. It is indicated for toenail fungus. Patients using efinaconazole must avoid heat, nail polish, and pedicures.  

The most commonly reported adverse effects of topical antifungals are local irritation, pruritus, a burning sensation, and scaling. 

 Antiviral Drugs 

A common topical viral infection is herpes simplex virus types 1 and 2. 

Topical antivirals are now used less frequently than before because systemic antiviral drug therapy has generally been shown to be superior for controlling such viral skin conditions. 

Viral infections are very difficult to treat because they live in the body’s own healthy cells and use their cell mechanisms to reproduce. 

The only topical antiviral drugs currently available to treat such viral infections are acyclovir (Zovirax) and penciclovir (Denavir). 

The most common adverse effects are stinging, itching, and rash. 

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Anesthetic, Antipruritic, and Antipsoriatic Drugs 

Topical Anesthetics 

Topical anesthetics are drugs used to numb the skin by inhibiting the conduction of nerve impulses from sensory nerves, thereby reducing or eliminating the pain or pruritus associated with insect bites, sunburn, and allergic reactions to plants such as poison ivy, and other skin disorders. They are also used to numb the skin before a painful injection (e.g., insertion of an intravenous line [IV] in a pediatric patient). They are available as ointments, creams, sprays, liquids, and jellies. 

A lidocaine/prilocaine combination drug (EMLA [eutectic mixture of local anesthetics]) and lidocaine alone (Ela-Max) are topical anesthetic drugs that are used frequently, especially in pediatric patients. EMLA is applied 1 hour before the procedure, whereas Ela-Max is effective within 30 minutes. 

Topical Antipruritics and Antiinflammatories 

Topical antipruritic (antiitching) drugs contain antihistamines or corticosteroids. Many exert a combined anesthetic and antipruritic action when applied topically. 

New recommendations for topical antihistamines state that these drugs are not to be used to treat the following conditions because of systemic absorption and subsequent toxicity: chickenpox, widespread poison ivy lesions, and others involving large body surface areas. 

The most commonly used topical anti-inflammatory drugs are the corticosteroids. 

When topically administered corticosteroids are used, many of the undesirable systemic adverse effects associated with systemically administered corticosteroids are avoided. 

The beneficial drug effects of topically administered corticosteroids are their anti-inflammatory, antipruritic, and vasoconstrictive actions. 

Adverse effects of these drugs include skin reactions such as acne eruptions, allergic contact dermatitis, burning sensations, dryness, itching, skin fragility, hypopigmentation, purpura, hirsutism (usually facial), folliculitis, round and swollen face, alopecia (usually of the scalp), and the opportunistic overgrowth of bacteria, fungi, or viruses as a result of the immunosuppressive effects. 

Antipsoriatic Drugs 

Psoriasis is a common skin condition in which areas of the skin become thick, reddened, and covered with silvery scales. Psoriasis is actually a result of a disordered immune system, although it is generally referred to as a skin condition. It is believed to involve polygenic (multigene) inheritance. Psoriasis has fluctuating patterns of recurrence and remission. 

Treatment begins with a topical corticosteroid for mild to moderate cases. If not successful, topical antipsoriatic drugs are used. 

In addition to these topical drugs, there are also newer systemically administered antipsoriatic drugs. Those given by injection include the biologic response modifier etanercept (Enbrel), the antineoplastic drug methotrexate (antipsoriatic properties), and the interleukin 12 inhibitor ustekinumab (Stelara). 

Ixekizumab (Taltz), is an antibody that binds to interleukin-17A, which reduces inflammation and is indicated for plaque psoriasis. Patients must receive an FDA-approved patient medication guide when receiving ixekizumab. The most serious side effect is an increased risk of infection.  

Secukinumab (Cosentyx) is a similar systemic drug. Other systemic drugs include apremilast (Otezla) which is a phosphodiesterase-4 enzyme inhibitor as well as many biological drugs including, but not limited to the following: adalimumab (Humira), brodalumab (Siliq), etanercept (Enbrel), guselkumab (Temfya), risankizumab (Skyrizi) and ustekinumab (Stelara). 

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Miscellaneous Dermatologic Drugs 

Ectoparasites are insects that live on the outer surface of the body, and the drugs that are used to kill them are called ectoparasiticidal drugs. Lice are transmitted from person to person by close contact with infested individuals, clothing, combs, or towels. 

A parasitic infestation on the skin with lice is called pediculosis. 

Common findings in infested persons include itching; eggs of the lice attached to hair shafts (called nits); lice on the skin or clothes; and, in the case of pubic lice, sky blue macules (discolored skin patches) on the inner thighs or lower abdomen. Pediculoses are treated with a class of drugs called pediculicides. A second common parasitic skin infection known as scabies is caused by the itch mite Sarcoptes scabiei. Scabies are transmitted from person to person by close contact, such as by sleeping next to an infested person. 

Treatment of these parasites begins with identification of the source of infestation to prevent re-infestation. The clothing and personal articles of the infested person are decontaminated. 

In addition to lindane, malathion (Ovide) and crotamiton (Eurax) are also ectoparasiticidal drugs. 

The newest drugs approved for lice treatment are benzyl alcohol 5% (Ulesfia), which works by suffocating the lice, and spinosad (Natroba). Natroba is indicated for children 4 years of age and older and offers the benefit of not requiring nit combing as do the other treatments. 

Minoxidil (Rogaine) is a vasodilating drug that is administered systemically to control hypertension. Topically it has the same vasodilating effect, but when used in this way it is applied to the scalp to stimulate hair growth. 

Minoxidil can be used by both men and women who experience baldness or hair thinning. 

Systemic absorption of topically applied minoxidil may occur with possible adverse effects, including tachycardia, fluid retention, and weight gain. Local effects may include skin irritation, and the drug is not to be applied to skin that is already irritated or used concurrently with other topical medications applied to the same site. 

The systemically administered drug finasteride (Proscar, 5 mg) is used to treat benign prostatic hyperplasia. A lower-strength version known as Propecia (1 mg) is also used to treat male pattern alopecia. Finasteride is classified as a pregnancy category X drug, and women are not to handle this drug without gloves or crush this drug, thereby making it airborne. 

Sunscreens are topical products used to protect the skin from damage caused by the ultraviolet (UV) radiation of sunlight. Most sunscreens come in lotion, cream, gel form, or lip balm. 

Sunscreens are given a sun protection factor (SPF) rating, which is a number ranging from 2 to 50 (and even higher in some newer products) in order of increasing potency of UV protection. In 2011, the FDA stated that only those with an SPF of 15 or greater may state they reduce the risk of skin cancer and early skin aging. 

Skin cancer is the most common form of cancer. There are two types of nonmelanoma skin cancer: basal cell carcinoma and squamous cell carcinoma. Basal cell carcinoma is the most common and is rarely fatal, but it can be highly disfiguring. Squamous cell carcinoma, on the other hand, can be fatal, with 2500 deaths reported annually. The most aggressive skin cancer is melanoma, which accounts for only 3% of all skin cancers but is responsible for 75% of deaths associated with skin cancer. The most common cause of skin cancer is exposure to the sun and tanning beds. Early detection and prevention are of the utmost importance. 

Various premalignant skin lesions and basal cell carcinomas may be treated with the topically applied antineoplastic drug fluorouracil (Efudex). It is also used topically in the treatment of solar or actinic keratosis and superficial basal cell carcinomas of the skin—often in addition to local surgical excision. 

More aggressive skin cancers (squamous cell carcinoma and malignant melanoma) are not treated with fluorouracil but are usually treated with more aggressive interventions, such as surgery, radiation therapy, and/or systemic chemotherapy. 

The adverse effects associated with the topical use of this antineoplastic drug are generally limited to local inflammatory reactions such as dermatitis, stomatitis, and photosensitivity. More serious effects include swelling, scaling, pain, pruritus, burning, soreness, tenderness, suppuration, scarring, and hyperpigmentation. 

Another topical drug also used for the treatment of actinic keratoses and basal cell carcinomas is the immunomodulator imiquimod. 

Although superficial skin wounds usually require minimal interventions, deeper skin wounds often require more definitive care for optimal healing. Vitamin C and zinc have been shown to improve wound healing when they are given orally. 

Tar derivatives have antiseptic, antibacterial, and antiseborrheic properties. 

Isopropyl alcohol (70%) is most commonly used to prepare the skin before minor procedures such as drawing blood or giving injections. 

Other drugs that are used to prepare the skin include povidone-iodine (Betadine), chlorhexidine (Hibiclens), and benzalkonium chloride (Zephiran). 

Benzalkonium chloride is a surface-active drug that works by denaturing the microorganism or essentially destroying its protein. 

Chlorhexidine acts by disrupting bacterial membranes and inhibiting cell wall synthesis. It is used primarily as a surgical scrub or handwashing agent by health care professionals. 

Povidone-iodine is an antiseptic that kills bacteria, fungi, and viruses. It is used for the prevention or treatment of topical infections associated with surgery, burns, and minor cuts and scrapes, and for relief of minor vaginal infections. It is the most widely used antiseptic, but patients should be screened for iodine or shellfish allergies before using it. 

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Nursing Process 

Topical antibacterials are associated with a wide range of reactions because of the generalized sensitivity of patients to antibiotics, even when in a different dosage form; therefore, if a patient is allergic to a systemic antibacterial, they will also be allergic to topical dosage forms. 

The skin of very young and older adult patients is more fragile and permeable to certain topical dermatologic preparations. This could also lead to a higher risk of systemic absorption from the skin. 

Before any topical medication is applied, cleanse the affected area of any debris, drainage, and/or residual medication, taking care to follow any specific directions such as removing water- or alcohol-based topical preparations with soap and water. 

Most topical dermatologic drugs do not require the use of a dressing once the medication is applied. 

Medicated areas may also need to be protected from exposure to air or sunlight. 

Therapeutic responses to the various dermatologic preparations include improved condition of the skin and healing of lesions or wounds; a decrease in the size of lesions with eventual resolution; and a decrease in swelling, redness, weeping, itching, and burning of the area. 

Adverse effects include increased severity of symptoms—for example, increased redness, swelling, pain, and drainage; fever; or any other unusual problems in the affected area. Adverse effects may range from slight irritation of the site where the topical drug has been applied to an allergic reaction to toxic systemic effects. 

Topical anesthetics are used therapeutically to numb the skin. Indications for topical anesthetics include insect bites, sunburn, poison ivy, and prevention of pain from injections. 

Corticosteroids are some of the most widely used topical drugs and are indicated for the relief of topical inflammatory and pruritic disorders. Beneficial effects of corticosteroids include anti-inflammatory, antipruritic, and vasoconstrictor actions. Some of the negative effects of potent corticosteroid use or prolonged use of weaker corticosteroids include dermal atrophy and adrenal insufficiency. 

Adverse and toxic reactions to dermatologic drugs can and do occur; therefore, administer these drugs cautiously, and follow the prescriber’s orders and manufacturer’s guidelines. This is critical to ensure safe and effective treatment. 

Patient education about the medication, its administration, and its effectiveness is important to ensure compliance with the treatment regimen. 

With medications that block interleukin-17A, provide medication-guide and instructions for use including adverse effects, application techniques, and reporting of any infections or history of such.   

Drugs inhibiting interleukin-17A, such as Taltz, require the education of patients about how to administer subcutaneous injections. 

Educate the patient about the monitoring and reporting of fever, sweats, chills, muscle aches, and shortness of breath. 

Monitor laboratory values, especially white blood cell (WBC) counts due to the side effect of increased risk for infection. 

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Immunosuppressant Drugs

Anatomy, Physiology, and Pathophysiology of Disease Overview 

The purpose of the immune system is to distinguish self from nonself and to protect the body from foreign material (antigens). 

In addition to performing this beneficial function, the immune system can also attack itself and cause what are known as autoimmune diseases or immune-mediated diseases. The immune system also participates in hypersensitivity, or anaphylactic, reactions, which can be life-threatening. 

There are three layers of barriers to protect the body: (1) mechanical barriers and chemical barriers, (2) inflammation response and phagocytosis, and (3) specific immune responses and natural killer cells. There are two types of immunity: humoral immunity, which is mediated by B lymphocytes, and cellular immunity, which is mediated by T lymphocytes. 

Immunosuppressants decrease or prevent the body’s immune response. Treatment with such drugs is referred to as immunosuppressive therapy. 

Some clinical uses for immunosuppressants are suppression of immune-mediated disorders and malignancies and improvement of short-term and long-term allograft survival. 

Immunosuppressants are used for many immune-related disorders, including rheumatoid arthritis, systemic lupus erythematosus, Crohn’s disease, multiple sclerosis, myasthenia gravis, psoriasis, and others. 

These drugs include cyclophosphamide, glatiramer acetate, fingolimod, and many immunomodulators. 

Transplant patients receive immunosuppressant therapy for their lifetime. 

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Pharmacology Overview 

All immunosuppressants have similar mechanisms of action in that they selectively suppress certain T-lymphocyte cell lines. 

The major classes of immunosuppressant drugs used in preventing organ rejection include glucocorticoids, calcineurin inhibitors, antimetabolites, and biologics. 

Corticosteroids inhibit all stages of T-cell activation and are used for induction, maintenance immunosuppression, and acute rejection. 

Calcineurin inhibitors (e.g., cyclosporine, tacrolimus, sirolimus) inhibit the phosphate required for interleukin-2 production. Sirolimus does not inhibit calcineurin but instead inhibits the mammalian target of rapamycin (mTOR), which ultimately inhibits interleukin-2 communication. 

Cyclosporine and cyclosporin modified (Neoral, Gengraf) are not interchangeable. 

Antimetabolites (e.g., azathioprine, mycophenolate) inhibit cell proliferation. 

Biologics (e.g., basiliximab, daclizumab) inhibit cytotoxic T killer cell function. 

Mycophenolate and tacrolimus are indicated for both prevention of rejection and treatment of organ rejection. 

Mycophenolate has a black box warning stating that it is associated with an increased risk for congenital malformations and spontaneous abortions when used during pregnancy, as well as an increased risk for infections and the development of lymphoma and skin cancers. 

Fingolimod and glatiramer acetate are immunosuppressants that are indicated for the reduction of the frequency of relapses (exacerbations) in a type of multiple sclerosis known as relapsing-remitting multiple sclerosis. 

Relative contraindications, depending on the patient’s condition, may include renal or hepatic failure, hypertension, and concurrent radiation therapy. Pregnancy is not necessarily a contraindication, but these drugs should be given only in clinically urgent situations. 

By virtue of their actions, immunosuppressants place patients at increased risk of opportunistic infections. Immunosuppressant drugs may also increase the risk of certain types of cancers, especially skin cancers. 

Other serious adverse effects are limited to the particular drug. Cyclosporine and tacrolimus can cause nephrotoxicity, and corticosteroids, cyclosporine, and tacrolimus can cause posttransplant diabetes mellitus. 

Patients taking immunosuppressant drugs need to avoid live vaccines. 

Immunosuppressants have narrow therapeutic windows, and drug interactions can be significant. 

Drugs that cause increased levels of immunosuppressant drugs can cause toxicity, whereas drugs that reduce immunosuppressant drug levels may lead to organ rejection. 

Grapefruit can inhibit metabolizing enzymes and thus can increase the activity of cyclosporine, tacrolimus, and sirolimus. Grapefruit juice may increase the bioavailability of cyclosporine by 20% to 200% and should be avoided. 

Foods that are high in potassium, such as bananas and tomatoes, can increase cyclosporine nephrotoxicity. Meals that have high-fat content can increase sirolimus levels. 

There is potential for interactions between immunosuppressant drugs and herbal preparations. The enzyme-inducing properties of St. John’s wort have been demonstrated to reduce the therapeutic levels of cyclosporine and cause organ rejection. The immunostimulant properties of cat’s claw and echinacea may be undesirable in transplant recipients because they have effects that are opposite those of the immunosuppressants. 

Fingolimod (Gilenya), which failed as an antirejection drug, was approved in 2010 for multiple sclerosis. It is the only oral drug for relapsing forms of multiple sclerosis. It has significant adverse effects, including headache, hepatotoxicity, flulike symptoms, back pain, AV block, bradycardia, hypertension, and macular edema.

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Nursing Process 

Before administering any of the immunosuppressants, perform a thorough patient assessment with baseline measurements of vital signs and weight. 

Obtain a thorough history of past and present medical conditions. 

With azathioprine, assess white blood cell and platelet counts, noting any signs and symptoms of infection as well as any bleeding tendencies due to the potential for drug-related leukopenia and thrombocytopenia. 

With cyclosporine therapy: 

Specifically assess the functional level of all organs as well as assess for any underlying cardiovascular, central nervous system, hepatic, and/or renal disease because of potential drug-related toxicities involving these systems and the physiologic impact of the organ transplant process on multiple systems. 

Perform a baseline oral assessment because of the possible adverse effect of drug-induced gingival hyperplasia. 

Assess and document baseline blood pressures because as many as 50% of patients taking this drug have moderate hypertension.  

Cyclosporine is now available in several oral formulations, but these are not to be used interchangeably. Do not refrigerate these oral solutions. Oral solutions may be mixed in a glass container with chocolate milk, milk, or orange juice and served at room temperature. Once the solution is mixed, make sure the patient drinks it immediately. Avoid Styrofoam containers or cups because the drug has been found to adhere to the inside wall of such containers. 

Administered intravenously, cyclosporine is usually diluted with normal saline or 5% dextrose in water and infused using an intravenous (IV) infusion pump. Always infuse over the recommended time period. Monitor the patient very closely during the infusion, especially during the first 30 minutes, for any allergic reactions, as manifested by facial flushing, urticaria, wheezing, dyspnea, and rash. 

With tacrolimus: 

Obtain a thorough patient history with attention to medication use, and perform a physical assessment with close attention to renal functioning through monitoring of blood urea nitrogen (BUN), serum creatinine, and serum electrolyte levels. 

Concern for anaphylactic reaction also continues past the first 30 minutes and first dose, and it is usually important to confirm that resuscitative equipment is accessible and functioning. 

Sirolimus and tacrolimus are administered as ordered by intravenous or oral route. If IV tacrolimus is to be discontinued and maintenance dosing is needed, oral tacrolimus is usually ordered to be given 8 to 12 hours after the discontinuation of the IV drug. 

With sirolimus and tacrolimus, do not store IV solutions in polyvinyl chloride containers. It must be administered in an appropriately designed container and tubing. 

With basiliximab and daclizumab, complete a thorough documentation of baseline vital signs and presenting complaints because of the possible occurrence of cytokine release syndrome with resultant fever, dyspnea, tachycardia, sweating, chills, vomiting, diarrhea, muscle/joint pain, and general malaise. 

Immunosuppressants must be given at the same time every day. 

Oral immunosuppressants need to be taken with food to minimize GI upset. Oral forms of the drugs are used whenever possible to decrease the risk of infection associated with parenteral injections and subsequent injury to the first line of defense (the skin). 

The use of premedication protocols involving various antihistamines and/or anti-inflammatory drugs is common. 

It is very important with the use of any of the immunosuppressants to be sure that supportive treatment equipment and related drugs are available in case of an anaphylactic or allergic reaction. 

Oral dosage forms of tacrolimus should not be put in Styrofoam containers. Inform the patient to avoid the consumption of grapefruit within 2 hours of taking the drug. 

Patients need to always have a 1-week supply of medications available so that there is never a risk of running out. 

Oral antifungals are generally given with immunosuppressant medications to treat the oral candidiasis that occurs as a result of immunosuppression and fungal overgrowth. 

Inspect the oral cavity as often as necessary (at least once every shift) for any white patches on the tongue, mucous membranes, and/or oral pharynx that may indicate oral candidiasis. 

Monitor the results of prescriber-ordered laboratory studies such as hemoglobin level, hematocrit, and white blood cell and platelet counts. If the values drop below normal ranges, notify the prescriber. 

Therapeutic responses to immunosuppressants may include acceptance of the transplanted organ or graft in transplant patients and improved symptoms in those with autoimmune disorders. 

Because of the lifelong nature of the diseases or disease states being managed with these immunosuppressants, always be aware of the financial, emotional, psychosocial, cultural, and body-image impact on the patient, significant other, and/or family members. 

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Biologic Response–Modifying and Antirheumatic Drugs

Anatomy, Physiology, and Pathophysiology Overview  

Overview of Immunomodulators 

Cancer treatment has traditionally involved surgery, radiation, and chemotherapy. 

Surgery and radiation are usually local or regional therapies. Chemotherapy is generally systemic, but it often does not completely eliminate all of the cancer cells in the body. Adjuvant therapy is frequently used to destroy undetected distant micrometastases. 

The two major components of the body’s immune system are humoral immunity, mediated by B-cell functions (primarily antibody production), and cell-mediated immunity, which is mediated by T-cell functions. The humoral and cellular immune systems act together to recognize and destroy foreign particles and cells in the blood or other body tissues. The humoral immune system is composed of lymphocytes that are known as B cells until they are transformed into plasma cells when they come in contact with an antigen (foreign substance). The plasma cells then manufacture antibodies to that antigen. 

Over the last two decades, medical technology has developed a group of drugs impacting the immune system, and a new addition to these drugs includes the biologic response-modifying drugs or biologic response modifiers (BRMs). 

These drugs alter the body’s response to diseases such as cancer and autoimmune, inflammatory, and infectious diseases and can enhance or restrict the patient’s immune response to disease, can stimulate a patient’s hematopoietic function, and prevent disease. 

Biologic response–modifying drugs provide another treatment option for patients who have malignancies and/or are receiving chemotherapy and need to boost blood cell counts. 

Two broad classes of biologic response–modifying drugs are hematopoietic drugs and immunomodulating drugs. Subclasses of immunomodulating drugs include interferons, monoclonal antibodies, interleukin receptor agonists and antagonists, and miscellaneous drugs. Disease-modifying antirheumatic drugs are drugs used to treat rheumatoid arthritis. 

Immunomodulating drugs therapeutically alter a patient’s immune response. 

An intact immune system can identify cells as malignant and destroy them; a healthy immune system can distinguish between tumor cells and normal body tissues. 

People develop cancerous cells in their bodies on a regular basis; normally the immune system is able to eliminate these cells before they multiply to uncontrollable levels. Only when the natural immune responses fail to keep pace with these initially microscopic cancer cell growths does a person develop a true “cancer” requiring clinical intervention. 

Biologic response–modifying drugs work by one of three mechanisms: (1) enhancement or restoration of the host’s immune system defenses against the tumor; (2) direct toxic effect on the tumor cells, which causes them to lyse, or rupture; or (3) adverse modification of the tumor’s biology, which makes it harder for the tumor cells to survive and reproduce. 

Some immunomodulating drugs are used to treat autoimmune, inflammatory, and infectious diseases. They either reduce the patient’s inappropriate immune response (as in rheumatoid arthritis) or strengthen the immune response against microorganisms and cancer cells.

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Immune System 

Tumor cells express chemical compounds on their surfaces that signal the immune system that these cells are a threat. These chemical markers are called tumor antigens or markers. 

An antigen is any substance that the body’s immune system recognizes as foreign. Recognition of antigens varies among individuals, which is why some people are more prone than others to immune-related diseases such as allergies, inflammatory diseases, and cancer. 

Humoral immunity is mediated by B-cell functions (primarily antibody production), and cell-mediated immunity is mediated by T-cell functions. 

Attack against tumor cells by antibodies produced by the B lymphocytes of the humoral immune system prepares those tumor cells for destruction by the T lymphocytes. 

The immune system in a healthy individual is genetically preprogrammed to be able to mount an antibody response against literally millions of different antigens resulting from the individual’s lifetime antigen exposure and through exposure to new antigens passed down. 

Antibodies that a single plasma cell makes are all identical and are called monoclonal. 

Monoclonal antibodies have also been prepared synthetically using recombinant DNA technology, which has resulted in newer drug therapies. 

When B lymphocytes differentiate into plasma cells, some of these B cells become memory cells that “remember” the exact characteristics of a particular foreign antigen, allowing a stronger and faster immune response in re-exposure to the same antigen. 

The functional cells of the cell-mediated immune system are the T lymphocytes, which mature in the thymus. T cells include cytotoxic T cells, T helper cells, and T suppressor cells. 

Cytotoxic T cells directly kill their targets by causing cell lysis or rupture. 

T helper cells are considered the master controllers of the immune system. They direct the actions of many other immune components, such as lymphokines and cytotoxic T cells. 

Cytokines are non-antibody proteins serving as chemical mediators of physiologic functions. 

Lymphokines are a subset of cytokines released by T lymphocytes upon contact with antigens; they serve as chemical mediators of the immune response. 

T suppressor cells have an effect on the immune system that is opposite to that of T helper cells and serve to limit or control the immune response. A healthy immune system has about twice as many T helper cells as T suppressor cells at any given time. 

The cancer-killing cells of the cellular immune system are the macrophages (derived from monocytes), natural killer (NK) cells (another type of lymphocyte), and polymorphonuclear leukocytes (not lymphocytes), which are also called neutrophils. 

In contrast, T suppressor cells have an important negative influence on antitumor actions of the immune system. Overactive T suppressor cells may be responsible for clinically significant cancer cases by permitting tumor growth beyond the immune system’s control.

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Pharmacology Overview 

Therapeutic effects of the biologic response-modifying drugs include enhancement of hematopoietic function, regulation or enhancement of the immune response, inhibition of metastases, prevention of cell division, or inhibition of cell maturation. 

Fingolimod (Gilenya) is a newer oral drug for the treatment of relapsing forms of MS to reduce the frequency of clinical exacerbations and delay disability progression. It is a sphingosine 1-phosphate receptor modulator. 

Hematopoietic Drugs 

Erythropoietic drugs (epoetin alfa and darbepoetin alfa), three colony-stimulating factors (filgrastim, pegfilgrastim, and sargramostim) promote the synthesis of various types of major blood components by promoting the growth, differentiation, and function of their corresponding precursor cells in the bone marrow. 

All hematopoietic drugs decrease the duration of chemotherapy-induced anemia, neutropenia, and thrombocytopenia and allow higher dosages of chemotherapy to be given; decrease bone marrow recovery time after bone marrow transplantation or irradiation; and stimulate other cells in the immune system to destroy or inhibit the growth of cancer cells, as well as virus- or fungus-infected cells. 

All of these drugs are produced by recombinant DNA technology, which allows them to be essentially identical to their endogenously produced counterparts. 

Neutrophils are the most important granulocytes for fighting infection. Colony-stimulating factors stimulate neutrophils to grow and mature and thus directly oppose the detrimental bone marrow actions of chemotherapy. 

Colony-stimulating factors also enhance the functioning of mature cells of the immune system, such as macrophages and granulocytes. This increases the ability of the body’s immune system to kill cancer cells, as well as virus- and fungus-infected cells. 

The effect of hematopoietic drugs on the bone marrow cells also reduces the recovery time after bone marrow transplantation and radiation therapy. 

Filgrastim and sargramostim have significant drug interactions when these two drugs are given with myelosuppressive antineoplastic drugs. When myelosuppressive antineoplastics are given with them, the drugs directly antagonize each other. Filgrastim and sargramostim are not given within 24 hours of administration of myelosuppressive antineoplastics.

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Interferons 

Interferons are proteins with three basic properties: antiviral, antitumor, and immunomodulating. There are three different groups of interferon drugs—the alpha, beta, and gamma interferons—each with its own antigenic and biological activity. 

Interferons are most commonly used in the treatment of certain viral infections and types of cancer. 

Interferons are recombinantly manufactured substances that are identical to the interferon cytokines that are naturally present in the human body. 

Overall, interferons have three different effects on the immune system. They can (1) restore its function if it is impaired, (2) augment (amplify) the immune system’s ability to function as the body’s defense, and (3) inhibit the immune system, useful when the immune system has become dysfunctional, causing autoimmune disease such as multiple sclerosis. 

The beneficial actions of interferons make them excellent drugs for the treatment of viral infections, various cancers, and some autoimmune disorders. 

The most commonly used interferon products are in the alfa class and are referred to as leukocyte interferons because they are produced from human leukocytes. Two newer types of interferon alfa include peginterferon alfa-2a and peginterferon alfa-2b. 

Contraindications to the use of interferons include known drug allergy and may include autoimmune disorders, hepatitis or liver failure, concurrent use of immunosuppressant drugs, Kaposi’s sarcoma related to AIDS, and severe liver disease. 

The most common adverse effects can be broadly described as flulike symptoms: fever, chills, headache, malaise, myalgia, and fatigue. 

The major dose-limiting adverse effect of interferons is fatigue.

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Monoclonal Antibodies 

Monoclonal antibodies are becoming the standard of therapy in many areas, including the treatment of cancer, rheumatoid arthritis and other inflammatory diseases, multiple sclerosis, and organ transplantation. They can specifically target cancer cells with minimal effect on healthy cells. 

The mab suffix in a drug name is usually an abbreviation for “monoclonal antibody.” 

The FDA recently approved biosimilar products to infliximab (Inflectra), etanercept (Ereizi), and adalimumab (Amjevita). 

Vedolizumab (Entyvio) was approved in 2014 for the treatment of Crohn’s disease and ulcerative colitis. The most common side effects are nausea, nasopharyngitis, upper respiratory tract infection, arthralgia, pyrexia, fatigue, headache, cough, and infusion-related reactions.  

Patients receiving these very potent drugs can manifest acute symptoms that are comparable to classic allergy or flulike symptoms, such as fever, dyspnea, and chills. 

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Interleukins and Related Drugs 

Interleukins are a natural part of the immune system and are classified as lymphokines. 

Lymphokines are soluble proteins that are released from activated lymphocytes such as natural killer cells. 

Interleukins cause multiple effects on the immune system, one of which is antitumor action. 

Aldesleukin was previously indicated only for the treatment of metastatic renal cell carcinoma. It is now also approved for the treatment of metastatic melanoma. 

Denileukin diftitox is currently indicated only as therapy for a skin-based lymphoma known as cutaneous T-cell lymphoma, which often metastasizes to other areas of the body. 

Anakinra and tocilizumab are indicated for symptom control in patients with rheumatoid arthritis for whom other therapy has failed. 

Therapy with aldesleukin is commonly complicated by severe toxicity. A syndrome known as capillary leak syndrome is responsible for the severe toxicities of aldesleukin. 

Common adverse effects associated with denileukin diftitox administration are GI upset, hypoalbuminemia, elevated liver enzyme levels, edema, dyspnea, cough, fever, chills, asthenia, generalized pain, chest pain, infection, and headache. 

Anakinra has a much milder adverse effect profile that includes local reactions at the injection site, various respiratory tract infections, and headaches. 

Tocilizumab has a high risk of causing anaphylaxis. 

The most common side effects of ixekizumab are neutropenia, immunogenicity, infection, and injection site reactions. 

Some additional medications can be broadly classified as miscellaneous immunomodulating drugs. A special term for immunostimulant drugs that are nonspecific is adjuvant. 

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Pathophysiology Overview 

Rheumatoid Arthritis 

Rheumatism is a general term for any of several disorders characterized by inflammation, degeneration, or metabolic derangement of connective tissue structures, especially joints and related structures such as muscles, tendons, bursae, fibrous tissue, and ligaments. 

Rheumatoid arthritis is a chronic autoimmune disorder that commonly causes inflammation and tissue damage in joints. It can also cause anemia and diffuse inflammation in the lungs, eyes, and pericardium of the heart, and subcutaneous nodules under the skin. 

Disease-modifying antirheumatic drugs (DMARDs) not only provide antiinflammatory and analgesic effects, but they can arrest or slow the disease processes associated with arthritis. 

They exhibit anti-inflammatory, antiarthritic, and immunomodulating effects and work by inhibiting the movement of various cells into an inflamed, damaged area, such as a joint. 

DMARDs often have a slow onset of action of several weeks versus minutes to hours for NSAIDs; sometimes these drugs are also referred to as slow-acting antirheumatic drugs (SAARDs). 

They were previously thought of as second-line drugs for the treatment of arthritis because they can have much more toxic adverse effects than do the NSAIDs. The American College of Rheumatology updated its treatment guidelines in 2012 and again in 2015, and now recommends the use of DMARDs as first-line therapy in many patients. 

Nonbiologic DMARDs include methotrexate, leflunomide, hydroxychloroquine, and sulfasalazine. 

The biologic DMARDs include adalimumab, anakinra, certolizumab, etanercept, golimumab, infliximab, adalimumab, abatacept, rituximab, tocilizumab and, most recently, tofacitinib. 

Tofacitinib (Xeljanz) is a drug of the Janus kinase inhibitor (JAK) class for adult patients with moderately to severely active RA with an inadequate response or intolerance to methotrexate. However, serious infections including TB and other infections are concerns with the use of the drug and the patient needs to know the signs and symptoms to report to the prescriber. Similar drugs include baricitinib (Olumiant), fedratinib (Inrebic), ruxolitinib (Jakafi) and upadacitinib (Rinvoq). This class of drugs is given orally. 

DMARDs are not used in patients with active bacterial infection, active herpes zoster, active or latent tuberculosis, or acute or chronic hepatitis B or C. 

Etanercept, infliximab, and adalimumab are not to be used in patients with heart failure, lymphoma, or multiple sclerosis. 

Methotrexate and leflunomide are to be avoided during pregnancy and lactation. 

The recommended therapy with nonbiologic DMARDs usually begins with methotrexate or leflunomide for most patients. 

Biologic DMARDs are generally reserved for those patients whose disease does not respond to methotrexate or leflunomide. The biologic DMARDs include etanercept, infliximab, adalimumab, abatacept, and rituximab. 

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Pathophysiology Overview 

Rheumatoid Arthritis 

Rheumatism is a general term for any of several disorders characterized by inflammation, degeneration, or metabolic derangement of connective tissue structures, especially joints and related structures such as muscles, tendons, bursae, fibrous tissue, and ligaments. 

Rheumatoid arthritis is a chronic autoimmune disorder that commonly causes inflammation and tissue damage in joints. It can also cause anemia and diffuse inflammation in the lungs, eyes, pericardium of the heart, and subcutaneous nodules under the skin. 

Disease-modifying antirheumatic drugs (DMARDs) not only provide anti-inflammatory and analgesic effects, but they can arrest or slow the disease processes associated with arthritis. 

They exhibit anti-inflammatory, antiarthritic, and immunomodulating effects and work by inhibiting the movement of various cells into an inflamed, damaged area, such as a joint. 

DMARDs often have a slow onset of action of several weeks versus minutes to hours for NSAIDs; sometimes these drugs are also referred to as slow-acting antirheumatic drugs (SAARDs). 

They were previously thought of as second-line drugs for the treatment of arthritis because they can have much more toxic adverse effects than NSAIDs. The American College of Rheumatology updated its treatment guidelines in 2012 and again in 2015, and now recommends the use of DMARDs as first-line therapy in many patients. 

Nonbiologic DMARDs include methotrexate, leflunomide, hydroxychloroquine, and sulfasalazine. 

The biologic DMARDs include adalimumab, anakinra, certolizumab, etanercept, golimumab, infliximab, adalimumab, abatacept, rituximab, tocilizumab and, most recently, tofacitinib. 

Tofacitinib (Xeljanz) is a drug of the Janus kinase inhibitor (JAK) class for adult patients with moderately to severely active RA with an inadequate response or intolerance to methotrexate. However, serious infections including TB and other infections are concerns with the use of the drug and the patient needs to know the signs and symptoms to report to the prescriber. Similar drugs include baricitinib (Olumiant), fedratinib (Inrebic), ruxolitinib (Jakafi), and upadacitinib (Rinvoq). This class of drugs is given orally. 

DMARDs are not used in patients with active bacterial infection, active herpes zoster, active or latent tuberculosis, or acute or chronic hepatitis B or C. 

Etanercept, infliximab, and adalimumab are not to be used in patients with heart failure, lymphoma, or multiple sclerosis. 

Methotrexate and leflunomide are to be avoided during pregnancy and lactation. 

The recommended therapy with nonbiologic DMARDs usually begins with methotrexate or leflunomide for most patients. 

Biologic DMARDs are generally reserved for those patients whose disease does not respond to methotrexate or leflunomide. The biologic DMARDs include etanercept, infliximab, adalimumab, abatacept, and rituximab. 

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Nursing Process 

Nursing management associated with the administration of biological response–modifying drugs focuses on the use of careful aseptic technique and other measures to prevent infection; proper nutrition; oral hygiene; monitoring of blood counts; and management of adverse effects, including joint and bone pain and flulike symptoms. 

Before administering these medications, document a baseline assessment of the following: vital signs, skin turgor and intactness, bowel sounds and patterns, and breath sounds. 

Assess potential intravenous and subcutaneous sites, and, if appropriate, note chemotherapy-induced absolute neutrophil nadir (low point). 

With the use of filgrastim, assess for any existing joint or bone pain because of the possible adverse effects of mild to severe bone pain with filgrastim. 

Do not administer filgrastim and sargramostim within 24 hours of a myelosuppressive antineoplastic, and follow the time frame for their use (as prescribed), whether in an inpatient or home setting. 

With biological response-modifying drugs, assess the patient for the presence of any conditions that represent contraindications or cautions to their administration. 

Assess the following systems: (1) respiratory system with attention to rate, rhythm, and depth as well as breath sounds, listening for any adventitious (abnormal) sounds; (2) cardiac system with attention to vital signs, heart sounds, heart rate and rhythm, and oxygen saturation levels, as well as assessment for edema and/or shortness of breath, presence of cyanotic discoloration around the mouth or nail beds, and any chest pain; (3) central nervous system with a focus on baseline mental status, as well as assessment for any seizure-like activity or central nervous system abnormalities; and (4) immune system, noting any history of chronic illnesses, ability to fight off infections, and history of suppressed immunity. 

Before interferons are given, assess the patient’s history of drug allergies as well as any history of autoimmune disorders, hepatitis, liver failure, or AIDS. 

Monitor the patient for capillary leak syndrome (CLS) if they are taking interleukins. Identification of early symptoms will allow critical, supportive treatment with discontinuation of the interleukin drug. Assess for drug allergy as well as contraindications of organ transplantation and abnormal thallium cardiac stress testing results or abnormal pulmonary function tests. 

The recommended therapy with nonbiologic DMARDs usually begins with methotrexate or leflunomide for most patients. Biologic DMARDs are generally reserved for those patients whose disease does not respond to methotrexate or leflunomide. The biologic DMARDs include etanercept, infliximab, adalimumab, abatacept, and rituximab. Assess for contraindications to the use of DMARDs, such as active bacterial infections, active herpes, active/latent tuberculosis, and acute or chronic hepatitis B or C. 

Before initiation of therapy with leflunomide, perform a complete assessment of hepatic functioning as well as baseline blood cell counts. Because of the possible adverse effects of diarrhea and respiratory infections, assess GI functioning and bowel patterns. 

Etanercept is to be avoided in those with sepsis and active infections, so conduct a thorough assessment of white blood cell (WBC) counts and for any signs and symptoms of infection, or a history of infection. Some dosage forms may contain latex; it is critical to also assess for latex allergy. 

Premedication with acetaminophen and diphenhydramine may be deemed necessary to help minimize any allergic-type reaction when any of the biological response-modifying drugs are administered. 

With some of the biological response-modifying drugs, treatment with opioids, other antihistamines, and/or anti-inflammatory drugs may be required for the management of bone pain and chills if treatment with acetaminophen or diphenhydramine is not successful. 

Antiemetics may also be needed for any drug-related nausea or vomiting and may be given before the administration of the specific biological response-modifying drug. 

With concerns of infection, as with many of the biologic response-modifying drugs, monitor the patient’s vital signs with attention to temperature and also for the occurrence of chills and headaches. 

With monoclonals, serious infections are a major concern. 

Therapeutic responses to biologic response–modifying drugs include a variety of responses, such as a decrease in the growth of the lesion or mass, decreased tumor size, and an easing of symptoms related to the tumor or disease process. Other therapeutic effects are an improvement in WBC, red blood cell (RBC), platelet counts, and/or a return of blood counts to normal levels, and absence of infection, anemias, and hemorrhage. 

DMARDs are expected to have therapeutic results within a documented time frame (often weeks) with the patient experiencing increased ability to move joints, less discomfort, and an overall increased sense of improvement and well-being. 

The toxicity of these drugs may be manifested by liver, renal, and respiratory dysfunction and, for methotrexate, bone marrow suppression. 

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Substance Abuse Drugs

Anatomy, Physiology, and Pathophysiology Overview 

Substance abuse affects people of all ages, sexes, and ethnic and socioeconomic groups. 

According to the Substance Abuse and Mental Health Services Administration in 2018, 164.8 million Americans 12 years of age or older were past month substance users. 

Heroin and prescription drugs showed the biggest increase in use, while marijuana was identified as the most commonly used illicit drug.  

Tobacco use has shown a consistent decline, however, it is on the rise due to vaping. 

The U.S. Department of Health and Human Services reports that alcohol is the substance abused most frequently by adolescents followed by marijuana and tobacco.  

Nearly 50% of the adult patients seen in many family practice clinics have an alcohol or drug disorder. 

Alcohol abuse and alcoholism cut across gender, race, and nationality. A substantial number of older adults are drinking at higher than recommended levels; thus, alcohol abuse is becoming a growing problem in this population. 

Physical dependence is a condition characterized by physiologic reliance on a substance, usually indicated by tolerance to the effects of the substance and the development of withdrawal symptoms when use of the substance is terminated. 

Psychologic dependence is a condition characterized by strong desires to obtain and use a substance. 

Physical dependence and psychological dependence on a substance are chronic disorders with remissions and relapses, as with any other chronic illness. 

Habituation refers to situations in which a patient develops tolerance to a certain drug and may have mild psychological dependence on it but does not show compulsive dose escalation, drug-seeking behavior, or major withdrawal symptoms on drug discontinuation. 

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Pharmacology Overview

Opioids 

Opioid analgesics are synthetic versions of pain-relieving substances that were originally derived from the opium poppy plant. 

Diacetylmorphine (heroin) and opium are classified as Schedule I drugs and are not available in the United States for therapeutic use. 

Heroin is one of the top 10 most abused drugs in the United States. Others in this opioid category are codeine, hydrocodone, hydromorphone, morphine, and oxycodone. 

Recently, the potent opioid fentanyl has been found laced with heroin and in pill form. Numerous deaths related to illegal fentanyl have been reported. 

Opioids work by blocking receptors in the central nervous system, resulting in the perception of pain being blocked. 

The effects of opioids are referred to as narcosis or stupor, involving reduced sensory response, especially to painful stimuli; opioid analgesics are also referred to as narcotics. 

The intended effects are to relieve pain and diarrhea, reduce cough, and induce anesthesia. 

Due to the high potential for abuse, opioids are classified as Schedule II controlled substances. 

Certain opioid drugs, such as methadone, are themselves used to treat opioid dependence. 

The major central nervous system (CNS)-related adverse effects include diuresis, miosis, convulsions, nausea, vomiting, and respiratory depression. 

Many of the non-CNS adverse effects are secondary to the release of histamine. 

Drug withdrawal symptoms vary with the class of drug and may even be the opposite of the drug's action. Signs and symptoms of opioid withdrawal include seeking the drug from more than one prescriber, mydriasis (pupil dilatation), rhinorrhea, diaphoresis, piloerection (goose bumps), lacrimation, diarrhea, insomnia, and elevated blood pressure and pulse rate. 

Many patients require formal detoxification while withdrawal symptoms are occurring. 

Certain medications are used to prevent relapse use once initial remission is achieved but are useful only when concurrent counseling is provided. 

The newest drug to help prevent relapse is lofexidine (Lucemyra), which is an alpha2 agonist.  

For opioid abuse or dependence, naltrexone, an opioid antagonist, works by blocking the opioid receptors so that the use of opioid drugs does not produce euphoria. 

Naloxone is an opioid antagonist which can be used in opioid overdose. Many first responders now carry naloxone and many states have approved pharmacists to dispense naloxone on request by those using opioids or their loved ones. 

Naloxone is combined with buprenorphine (Subutrex) or used alone (Suboxone). 

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Stimulants 

The abuse of stimulants is related to their ability to cause elevation of mood, reduction of fatigue, a sense of increased alertness, and invigorating aggressiveness. 

Amphetamine is a stimulant drug that is commonly abused. Three classes of amphetamine exist: salts of racemic amphetamine, dextroamphetamine, and methamphetamine. 

Methamphetamine has a much stronger effect on the CNS than the other two classes of amphetamine. 

Multiple slight chemical variants of amphetamine are referred to as “designer drugs,” which have psychoactive properties along with their stimulant properties. 

Another synthetic amphetamine derivative is methylenedioxymethamphetamine (MDMA, “ecstasy,” or “E”); it tends to have more calming effects than other amphetamine drugs. 

Marijuana and alcohol are commonly listed as additional drugs of abuse in those admitted for treatment of methamphetamine abuse. 

Cannabidiol, better known as CBD is the second most prevalent of the active ingredients of cannabis (marijuana); by itself, it does not cause a “high” like marijuana and to date, there is no evidence of abuse or dependence potential.   

Epidiolex is the first FDA cannabidiol product that is approved for seizure disorders. There are many CBD products available without a prescription, such as CBD oil.    

Cocaine also produces strong CNS stimulation and was originally classified as a narcotic. However, unlike opioid analgesics, cocaine does not normally induce a state of narcosis or stupor and is therefore more correctly categorized as a stimulant drug. 

Cocaine tends to give a temporary illusion of limitless power and energy but afterward leaves the user feeling depressed, edgy, and craving more. Crack is a smokable form of cocaine that has been chemically altered. Cocaine and crack are highly addictive. 

Stimulants work by releasing biogenic amines from their storage sites in the nerve terminals, primarily norepinephrine, resulting in stimulation of the CNS, as well as cardiovascular stimulation, increasing blood pressure and heart rate and possibly inducing cardiac dysrhythmias. 

The most common therapeutic use for stimulants is in treating attention deficit disorder or attention deficit hyperactivity disorder. Stimulants also are used in preventing or reversing fatigue and sleep (such as in narcolepsy) and in stimulating the respiratory center. 

CNS-related adverse effects, an extension of the therapeutic effects of stimulants, are restlessness, syncope (fainting), dizziness, tremor, hyperactive reflexes, talkativeness, tenseness, irritability, weakness, insomnia, fever, and sometimes euphoria. 

Death due to poisoning or toxic levels is usually a result of convulsions, coma, or cerebral hemorrhage and may occur during periods of intoxication or withdrawal. 

Signs and symptoms of CNS stimulant withdrawal include social isolation or withdrawal, psychomotor retardation, and hypersomnia. Signs and symptoms of CNS depressant withdrawal include increased psychomotor activity; agitation; muscular weakness; hyperthermia; diaphoresis; delirium; convulsions; elevated blood pressure, pulse rate, and temperature; and eyelid tremors. 

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Alcohol 

Alcohol, more accurately known as ethanol, causes CNS depression. A new hypothesis is that it causes local disordering in the lipid matrix of the brain, termed membrane fluidization. 

The therapeutic value of alcohol is extremely limited. Ethanol is an excellent solvent for many drugs and is commonly used as a vehicle for medicinal mixtures. When applied topically to the skin, ethanol acts as a coolant. Ethanol is the most popular skin disinfectant; however, isopropyl alcohol is most often used on the skin and is not drinkable. 

Long-term excessive ingestion of ethanol is associated with serious neurologic and mental disorders, such as seizures. Nutritional and vitamin deficiencies can result in Wernicke’s and nicotinic acid deficiency encephalopathy, Korsakoff’s psychosis, and polyneuritis. 

When consumed on a regular basis in large quantities, ethanol produces a constellation of dose-related negative effects such as alcoholic hepatitis or its progression to cirrhosis. 

Moderate amounts of ethanol may stimulate or depress respirations. Large amounts produce a dangerous or lethal depression of respiration. Although the circulatory effects of ethanol are relatively minor, acute severe alcoholic intoxication may cause cardiovascular depression. 

Teratogenic effects can be devastating and are caused by the direct action of ethanol, which inhibits embryonic cellular proliferation early in gestation. 

Alcohol can intensify the sedative effects of any medications that work in the CNS. 

Ethanol withdrawal produces varying degrees of signs and symptoms depending on the specific blood alcohol level. Delirium tremens are characterized by hypertensive crisis, tachycardia, and hyperthermia and may be life-threatening. 

Disulfiram (Antabuse), used in the treatment of alcoholism, works by altering the metabolism of alcohol. Patients know that if they are to avoid the devastating experience of acetaldehyde syndrome, they cannot drink for at least 3 or 4 days after taking disulfiram. 

The newest drug treatment indicated for alcoholism is acamprosate. It is used to maintain abstinence from alcohol in patients who are abstinent when starting the drug and who have additional psychosocial support. Its mechanism of action is not completely understood, but it may interact with glutamate and GABA receptors in the brain.

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Nicotine 

The medical significance of nicotine grows out of its toxicity, presence in tobacco, and propensity for eliciting dependence in its users. 

Smoking releases epinephrine, a hormone that creates physiologic stress in the smoker rather than relaxation; apparent calming effects may be related to increased deep breathing. 

Large doses of nicotine can produce tremors, convulsions, and respiratory stimulation. 

The cardiovascular effects of nicotine are an increase in heart rate and blood pressure. The effects of nicotine on the gastrointestinal system are largely due to parasympathetic stimulation, which results in increased tone and motor activity of the bowel and vomiting. 

The use of tobacco is addictive; most users develop tolerance and need greater amounts. Smokers become physically and psychologically dependent and will suffer withdrawal. 

Smoking cessation leads to nicotine withdrawal. An often-overlooked problem in hospitalized patients is nicotine withdrawal, which manifests as irritability, restlessness, and a decrease in heart rate and blood pressure. 

Many young people have turned from cigarettes to the use of electronic cigarettes, which is an electronic device that simulates smoking. Instead of smoke, it produces vapors, hence the term “vaping.” Serious lung injuries, including death, have been reported in people using e-cigarettes. 

Nicotine formulated into drug products may reduce cravings and promote smoking cessation. 

Varenicline (Chantix) is the newest drug indicated for smoking cessation; it has shown better efficacy than bupropion. 

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Nursing Process 

Assessment 

The purpose of a substance abuse assessment is to determine whether substance abuse exists, to evaluate the relationship between the abuse and other health concerns, and to begin the implementation of an effective health promotion and health restoration plan. 

Question all patients about the use and misuse of substances because addiction may be encountered in all clinical specialties. Abuse and misuse of substances or prescription medications may need to be assessed by other family members as well. 

A thorough and nonjudgmental patient assessment and history must include specific questions about the substance(s), duration of abuse, related physical and mental health concerns, and withdrawal. 

Valid and reliable assessment tools are available to nurses and health care professionals for use with patients suspected of drug or substance abuse. The goal of screening for alcohol and other drug abuse or addiction is to identify patients who have or are at risk for developing alcohol or drug-related problems and to further engage them in discussion. 

Assessment of opioid abuse includes determination of the route being used for drug delivery since intravenous drug use may cause health concerns such as HIV/AIDS or hepatitis. 

Opioid withdrawal includes seeking the drug from more than one prescriber, mydriasis, rhinorrhea, diaphoresis, piloerection, lacrimation, diarrhea, insomnia, and elevated blood pressure and pulse rate. 

Assessment of CNS stimulant abuse requires careful questioning about and observation for adverse effects, toxicity, and withdrawal signs and symptoms. 

CNS stimulant withdrawal includes social isolation or withdrawal, psychomotor retardation, and hypersomnia. 

Abuse of CNS depressants is manifested by a decrease in vital signs and mental functioning; therefore, frequent monitoring of vital signs and neurologic status is needed for safe care. 

CNS depressant withdrawal includes increased psychomotor activity; agitation; muscular weakness; hyperthermia; diaphoresis; delirium; convulsions; elevated blood pressure, pulse rate, and temperature; and eyelid tremors. 

Ethanol withdrawal produces varying degrees of signs and symptoms depending on the specific blood alcohol level. Delirium tremens is characterized by hypertensive crisis, tachycardia, and hyperthermia and may be life-threatening. 

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Implementation 

The nurse helps to meet the patient’s basic needs and teaches the patient, family, and/or significant others about addiction and its effect on the entire family. 

Nursing interventions involve maximizing all of the therapeutic plans and minimizing those factors contributing to the abusive behaviors. 

Substance withdrawal is treated with a multimodal approach that includes pharmacologic and nonpharmacologic interventions. 

The family will also be in need of treatment and therapeutic support; the caring, empathic, supportive, and educative responses by nurses will convey acceptance to the patient and family and help in the overall process of recovery and rehabilitation. 

Evaluation 

Patient safety is of utmost importance when the patient is experiencing signs and symptoms of withdrawal. Patients may enter life-threatening situations within a period of a day or two. 

Evaluation of the recovery and rehabilitation process is important, including monitoring of the therapeutic effects of the treatment regimen and monitoring for any physiologic and/or psychological ill effects from the withdrawal of the abused substance.

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Nutritional Supplements

Anatomy, Physiology, and Pathophysiology Overview  

Nutrients are dietary products that undergo chemical changes when metabolized that cause tissue to be enhanced and energy to be liberated. Nutrients are required for cell growth and division; enzyme activity; protein, carbohydrate, and fat synthesis; muscle contraction; secretion of hormones; wound repair; immune competence; gut integrity; and numerous other essential cellular functions. Providing these nutritional needs is known as nutritional support. 

Malnutrition is a condition in which the body’s essential need for nutrients is not met by nutrient intake. The purpose of nutritional support is the successful prevention, recognition, and management of malnutrition. 

The purpose of nutritional supplements is to promote anabolism (tissue building), nitrogen balance, and maintenance or improvement of body weight. 

Nutritional supplements are dietary products used to provide nutritional support. 

Enteral nutrition is the provision of food or nutrients via the gastrointestinal (GI) tract. 

Parenteral nutrition is the intravenous administration of nutrients. Its purpose is to promote anabolism (tissue building), nitrogen balance, and maintenance or improvement of body weight. It is used when the oral or enteral feeding routes cannot be used.

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Pharmacology Overview  

Enteral Nutrition 

The most common and least invasive route of administration for enteral nutrition is oral consumption. A feeding tube is used in the other five enteral routes. 

Patients who may benefit from feeding tube delivery of nutritional supplements include those with abnormal esophageal or stomach peristalsis, altered anatomy secondary to surgery, depressed consciousness, or impaired digestive capacity. The enteral route is considered to be the superior route of administration. 

Various enteral feeding formulations with different nutritional content are available, including some that are lactose-free. Different combinations and amounts of these nutrients are used based on the individual patient’s anabolic needs. 

Enteral nutrition can be used to supplement an oral diet that is insufficient for a patient’s nutrient needs or used alone to meet all of the patient’s nutrient needs. It supplies complete dietary needs through the GI tract by the normal oral route or by feeding tube. 

The most common adverse effect of nutritional supplements is GI intolerance, manifesting as diarrhea. Infant nutritional formulations are most commonly associated with allergies and digestive intolerance. Other supplements are associated with osmotic diarrhea. 

Rapid feeding or bolus doses can result in dumping syndrome, which produces intestinal disturbances. Tube feeding increases the risk of aspiration pneumonia. This is especially true in patients in whom mental status, gag reflexes, and general mobility are compromised. 

The enteral formulation groups are elemental, polymeric, modular, and altered amino acids. 

Elemental formulations contain dipeptides, tripeptides, or crystalline amino acids. Minimal digestion is required with these. They are indicated for pancreatitis, partial bowel obstruction, irritable bowel disease, radiation enteritis, bowel fistulas, and short bowel syndrome. 

Polymeric formulations contain complex nutrients derived from proteins, carbohydrates, and fat. Polymeric formulations are some of the most commonly used enteral formulations because they most closely resemble normal dietary intake. They are preferred over elemental formulations if patients have fully functional GI tracts and no specialized nutrient needs. 

The most commonly used enteral supplement in the polymeric formulation category of enteral nutrition products is Ensure. 

Moducal and Polycose are examples of commonly used enteral supplements in the carbohydrate modular formulation category that supply carbohydrates only. They are used in addition to monomeric or polymeric formulations to provide more specialized nutrient mixes. 

Microlipid and MCT Oil are the formulations available in the fat category of modular formulations. Microlipid is a fat supplement supplying only fats. These drugs help individualize nutrient formulations. They may be used in malabsorption, pancreatitis, and other GI disorders. 

Prosource TF and ProMod are examples of protein modular formulations and are used to increase patients’ protein intake and provide additional proteins. They are used to increase patients’ protein intake and are derived from whey, casein, egg whites, and amino acids. 

Specialized amino acid formulations are used most commonly in patients who have metabolic disorders such as phenylketonuria, homocystinuria, and maple syrup urine disease. They are also used to supply nutritional support to patients with illnesses such as renal impairment, eclampsia, heart failure, or liver failure.

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Parenteral Nutrition 

Parenteral nutrition (PN) supplementation (intravenously administered) is total parenteral nutrition (TPN) or hyperalimentation. PN or TPN may be administered through a central vein or through a peripheral vein (PPN). 

Parenteral nutritional supplementation (also called total parenteral nutrition [TPN] or hyperalimentation; intravenous administration) is the preferred method for patients who are unable to tolerate and/or maintain adequate enteral or oral intake. Vitamins, minerals, amino acids, dextrose, and lipids are administered intravenously directly into the circulatory system. This bypasses the entire GI system, which eliminates the need for absorption, metabolism, and excretion.  

TPN is administered through a central venous catheter because of the hyperosmolarity of the substances used and the need for dilution provided by a larger-diameter vein to prevent damage to the vein. 

Parenteral nutrition given through a peripherally inserted central catheter (PPN) line is another option but uses a solution with a lower concentration of dextrose and other ingredients. 

PPN is used to administer nutrients to patients who need more nutrients than their current oral intake can supply or to provide complete daily nutrition. It is meant only as a temporary means (less than 2 weeks) of delivering TPN. Long-term administration may cause phlebitis. 

PPN is limited to solutions with a lower dextrose concentration, generally less than 10%, to avoid sclerosing of the vein. Thus, large volumes are needed to meet daily requirements. 

In central TPN, a large central vein, such as the subclavian or internal jugular vein, is used to deliver nutrients directly into the patient’s circulation. Central TPN is used when nutritional supplements are required for longer than 7 to 10 days and can be used in the home setting. 

With central TPN, there is a greater potential for infection, more serious catheter-induced trauma and related events, metabolic alterations, and other technical or mechanical problems than with PPN. 

Rarely, a patient who is allergic to eggs may have cross-sensitivity to lipid formulations. TPN is used only when the GI tract cannot be used. 

Parenteral feedings may result in air embolism, fever, infection, fluid volume overload, hyperglycemia, or hypoglycemia. If they are discontinued abruptly, rebound hypoglycemia may result. 

The risks associated with the insertion of the infusion line, as well as the use and maintenance of the central vein for the administration of TPN, can create some complications. The most devastating adverse effect is phlebitis.

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Nursing Process 

Conduct a thorough nursing history and survey of all systems, including questions about any unusual symptoms, possible nutritional concerns, nausea, vomiting, loss of appetite, and weight gain or loss. Of most concern is assessing the patient’s cardiac and renal status and ensuring that the ingredients and the amount of solution are not too taxing on these systems. 

A thorough nutritional assessment and possible consultation with a registered dietitian or nutritionist are essential for adequate intervention for the malnourished patient. 

Consultation with a registered dietitian is crucial to identify the nutrients that are missing in a particular patient’s diet. Total body metabolic rate, body mass index, muscle mass, and other variables linked to nutritional status are assessed. 

Because these are given orally, either by mouth or via tube feedings, it is most important to assess the ability to swallow, gag reflex, and bowel sounds, and to note any nausea or vomiting. 

Protein-based formulations are avoided in patients with allergies to egg whites and whey. 

Parenteral feedings may result in air embolism, emboli related to protein or lipid aggregation (associated with central catheter intravenous lines), pneumothorax, fever, infection, septicemia related to the nutrient-rich solutions and invasive intravenous route of administration, fluid volume overload, metabolic imbalances due to the solution ingredients, vomiting (seen with lipid administration in the parenteral nutrition), hyperglycemia, or hypoglycemia. If they are discontinued abruptly, rebound hypoglycemia may result. 

Assess parenteral nutrition infusions every hour or per the facility’s policies and procedures. 

With tube feeding solutions, check for proper placement and detect gastric residuals to ensure that the tube is in the stomach and to avoid aspiration and other complications. 

Newer tubes for nasogastric and other enteral feeding have smaller diameters and are thinner (5 French to 10 French) and more pliable for better patient tolerance. However, the smaller-diameter tubes make checking for gastric aspiration more difficult. 

Although more rapid feeding increases the risk for hyperglycemia, dumping syndrome, and diarrhea continue to increase the patient’s intake because the total volume and number of calories to achieve recommended daily allowances are very important. 

Keep tube feeding formulas at room temperature, and never administer cold or warm. 

Enteral feedings can interact with quinolone and tetracycline antibiotics, and phenytoin and need to be separated by 2 hours. 

Check the patient frequently for signs and symptoms of hyperglycemia, such as polydipsia (excessive thirst), polyuria (excessive urination), polyphagia (excessive hunger), headache, dehydration, nausea, vomiting, and weakness. Never accelerate these infusion rates to increase plasma volume, because the rapid increase in the amount of dextrose solution may precipitate hyperglycemia and other related complications. 

Insulin replacement may be needed with the increase in dextrose; therefore, measure serum glucose levels by glucometer so that hyperglycemia may be recognized and treated. 

Hypoglycemia associated with parenteral nutrition may be prevented by a gradual reduction of the intravenous feeding rate to allow the pancreas time to adapt to the changing blood glucose levels. If parenteral nutrition is discontinued abruptly, rebound hypoglycemia may occur. This can be prevented by providing infusions of 5% to 10% glucose in situations in which parenteral nutrition must be discontinued immediately. 

Therapeutic responses to nutritional supplementation include improved well-being, energy, strength, and performance of activities of daily living; an increase in weight; and laboratory test results that reflect an improved nutritional status. Cautious and skillful nursing care may prevent or decrease the occurrence of complications associated with enteral or parenteral nutritional supplementation.

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Fluids and Electrolytes

Anatomy, Physiology, and Pathophysiology Overview 

Understanding fluid and electrolyte management requires knowledge of the extent and composition of the various body fluid compartments. 

Approximately 60% of the adult human body is water, distributed in the following proportions: intracellular fluid 67%; interstitial fluid 25%; and plasma volume 8%. 

Total body water (TBW) is divided into intracellular and extracellular compartments. Fluid volume outside the cells is either in the plasma or between the tissues, cells, or organs. 

Intravascular fluid describes the fluid inside the blood vessels, and extravascular fluid refers to the fluid outside the blood vessels. 

Plasma or serum is the fluid that flows through the blood vessels (intravascular fluid). The interstitial fluid (ISF) is the fluid that is in the space between cells, tissues, and organs. 

There is one big difference between the plasma and the ISF. Plasma has a protein concentration (primarily albumin) four times greater than that of the ISF. Protein solutes have a large molecular weight, making them too large to pass through the walls of blood vessels. 

Protein in the vessels exerts a constant osmotic pressure that prevents the leakage of too much plasma through the capillaries into the tissues. This is called colloid oncotic pressure and normally it is 24 mmHg. The opposing pressure exerted by the interstitial fluid is called hydrostatic pressure and normally it is 17 mmHg—less than the colloid oncotic pressure. 

Dehydration leads to a disturbance in the balance between the amount of fluid in the extracellular compartment and that in the intracellular compartment. Dehydration may be hypotonic, resulting from the loss of salt; hypertonic, resulting from fever with perspiration; or isotonic, resulting from diarrhea or vomiting. Each form of dehydration is treated differently. Carefully assess intake and output as well as skin turgor, urine specific gravity, and blood levels of potassium, sodium, and chloride. 

Death often occurs when 20% to 25% of TBW is lost. 

Acid-base balance is also important to normal bodily functions and is regulated by the respiratory system and the kidney.

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Pharmacology Overview

Crystalloids 

The choice of whether to use a crystalloid or a colloid depends on the patient’s condition. 

Crystalloids are fluids given by intravenous (IV) injection that supply water and sodium to maintain the osmotic gradient between the extravascular and intravascular compartments. 

Crystalloid solutions contain fluids and electrolytes that are normally found in the body but do not contain proteins. The administration of large quantities of crystalloid solutions for fluid resuscitation decreases the colloid oncotic pressure via a dilutional effect. They can leak from the plasma into the tissues and cells, resulting in edema anywhere in the body. 

Crystalloids are distributed faster into the interstitial and intracellular compartments than colloids, making them better for treating dehydration than for expanding the plasma volume. 

Crystalloid solutions are most commonly used as maintenance fluids to compensate for insensible fluid losses, replace fluids, and manage specific fluid and electrolyte disturbances. Crystalloids also promote urinary flow and are less expensive. 

Hypertonic solutions must be used very cautiously and given slowly because of the risk of hypervolemia from overzealous replacement. 

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Colloids 

Colloids are large protein particles that increase the colloid oncotic pressure and cannot leak from the blood vessels. They are naturally occurring and consist of proteins (albumin), carbohydrates (dextrans or starches), fats (lipid emulsion), and animal collagen (gelatin). 

The total protein level must be in the range of 7.4 g/dL. If this level falls below 5.3 g/dL, fluid shifts from blood vessels into the tissues. 

Colloid oncotic pressure decreases with age and with hypotension and malnutrition. 

The mechanism of action of colloids is related to their ability to increase the colloid oncotic pressure. Colloids increase the blood volume and are sometimes called plasma expanders. 

Clinically, colloids are superior to crystalloids because of their ability to maintain the plasma volume for a longer time. They can maintain the colloid oncotic pressure for several hours. 

Colloids are relatively safe agents, although they have no oxygen-carrying ability and contain no clotting factors, unlike blood products. Because of this, they can alter the coagulation system through a dilutional effect, which results in impaired coagulation and possibly bleeding. They may also dilute the plasma protein concentration, which in turn may impair platelet function. Rarely, dextran therapy can cause anaphylaxis or renal failure. 

The three most commonly used colloids are 5% albumin, dextran 40, and hetastarch. They all have a very rapid onset of action as well as a long duration of action.

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Blood Products 

The mechanism of action of blood products is related to their ability to increase the colloid oncotic pressure, and hence the plasma volume. Blood products are the only fluids that are able to carry oxygen because they are the only fluids that contain hemoglobin. Patients will hopefully begin to show improved energy and increasing tolerance for activities of daily living as a result of the treatments with blood products. Pulse oximeter readings will also show improved readings. 

Blood products are used to treat a wide variety of clinical conditions; the blood product used depends on the specific indication. 

Because there is a risk for the transfer of infectious disease, although remote, their use needs to be based on careful clinical evaluation of the patient’s condition. 

Because these products come from other humans, they can be incompatible with the recipient’s immune system. They can also transmit pathogens from the donor to the recipient. 

Blood products can be administered with normal saline only.

Physiology of Electrolyte Balance 

The principal electrolytes in the extracellular fluid are sodium cations (Na+) and chloride anions (Cl–). The major electrolyte in the intracellular fluid (ICF) is the potassium cation (K+). Other important electrolytes are calcium, magnesium, and phosphorus. 

Electrolytes are controlled by the renin-angiotensin-aldosterone system, antidiuretic hormone system, and sympathetic nervous system. When these neuroendocrine systems are out of balance, adverse electrolyte imbalances commonly result. Patients who receive diuretics are at risk of electrolyte abnormalities. 

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Potassium 

Hyperkalemia is defined as a serum potassium level exceeding 5.5 mEq/L. Symptoms include muscle weakness, paresthesia, paralysis, cardiac rhythm irregularities that can result in ventricular fibrillation, and cardiac arrest. 

Hypokalemia is defined as a serum potassium level of less than 3.5 mEq/L. 

Early symptoms of hypokalemia include hypotension, lethargy, mental confusion, nausea, and muscle weakness. Late symptoms include cardiac dysrhythmias (the patient may feel palpitations or shortness of breath), neuropathies, and paralytic ileus. 

A number of life-sustaining physiologic functions require potassium. Muscle contraction, the transmission of nerve impulses, and the regulation of heartbeats are a few. 

Potassium is also essential for the maintenance of acid-base balance, isotonicity, and the electrodynamic characteristics of the cell. It plays a role in many enzymatic reactions and is essential in gastric secretion, renal function, tissue synthesis, and carbohydrate metabolism. 

Potassium replacement therapy is indicated in the treatment or prevention of potassium depletion in patients whenever dietary measures prove inadequate. Potassium salts used for this purpose include potassium chloride, potassium phosphate, and potassium acetate. 

The adverse effects of oral potassium are primarily limited to the gastrointestinal (GI) tract, including diarrhea, nausea, and vomiting. GI bleeding and ulceration are more significant. 

The parenteral administration of potassium usually produces pain at the injection site. 

Intravenous potassium is identified as a high-alert drug because of the serious toxicity that can occur when potassium is given intravenously. 

IV potassium can be given no faster than 10 mEq/hour in unmonitored patients. 

Patiromer (Veltassa) is a newer oral drug indicated for hyperkalemia. It is a non-absorbed cation exchange polymer that increases fecal potassium excretion and ultimately reduces serum potassium levels. 

Patiromer has a black box warning regarding the decreased absorption of many oral medications.  

Sodium Zirconium Cyclosillicate (Lokelma) is another option to treat hyperkalemia. It is available orally and is not to be used for emergency treatment of hyperkalemia because it has a delayed onset of action.

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Sodium 

Sodium is the major cation in extracellular fluid and is involved in the control of water distribution, fluid and electrolyte balance, and osmotic pressure of body fluids. Sodium also participates along with both chloride and bicarbonate in the regulation of acid-base balance. 

Hyponatremia is a condition of sodium loss or deficiency and occurs when the serum levels decrease to less than 135 mEq/L. Hyponatremia is manifested by lethargy, hypotension, stomach cramps, vomiting, diarrhea, and seizures. 

Osmotic demyelination syndrome (previously called central pontine myelinolysis) may occur when there is rapid correction of chronic hyponatremia. 

Hypernatremia is the condition of sodium excess and occurs when the serum levels of sodium exceed 145 mEq/L. Hypernatremia is associated with symptoms of water retention but can be associated with normal fluid or even low fluid volume. Hypernatremia symptoms include edema, hypertension, red, flushed skin; dry, sticky mucous membranes; increased thirst; temperature elevation; and decreased or absent urination. 

Sodium is primarily administered for the treatment or prevention of sodium depletion when dietary measures have proved inadequate. Sodium chloride is used for this purpose. 

Hypertonic saline (3% NaCl), sometimes used for severe hyponatremia, is a high-risk treatment because if it is given rapidly or at too high a dose it can cause central pontine myelinolysis (osmotic demyelination syndrome) that can lead to irreversible brainstem damage. 

The oral administration of sodium chloride can cause gastric upset consisting of nausea, vomiting, and cramps. 

Drugs for the treatment of euvolemic (normal fluid volume) hyponatremia include the dual arginine vasopressin (AVP) V1A and V2 receptor antagonists. These drugs are conivaptan (Vaprisol) and tolvaptan (Samsca) (vaptans). 

Conivaptan (Vaprisol) is a nonpeptide dual arginine vasopressin (AVP) V1A and V2 receptor antagonist that inhibits the effects of AVP, also known as antidiuretic hormone, on receptors in the kidneys. It is indicated for the treatment of hospitalized patients with euvolemic hyponatremia, or low serum sodium levels at normal water volumes. 

Tolvaptan has a black box warning stating that the patient must be in a hospital where sodium levels can be closely monitored when starting therapy.

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Nursing Process 

Before administering a fluid and/or electrolyte solution, complete a thorough physical assessment as well as a review of the medications/solutions prescribed. 

Assess the patient’s medical history, including diseases of the GI, renal, cardiac, and/or hepatic systems. 

Assess fluid volume and electrolyte status (through laboratory testing and measurement of urinary specific gravity, vital signs, and intake and output) and document the findings. 

Confirm orders with authoritative resources or by speaking with a pharmacist. 

After verifying all prescriber orders, assess the solution or product, the patient, and the IV site. Assess the following for IV infusions of fluids and/or electrolytes: the solution to be infused, infusion equipment, the infusion rate of the solution, the concentration of the parenteral solution, related mathematical calculations, laboratory values (e.g., sodium, chloride, potassium), and parenteral compatibilities. 

Remember that you are responsible for making sure that the drug therapy administration process—beginning with the assessment phase of the nursing process and through to evaluation—is accurate and safe and meets professional standards of care. 

Each form of dehydration is treated differently. Carefully assess intake and output as well as skin turgor, urine specific gravity, and blood levels of potassium, sodium, and chloride. 

Hydrating and hypotonic solutions include 0.25% NaCl and 0.45% NaCl/D5W. 

Isotonic solutions (e.g., 0.9% NaCl [normal saline] and lactated Ringer’s solution) are used to augment extracellular volume in patients experiencing blood loss and/or severe vomiting. 

Hypertonic solutions (e.g., 3% or 5% sodium chloride) are used for replacement of fluids and electrolytes in specific situations. 

The skin and mucous membranes also reflect a patient’s hydration status; assess skin turgor and/or rebound elasticity of skin over the top of the hand and other areas over the body. Document the findings as “immediate” rebound or “delayed” rebound. Count the number of seconds that the patient’s skin stays in the pinched-up position, with the normal return being immediately or within 3 to 5 seconds. 

Administer albumin with caution because of the high risk of hypervolemia and possible heart failure. Monitor intake and output, weights, heart and breath sounds, and lab values. 

Venous access is an issue with parenteral potassium supplementation because the vein can be irritated if infiltration occurs or if the solution has not been mixed thoroughly. 

During the infusion of blood components, constantly assess for the occurrence of fever and blood in the urine, both being indicative of a reaction requiring immediate attention. 

During replacement therapy, serum electrolyte levels need to remain within normal ranges and not exceed these ranges. 

With parenteral dosing, monitor infusion rates as well as the appearance of the fluid or solution; potassium and saline solutions are clear and albumin is brown, clear, and viscous. 

Frequently monitor the IV site for evidence of infiltration. 

Remember that elderly and/or pediatric patients have an increased sensitivity to these solutions and fluids. 

For the patient who is at risk for hypokalemia, provide educational materials and patient teaching to encourage the consumption of certain foods high in potassium. 

Early symptoms of hypokalemia include hypotension, lethargy, mental confusion, nausea, and muscle weakness. Late symptoms include cardiac dysrhythmias (the patient may feel palpitations or shortness of breath), neuropathies, and paralytic ileus. 

Symptoms of hyperkalemia include muscle weakness, paresthesia, paralysis, and cardiac rhythm abnormalities. 

Hyperkalemia is treated with sodium polystyrene sulfonate (Kayexalate). It is used only under very specific situations and under very close monitoring of the patient and his or her serum potassium, sodium, calcium, and magnesium levels. 

Patiromer (Veltassa), a new drug, is indicated for the treatment of hyperkalemia. Because of altering the absorption of other oral medications, patiromer is not to be given six hours before or after other oral medications. Patiromer needs to be diluted and given with food. 

Potassium is never given by IV push or IV bolus or in an undiluted form. Potassium administered in this manner is associated with cardiac arrest. 

Always carry out IV infusion of albumin and other colloids slowly and cautiously, and carefully monitor the patient to prevent fluid overload and potential heart failure. 

With administration of blood products, measurement of vital signs, and frequent monitoring of the patient before, during, and after infusions are critical to patient safety. 

Blood products must be given only with normal saline (0.9% sodium chloride). The solution of D5W results in the hemolysis of red blood cells if infused together. 

A transfusion reaction may include apprehension, restlessness, flushed skin, increased pulse and respirations, dyspnea, rash, joint or lower back pain, swelling, fever, chills (a febrile reaction beginning 1 hour after the start of the administration and possibly lasting up to 10 hours), nausea, weakness, and jaundice. 

Encourage patients receiving any type of fluid or electrolyte substance, colloid, or blood component to immediately report unusual adverse effects to their prescriber, including chest pain, dizziness, weakness, and shortness of breath. 

The therapeutic response to fluid, electrolyte, and blood or blood component therapy includes normalization of fluid volume and laboratory values, including RBC and WBC counts, hemoglobin level, hematocrit, and sodium and potassium levels. 

Frequently monitor for adverse effects of any of these drugs and/or solutions, and check for distended neck veins; shortness of breath; anxiety; insomnia; expiratory crackles; frothy, blood-tinged sputum; and cyanosis (indicative of fluid volume overload). 

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Psychotherapeutic Drugs

Anatomy, Physiology, and Pathophysiology Overview

The treatment of mental disorders is called psychotherapeutics.

Long-term pharmacotherapy in conjunction with psychotherapy is recommended when emotions or behaviors compromise the quality of life, ability to carry out normal activities of daily living, social functioning, or occupational functioning over a prolonged period.

In the biochemical imbalance theory, mental disorders are thought to arise as the result of abnormal levels of endogenous chemicals in the brain known as

Drugs used to treat mental illnesses, including anxiety, affective disorders, and psychoses, work by blocking or stimulating the release of various endogenous neurotransmitters.

Patients with mental illness are at greater risk for physical illnesses associated with obesity, including diabetes, hypertension, and heart disease.

Economic, educational, and psychosocial issues may preclude a mentally ill person from seeking psychiatric health care, resulting in self-medication with substances of abuse, including alcohol, tobacco, and illegal or unauthorized prescription drugs.

Ideal mental health care involves many components, including a carefully detailed patient interview and carefully chosen and regularly monitored drug therapy.

Nonpharmacologic treatments include psychotherapy, support groups, social and family support systems, and often spiritual support systems.

There are three common types of mental illness: anxiety, affective, and psychotic disorders. The drugs used to treat anxiety are anxiolytics. Mood stabilizers and antidepressants are used to treat affective disorders, while antipsychotics are used to treat psychotic disorders.

Psychosis is a major emotional disorder that impairs mental function. A person experiencing psychosis cannot participate in everyday life and shows a loss of contact with reality.

Affective disorders are emotional disorders characterized by changes in mood. They range from mania to depression and include anxiety, a normal emotion that may be a healthy reaction but becomes pathologic when it is life-altering.

Anxiety disorders occur in approximately 18.1% of the adult population in the US.

Obsessive-compulsive disorder is twice as common as schizophrenia or panic disorders in the general population.

Situational anxiety arises in response to specific life events, and nursing assessment is key to identifying patients at risk.

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Pharmacology Overview

Psychotropic drugs are among the most commonly prescribed drugs in the United States.

The effectiveness of drug therapy is often measured by verbal reports from patients regarding the level of improvement (if any) in their social and occupational functioning.

Nonadherence to the prescribed regimen is common as patients may remain in denial about the reality of their mental illness, including the need to take psychotropic medications.

Anxiolytic Drugs

Primary anxiolytic drugs include the benzodiazepine drug class and the miscellaneous drug buspirone. The benzodiazepines are commonly used as first-line drug therapy for both acute and chronic anxiety disorders.

Other drugs that are effective as anxiolytics include selective serotonin reuptake inhibitors (SSRIs), tricyclic antidepressants (TCAs), monoamine oxidase inhibitors (MAOIs), antipsychotics, and the antihistamine hydroxyzine.

All anxiolytic drugs decrease anxiety by reducing overactivity in the central nervous system (CNS).

Benzodiazepines are the largest and most commonly prescribed anxiolytic drug class because they offer several advantages over other drugs used to treat anxiety.

Benzodiazepines exert their effect by depressing activity in areas of the brain when they increase the action of gamma-aminobutyric acid (GABA), which is an inhibitory neurotransmitter in the brain that blocks nerve transmission in the CNS.

The most common undesirable effect is overexpression of their therapeutic effects, in particular CNS depression. Benzodiazepines can also cause hypotension.

Elderly patients tend to be more sensitive to the sedating effects of benzodiazepines, which can increase their risk for falls; lower doses are usually needed.

When benzodiazepines are taken alone, an overdose is generally not life-threatening. When they are combined with alcohol or other CNS depressants, the outcome is much more severe.

Buspirone (BuSpar) is an anxiolytic drug that is different from benzodiazepines; it appears to have agonist activity at both serotonin and dopamine receptors.

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Affective Disorders

Mood-Stabilizing Drugs

Mood stabilizers are drugs used to treat bipolar illness. Catecholamines play an important role in the development of mania; serotonin also appears to be involved.

Lithium has been in use for many years and is still used to effectively alleviate the symptoms of acute mania in bipolar disorder as well as for maintenance therapy to prevent episodes.

When taking lithium, patients need to maintain their sodium intake and not change it dramatically.

A new antipsychotic, cariprazine (Vraylar), was approved in 2016 for the treatment of bipolar disorder.

A variety of medications may be used in conjunction with lithium to regulate mood or achieve stability, including benzodiazepines, antipsychotic drugs, antiepileptic drugs, and dopamine receptor agonists.

Antidepressant Drugs

Antidepressants are the pharmacologic treatment of choice for major depressive disorders. They are also useful in treating other disorders, such as dysthymia, schizophrenia, eating disorders, and personality disorders.

Some of the antidepressants are also used in the treatment of various medical conditions, including migraine headaches, chronic pain syndromes, sleep disorders, premenstrual syndrome, and hot flashes associated with menopause.

Many drugs used to treat affective disorders increase the levels of neurotransmitter concentrations in the CNS, including serotonin, dopamine, and norepinephrine.

The permissive hypothesis led to the creation of the selective SSRI drug class. The permissive theory postulates that reduced concentrations of serotonin are the predisposing factor in patients with affective disorders. Depression results from decreases in both the serotonin and catecholamine levels, whereas mania results from increased dopamine and norepinephrine levels but decreased serotonin.

Anxiety and depression commonly occur together, so there is much crossover in symptom control between antidepressant and anxiolytic drugs.

A nonresponse to antidepressant drug therapy is defined as failure to respond to at least 6 weeks of therapy with adequate drug dosages. Twenty percent to 30% of patients who do not respond to the usual dosage of an antidepressant will respond to higher dosages.

In 2005, the Food and Drug Administration (FDA) issued special black box warnings for all classes of antidepressants in both adult and pediatric patient populations; data indicated a higher risk for suicide in patients receiving these medications.

Current recommendations for all patients receiving antidepressants include regular monitoring for signs of worsening depressive symptoms, especially when the medication is started or the dosage is changed.

Tricyclic Antidepressants

TCAs were the original first-generation antidepressants; their use has largely been replaced with SSRIs and serotonin-norepinephrine reuptake inhibitors.

The TCAs are considered second-line drug therapy in patients for whom the SSRIs are ineffective or as adjunct therapy with newer drugs.

Originally used to treat depression, currently, TCAs are most commonly used to treat neuropathic pain syndromes and insomnia.

Undesirable effects of TCAs are a result of their effects on various receptors.

Blockade of cholinergic receptors results in undesirable anticholinergic adverse effects, the most common being constipation and urinary retention.

TCA overdoses are notoriously lethal. It is estimated that 70% to 80% of patients who die of TCA overdose do so before reaching the hospital, especially if the drugs are taken with alcohol. The systems affected are the CNS and cardiovascular system.

Most TCAs are rated as pregnancy category D drugs, which makes their use by pregnant women relatively more hazardous than that of most of the newer drugs.

Monoamine Oxidase Inhibitors

MAOIs, along with TCAs, represent the first generation of antidepressant drug therapy; they are rarely used as antidepressants but are used to treat Parkinson’s disease.

MAOI use may cause a hypertensive crisis when taken with stimulant medications or with a substance containing tyramine, which is found in many common foods and beverages.

Clinical symptoms of MAOI overdose generally do not appear until about 12 hours after ingestion. The primary signs and symptoms are cardiovascular and neurologic. 

Second-Generation Antidepressants

The second-generation antidepressants include trazodone, bupropion, SSRIs (e.g., fluoxetine, sertraline, paroxetine), serotonin-norepinephrine reuptake inhibitors (e.g., venlafaxine), and miscellaneous drugs, nefazodone, and mirtazapine.

The inhibition of serotonin reuptake is the primary mechanism of action of the selective serotonin reuptake inhibitor (SSRIs).

SSRIs and SNRIs are often prescribed because of their superiority to older antidepressants.

The adverse effect profiles of second-generation antidepressants are associated with significantly fewer and less severe effects than TCAs and MAOIs.

Second-generation antidepressants take the same amount of time to reach maximum clinical effectiveness as do the TCAs and MAOIs—typically 4 to 6 weeks.

Although depression is the primary indication, the drugs have shown benefit in treating other mental and physical disorders, such as bipolar disorder, obesity, eating disorders, obsessive-compulsive disorder, panic attacks or disorders, social anxiety disorder, posttraumatic stress disorder, premenstrual dysphoric disorder, the neurologic disorder myoclonus, and various substance abuse problems such as alcoholism.

Some of the most common adverse effects are insomnia, weight gain, and sexual dysfunction, primarily related to the inability to achieve orgasm.

One potentially hazardous adverse effect of any drug or combination of drugs that have serotoninergic activity is known as serotonin syndrome.

SSRIs are associated with a discontinuation syndrome or withdrawal syndrome, and the drugs must be very slowly tapered. SSRIs with the shortest half-lives (citalopram, escitalopram, sertraline, paroxetine) are most commonly associated with discontinuation syndrome. Symptoms include flulike feeling, difficulty concentrating, faintness, and GI symptoms. While most commonly associated with SSRIs, it can occur with the SNRIs: venlafaxine, desvenlafaxine, duloxetine, milnacipran, and levomilnacipran.

To prevent potentially fatal pharmacodynamic interactions with the MAOIs, a 2- to 5-week washout period is recommended between the use of SSRIs and MAOIs.

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Nursing Process

Nursing considerations related to psychotherapeutic drugs include the need for skillful patient assessment with an emphasis on past and present medical history, physical examination, and a thorough medication history and profile as a comparative baseline for the patient during and after initiation of therapy.

Thoroughly assess the patient’s neurologic functioning, including level of consciousness, mental alertness, and level of motor and cognitive functioning.

The Mini-Mental State Examination (MMSE) is one tool that you may use to assess cognitive status and help identify impairments often found in mental illnesses.

Constantly assess the patient for any suicidal ideations or tendencies because of the potential for suicide, with or without the concurrent use of other medications or alcohol.

If an assessment reveals any concerns and/or the patient acknowledges suicidal thoughts, it is critical to share assessment findings with nursing staff so that an appropriate referral for immediate assessment and/or treatment may be initiated.

It is important to assess sleep habits and nutritional intake and to perform a head-to-toe physical examination for baseline and comparative purposes. Note any drug allergies as well as any contraindications, cautions, and potential drug interactions.

With psychotherapeutic drug therapy, assess the patient’s mouth and oral cavity to make sure the patient has swallowed the entire oral dosage. This helps to prevent hoarding or “cheeking” of medications, and noncompliance that may lead to drug toxicity or overdose.

All psychotherapeutic drugs are to be taken exactly as prescribed and at the same time every day and without failure. If omission occurs, contact the prescriber immediately. Abrupt withdrawal may have negative effects on the patient’s physical and mental status.

Patients taking psychotherapeutic drugs who have a history of cardiac disease may be at a greater risk for experiencing dysrhythmias, tachycardia, stroke, myocardial infarction, and/or heart failure.

Always provide a medication guide and instructions upon dispensing all psychotherapeutic medications.

Monitor the therapeutic effects of psychotherapeutic medications and the patient’s progress before and during drug therapy. Mental alertness, cognition, affect, mood, ability to carry out activities of daily living, appetite, and sleep patterns are all areas that need to be closely monitored and documented.

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Antiepileptic Drugs

Anatomy, Physiology, and Pathophysiology Overview 

Epilepsy is a disorder of the brain manifested as a chronic, recurrent pattern of seizures. It is the most common chronic neurologic illness, affecting 3 million people in the United States and 50 million people worldwide.

A seizure is a brief episode of abnormal electrical activity in the nerve cells of the brain.

A convulsion is a more severe seizure characterized by involuntary spasmodic contractions of any or all voluntary muscles throughout the body, including skeletal, facial, and ocular muscles. Commonly reported symptoms include abnormal motor function, loss of consciousness, altered sensory awareness, and psychic changes.

Seizures are classified as follows: partial-onset seizures or those originating in a more localized region of the brain; status epilepticus, characterized by generalized tonic-clonic convulsions that occur repeatedly in succession; and tonic-clonic seizures involving initial muscular contraction throughout the body (tonic) and progressing to alternating contraction and relaxation (clonic phase).

Generalized onset seizures, formerly called grand mal seizures, are characterized by neuronal activity that originates simultaneously in the gray matter of both hemispheres.

Tonic-clonic seizures begin with muscular contraction throughout the body (tonic phase) and progress to alternating contraction and relaxation (clonic phase).

Partial onset seizures originate in a localized or focal region (e.g., one lobe) of the brain.

In status epilepticus, multiple seizures occur with no recovery between them. If appropriate therapy is not prompt, hypotension, hypoxia, brain damage, and death can quickly ensue.

Excessive electrical discharges can often be detected by an electroencephalogram.

Fluctuations in the brain’s electrical potential are seen in the form of waves. These waves correlate well with different neurologic conditions and are used as diagnostic indicators.

Epilepsy without an identifiable cause is known as primary epilepsy or idiopathic epilepsy. Primary epilepsy accounts for roughly 50% of cases.

In other cases, epilepsy has a distinct cause, such as trauma, infection, cerebrovascular disorder, or other illness; this is known as secondary or symptomatic epilepsy.

The chief causes of secondary epilepsy in children and infants are developmental defects, metabolic disease, and injury at birth.

Febrile seizures occur in children 6 months to 5 years of age and are caused by fever. Children usually outgrow the tendency to have such seizures, and thus these seizures do not constitute a chronic illness.

In adults, acquired brain disorder is the major cause of secondary epilepsy; including head injury, disease or infection of the brain and spinal cord, stroke, metabolic disorders, and drug reactions.

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Pharmacology Overview

Antiepileptic drugs, also called antiepileptic drugs, are a more appropriate term because many of these medications are indicated for the management of all types of epilepsy, and not necessarily just convulsions.

Anticonvulsants, on the other hand, are medications that are used to prevent the convulsive seizures typically associated with epilepsy.

The goal of antiepileptic drug therapy is to control or prevent seizures while maintaining a reasonable quality of life. Approximately 70% of patients can expect to become seizure-free while taking only one drug.

Single-drug therapy must fail before multidrug therapy is attempted. The dosage of the medication is slowly increased until the seizures are controlled or until clinical toxicity occurs.

Therapeutic drug monitoring of serum drug concentrations provides a useful guideline in assessing the effectiveness of and adherence to therapy.

The antiepileptic drugs traditionally used to manage seizure disorders include barbiturates, hydantoins, and iminostilbenes, plus valproic acid.

Second- and third-generation antiepileptics are also available.

Newer approved drugs include perampanel (Fycompa,) ezogabine (Potiga), vigabatrin (Sabril), eslicarbazepine (Aptiom), clobazam (Onfi), and brivaracetam (Briviact). These drugs fall into the miscellaneous category of antiepileptics and have greatly expanded the options currently available to treat patients with seizure disorders.

Ezogabine (Potiga) is indicated for adjunctive therapy for partial-onset seizures and can cause potential vision loss and skin discoloration both of which may be permanent. The FDA recommends it be used only in patients who have not responded to other drugs.

Perampanel (Fycompa) is also indicated as adjunctive therapy for partial-onset seizures. It is associated with a high incidence of dizziness.

Vigabatrin (Sabril) is indicated for refractory complex partial seizures. It carries the risk of visual impairment and as such is only available through a restricted distribution program.

Eslicarbazepine (Aptiom) is indicated as adjunctive therapy for partial-onset seizures.

Clobazam (Onfi) is a benzodiazepine indicated as adjunctive therapy for Lennox-Gastault syndrome.

Brivaracetam (Briviact) is indicated for partial-onset seizures in patients 16 years and older.

The major pharmacologic effects of antiepileptics are threefold. First, they increase the threshold of activity in the area of the brain called the motor cortex. Second, they act to limit the spread of a seizure discharge from its origin by suppressing the transmission of impulses from one nerve to the next. Third, they can decrease the speed of nerve impulse conduction within a given neuron.

Antiepileptics are used for the long-term maintenance treatment of epilepsy. However, they are also useful for the acute treatment of status epilepticus.

The only usual contraindication to antiepileptics is known drug allergy. Pregnancy is also a common contraindication; however, the prescriber must consider the risks to the mother and infant of untreated maternal epilepsy and the increased risk of seizure activity. Many women take antiepileptics throughout their pregnancy. The newer-generation antiepileptic drugs appear to be safer in pregnancy than the traditional drugs.

Antiepileptic drugs have many adverse effects, which often limit their usefulness. Many patients cannot tolerate the adverse effects, and therapy must be withdrawn.

Birth defects in infants of epileptic mothers are higher than normal, regardless of whether the mother was receiving drug therapy.

In December 2008, the U.S. Food and Drug Administration (FDA) required black box warnings on all antiepileptic drugs regarding the risk of suicidal thoughts and behavior. Patients being treated with antiepileptic drugs for any indication need to be monitored for the emergence or worsening of depression, suicidal thoughts or behavior, or any unusual changes in mood or behavior.

For certain antiepileptic drugs, the safe and toxic levels are very close together; that is, they have a narrow therapeutic range.

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Nursing Process

With the use of any of the antiepileptic drugs, perform a thorough physical assessment and obtain a comprehensive health and medication history so that any possible allergies, drug interactions, adverse reactions, cautions, and contraindications can be identified.

You must be able to distinguish between the different types of seizures and assess and document all symptoms, events, and problems that occur before, during, and after any seizure activity. This information may aid in the diagnosis of the type of seizure the patient is experiencing.

Thoroughly review the patient’s medical history and note any type of seizure disorder, precipitating events, and the duration, frequency, and intensity of the seizure activity.

Before giving these drugs, review the laboratory test results, which may include the results of red blood cell and white blood cell counts, clotting studies, and renal and/or liver function studies.

If barbiturates have been ordered, carefully assess not only the neurologic system but also vital signs because of the central nervous system depression associated with this class of drugs.

In addition, identify patients at high risk for excessive sedation for safety purposes.

Interventions for patients taking antiepileptic drugs are aimed at monitoring the patient while providing safety measures and securing the airway, breathing, and circulation.

Airway maintenance is of critical importance for epileptic patients because the tongue relaxes during seizure activity, falling backward and subsequently blocking the airway.

Maintain the patient’s airway in the same way as during cardiopulmonary resuscitation, using the chin lift or jaw thrust method.

Distinguish between the different types of seizures and assess and document all symptoms, events, and problems that occur before, during, and after any seizure activity.

With antiepileptic drug administration, adhere closely to the drug dose and frequency of dosing, as ordered. Close monitoring of dosing is important to attain therapeutic blood levels. Administering the antiepileptic drug at the same time every day is also important to maintain blood levels.

Grapefruit or related citrus fruits or pomegranate juice needs to be avoided with carbamazepine (Tegretol).

The occurrence of a therapeutic response to antiepileptic drugs does not mean that the patient has been cured of the seizures but only that seizure activity is decreased or absent.

Thoroughly document any response to the medication in the medical record.

Noncompliance with the drug regimen is the most important factor leading to treatment failure.

Monitor therapeutic blood levels at all times, and avoid abrupt withdrawal of the antiepileptic drug to prevent rebound seizure activity.

Intravenous infusions of antiepileptic drugs are very dangerous and must be managed cautiously, with adherence to hospital or facility policy and manufacturer’s guidelines. Avoid rapid infusions because of the risk of cardiac and/or respiratory arrest.

Older adult patients may experience paradoxical reactions to antiepileptic drugs, resulting in hyperactivity and irritability versus sedation.

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Anti-Parkinson's

Anatomy, Physiology, and Pathophysiology Overview

Parkinson’s disease is a chronic, progressive, neurodegenerative disorder causing the degeneration of dopamine-producing neurons in the brain. Patients with this disease also have elevated acetylcholine levels and lowered dopamine levels.

Dopamine is an inhibitory neurotransmitter and acetylcholine is an excitatory neurotransmitter in this area of the brain. Parkinson’s disease results from an imbalance in these two neurotransmitters in the basal ganglia.

Parkinson’s disease affects at least 1 million Americans and 4 million people worldwide. Over 60,000 patients are diagnosed each year in the United States. It is the second most common neurodegenerative disease after Alzheimer’s disease.

There are no readily available laboratory tests that can detect or confirm Parkinson’s disease. The diagnosis is usually made on the basis of the classic symptoms and physical findings.

The classic symptoms of Parkinson’s disease include bradykinesia, postural instability, rigidity, and tremors (TRAP [tremor, rigidity, akinesia, postural instability] with akinesia really manifesting as bradykinesia).

Symptoms of Parkinson’s disease do not appear until approximately 80% of the dopamine stored in the substantia nigra has been deleted; thus, by the time the disease is diagnosed, only approximately 20% of the patient’s original dopaminergic terminals are functioning normally.

Rapid swings in the response to levodopa, called the on-off phenomenon, result in the worsening of the disease with too little dopamine or dyskinesias with too much.

In contrast, the wearing-off phenomenon occurs when anti–Parkinson’s disease medications begin to lose their effectiveness, despite maximal dosing, as the disease progresses.

Dyskinesia is the difficulty in performing voluntary movements and is commonly seen in the disease. Most frequent are chorea (irregular, spasmodic, involuntary movements of the limbs or facial muscles) and dystonia (abnormal muscle tone leading to impaired or abnormal movements). Dystonia commonly involves the head, neck, or feet and is a symptom common to patients with Parkinson’s disease.

Dyskinesias also occur as an adverse effect of some of the anti-Parkinson's drugs.

These motor complications make Parkinson’s disease a prominent cause of disability. Dementia may also result and is referred to as Parkinson’s disease-associated dementia.

Up to 40% of patients with Parkinson’s disease will experience psychosis and hallucinations. In 2016, a new drug, pimavanserin (Nuplazid), was approved for the treatment of hallucinations and delusions associated with Parkinson’s disease psychosis. Pimavanserin is a selective serotonin 5-HT2A inverse agonist and has no effect on dopaminergic receptors.

Treatment of the disease centers around drug therapy, but many experts believe that physical activity is as important as any drug therapy, and together these greatly improve mobility. For severe cases, the surgical technique of deep brain stimulation may be used.

Drug therapy is aimed at increasing the levels of dopamine and/or antagonizing the effects of acetylcholine. Drug therapy is used to slow the progression of symptoms.

Drugs used in the treatment of Parkinson’s disease include amantadine, benztropine, bromocriptine, carbidopa-levodopa, entacapone, ropinirole, and selegiline. They have a variety of mechanisms of action and many adverse effects, drug interactions, and dosing concerns.

As long as there are functioning nerve terminals that can take up dopamine, the symptoms of Parkinson’s disease can be at least partially controlled.

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Pharmacology Overview

Indirect-Acting Dopaminergic Drugs

Monoamine Oxidase Inhibitors

The primary role of monoamine oxidase (MAO) enzymes is the breakdown of catecholamines, such as dopamine, norepinephrine, and epinephrine, as well as serotonin.

Giving an MAO-B inhibitor such as selegiline or rasagiline causes an increase in the levels of dopaminergic stimulation in the central nervous system (CNS), helping to counter the dopaminergic deficiency.

Selegiline and rasagiline are adjunctive drugs currently approved for use in combination with carbidopa-levodopa when the response to levodopa is fluctuating; they may also be beneficial as prophylactic drugs to delay reduction in a patient’s response to levodopa. As Parkinson’s disease progresses, it becomes more difficult to manage it with levodopa, and ultimately the patient is seriously debilitated, generally 5 to 10 years after the start of therapy.

The newest drugs approved for “off” episodes include istradefyllins, (Nourianz) which is an adenosine receptor antagonist, and opicapone, which is a COMT inhibitor.

Dopamine Modulator

Only one drug—amantadine (Symmetrel)—is currently known to function as a dopamine modulator for the management of Parkinson’s disease.

Amantadine appears to work by causing the release of dopamine and other catecholamines from their storage sites and also blocks the reuptake of dopamine into the nerve fibers.

Because amantadine does not directly stimulate dopaminergic receptors, it is considered to be indirect acting. Amantadine also has some anticholinergic properties.

Amantadine is generally indicated in the early stages of Parkinson’s disease while there are still some intact neurons. It can be used in the moderate to advanced stages to help control symptoms of tremors but is usually effective for only 6 to 12 months.

Common adverse effects include dizziness, insomnia, and nausea. Amantadine causes increased anticholinergic adverse effects when given with anticholinergic drugs.

Catechol Ortho-Methyltransferase Inhibitors

Drugs in this category include entacapone (Comtan), tolcapone (Tasmar), and, most recently, opicapone (Ongentys), approved specifically as adjunctive treatment of "Off" episodes. 

Tolcapone acts both centrally and peripherally, whereas entacapone cannot cross the blood-brain barrier and therefore can act only peripherally. They prolong the duration of action of levodopa, especially when levodopa is given with carbidopa, resulting in the reduction of the wearing-off phenomenon.

Both catechol ortho-methyltransferase (COMT) inhibitors (tolcapone and entacapone) are contraindicated in cases of known drug allergy. Tolcapone is also contraindicated in cases of liver failure.

Tolcapone has been associated with severe liver failure and carries a black box warning related to hepatotoxicity.

Commonly reported adverse effects with both COMT inhibitors include gastrointestinal (GI) upset and urine discoloration. In addition, they also can worsen dyskinesia.

Neither tolcapone nor entacapone are to be taken with nonselective MAO inhibitors because of cardiovascular risk due to reduced catecholamine metabolism. However, the selective MAO-B inhibitor selegiline may be safely taken concurrently with COMT inhibitors.

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Direct-Acting Dopamine Receptor Agonists

Direct-acting dopamine receptor agonists are drugs used to treat Parkinson’s disease, often as first-line agents used on diagnosis. These drugs include two subclasses: nondopamine dopamine receptor agonists (NDDRAs) and dopamine replacement drugs.

All NDDRAs work by direct stimulation of presynaptic and/or postsynaptic dopamine receptors in the brain. They may be used in the early or late stages of the disease.

The traditional role of the NDDRAs bromocriptine, pramipexole, ropinirole, and rotigotine has been as adjuncts to levodopa for the management of motor fluctuations; however, they are now often used as first-line therapy.

Known allergy is a contraindication to dopaminergic drug therapy. These drugs are not to be used concurrently with catecholamines due to the cardiovascular risks.

The traditional cornerstone of therapy for Parkinson’s disease has been the drug levodopa, the biological precursor of dopamine. Dopamine must be administered orally as levodopa because exogenously administered dopamine cannot pass through the blood-brain barrier. Levodopa cannot be used by itself in the brain and must be combined with another substance, carbidopa. The combination product carbidopa-levodopa provides exogenous sources of dopamine and is the drug of choice in the later stages of Parkinson’s disease.

Large doses result in high peripheral levels of dopamine and lead to many unwanted adverse effects, including confusion, involuntary movements, GI distress, hypotension, and even cardiac dysrhythmias. These problems are avoided when levodopa is given with carbidopa.

Levodopa and carbidopa are both contraindicated in cases of angle-closure glaucoma because they can raise intraocular pressure, but they may be used cautiously in open-angle glaucoma. Neither drug is to be used in patients with any undiagnosed skin condition, because both drugs can activate malignant melanoma.

Adverse effects of dopamine replacement drugs include cardiac dysrhythmias, hypotension, chorea, muscle cramps, and GI distress.

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Anticholinergic Drugs

Anticholinergic drugs block the effects of the neurotransmitter acetylcholine at cholinergic receptors in the brain as well as in the rest of the body. They are used as adjunct drug therapy in Parkinson’s disease due to their antitremor properties.

Anticholinergic drugs can cause dry mouth or decreased salivation, urinary retention, decreased GI motility (constipation), dilated pupils (mydriasis), and smooth muscle relaxation.

Anticholinergics must be used cautiously in older adults because of significant potential adverse effects, such as confusion, urinary retention, visual blurring, palpitations, and increased intraocular pressure.

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Nursing Process

After patients are confronted with the diagnosis of Parkinson’s disease, they will soon learn that their quality of life depends on drug therapy and nondrug measures.

Before medications for Parkinson’s disease are given, assess and document vital signs and ABCs (airway, breathing, and circulation). Obtain a complete nursing history with a thorough physical assessment, including compiling a comprehensive medication profile.

With indirect-acting dopamine receptor agonists, such as amantadine, and direct-acting dopamine receptor agonists, such as carbidopa-levodopa, include supine and standing blood pressures (because of drug-related postural hypotension), height, weight, medication, and medical and nursing history. Include family, significant others, and caregivers in the assessment and data collection process.

Assess motor skills, including abilities and deficiencies, and for the presence of akinesia, bradykinesia, postural instability, rigidity, tremors, staggering gait, or drooling.

It is important to understand the gynecologic history of the patient and to know if the patient is pregnant and/or lactating. Some dopamine replacement drugs cross into the placenta and into breast milk and have unknown actions in the pediatric patient.

When anticholinergic drugs are prescribed, assess the patient carefully to determine the gross level of organ functioning—especially in those systems most affected by Parkinson’s disease, including the GI, genitourinary, visual, cardiac, and neurologic systems.

Pay close attention to any present or past changes in mental status as well as the presence of confusion, disorientation, or psychotic-like behavior. This is important to consider in elderly patients because of a decline in liver function, a subsequent higher risk for adverse effects and possible toxicity, and an overall increased sensitivity to drugs.

With indirect-acting dopamine receptor agonists, cardiac status is important to assess and document because of the adverse effects of hypotension/hypertension and chest pain.

Encourage patients, family, or caregivers to begin keeping a daily drug calendar or journal including the drugs prescribed, dosage, frequency/timing, and therapeutic and adverse changes.

During the start of dopaminergic drug therapy, the patient will most likely need assistance when walking because of the dizziness and possibly syncope caused by these drugs.

With anticholinergic drugs, patients need to take the medication as prescribed, after meals or at bedtime, and not at the same time as with other medications.

Be cautious with the sound-alike drugs: selegiline is an MAOI, whereas Salagen is an oral form of pilocarpine used to manage dry mouth in patients with Sjögren’s syndrome or in those receiving radiation therapy.

Nutritional concerns include making sure the patient is taking adequate fiber, vegetables, and fruits, as well as an increase in fluid intake, if not contraindicated. Additional concerns include the distribution of protein intake over the course of the day if taking levodopa/carbidopa. The drug is to be taken one-half hour before eating a protein-containing meal or one hour after.

Be aware of all other forms of therapies that may be beneficial, such as support groups, water aerobics, and occupational and physical therapy.

Aerobic exercise may have a positive effect on the patient while improving quality of life and socialization. Although it has not been proven that exercise can slow the progression of this disease, it can help patients feel better mentally and physically.

Tai Chi may be one option of exercise that has been shown to improve balance, flexibility, and strength in a variety of individuals.

Simple stretching and strengthening exercises are important to consider in those with Parkinson’s disease. All exercises must be approved by the patient’s health care provider.

Prevention of falls is important—reduce risk by installing shower or tub grab-bars, adequate lighting in the house especially at night, and removing or securing loose rugs that may increase the risk of tripping.

Therapeutic responses to the antiparkinson drugs include an improved sense of well-being, improved mental status, increased appetite, ability to perform activities of daily living, improved concentration and ability to think more clearly, and a decrease in the intensity of Parkinsonian symptoms.

Monitor for adverse effects such as dizziness; nausea; syncope; insomnia; GI upset (associated with indirect-acting dopamine receptor agonists such as selegiline, amantadine, entacapone, and tolcapone); ataxia; depression (associated with direct-acting dopamine receptor agonists such as bromocriptine); palpitations; hypotension; urinary retention; and depression (associated with dopamine replacement drugs such as levodopa and carbidopa).

Patient considerations include providing individual and family support along with options for care of the family member with Parkinson’s disease. The disease is long-term and lifelong, as well as debilitating. A holistic approach in which all aspects of the patient and family are considered and respected is the key to quality nursing care.